Faculty Bibliography

Introduction Physicians often struggle with the intricacies of brain death determination and communication about end-of-life care. In an effort to remedy this situation, we introduced an educational initiative at our medical school to improve student comprehension and comfort dealing with brain death. Methods Beginning in July 2017, students at our medical school were required to attend a 90-minute brain death didactic and simulation session during their neurology clerkship. Students completed a test immediately before and after participating in the initiative. Results Of the 145 students who participated in this educational initiative between July 2016 and June 2017, 124 (86%) consented to have their data used for research purposes. Students correctly answered a median of 53% of questions (IQR 47-58%) on the pretest and 86% of questions (IQR 78-89%) on the posttest (p<0.001). Comfort with both performing a brain death evaluation and talking to a family about brain death improved significantly after this initiative (18% of students were comfortable performing a brain death evaluation before the initiative and 86% were comfortable doing so after the initiative, p<0.001; 18% were comfortable talking to a family about brain death before the initiative and 76% were comfortable doing so after the initiative, p<0.001). Conclusions Incorporation of simulation in undergraduate medical education is high-yield. At our medical school, knowledge about brain death and comfort performing a brain death exam or talking to a family about brain death was poor prior to development of this initiative, but awareness and comfort dealing with brain death improved significantly after this initiative. This initiative was clearly a success and can serve as a model for brain death education at other medical schools

Introduction Patients with intracerebral hemorrhage (ICH) frequently present with hypertension. It is unclear whether this is due to preexisting hypertension (prHTN) causing the bleed, an effect of the bleed, or both. Methods We retrospectively analyzed a single-institution cohort of ICH patients presenting between 2013 and 2016. Data included home antihypertensive use; aSBP; TTE, and EKG and imaging results; and nicardipine administration. The primary objective was to assess the relationship between prHTN and aSBP, while the secondary objectives were to assess the relationship between prHTN, imaging and acute antihypertensive requirements. Results 112 ICH patients met inclusion criteria. In our assessment for prHTN, we found that 46% of patients were on antihypertensives, 16% had LVH on EKG, and 15% had LVH on TTE. There was a significant relationship between LVH on TTE and LVH on EKG (p<0.001), but not between home antihypertensive use and presence of LVH using either modality. aSBP was higher for all patients with markers of pHTN, but this was only significant for patients with LVH on TTE (181mmHg, IQR 153-214 vs. 152mmHg, IQR 137-169, p < 0.001) and patients with LVH on EKG (195 mm Hg, IQR 155-216 vs. 147 mm Hg, IQR 129- 163, p<0.001). All patients with markers of prHTN were more likely to require nicardipine, but this was only significant for patients with LVH on TTE (94% vs. 64%, p=0.016) and patients with LVH on EKG (83% vs. 52%, p=0.018). All patients with markers of prHTN were more likely to have deep bleeds (p=0.017 for patients with LVH on EKG vs. those without LVH on EKG). There was no relationship between any markers of prHTN and the presence of a spot sign. Conclusions In patients with ICH, prHTN is related to higher aSBP, deep bleed location, and increased acute antihypertensive requirements

Introduction Postoperative antibiotics (PA) are often administered to patients after instrumented spinal surgery until all drains are removed to prevent surgical site infections (SSI). This practice is discouraged by numerous medical society guidelines, so our institutional Neurosurgery Quality Improvement Committee decided to discontinue use of PA for this population. Methods We retrospectively reviewed data for patients who had instrumented spinal surgery at our institution for seven months before and after this policy change and compared the frequency of SSI and development of antibiotic related complications in patients who received PA to those who did not (non- PA). Results We identified 188 PA patients and 158 non-PA patients. Discontinuation of PA did not result in an increase in frequency of SSI (2% of PA patients vs. 0.6% of non-PA patients, p=0.4). Growth of resistant bacteria was not significantly reduced in the non-PA period in comparison to the PA period (2% vs. 1%, p=1). The cost of antibiotics for PA patients was $5,499.62, whereas the cost of antibiotics for the non- PA patients was $0. On a per patient basis, the cost associated with antibiotics and resistant infections was significantly greater for patients who received PA than for those who did not (median of $26.32 with IQR $9.87-$46.06 vs. median of $0 with IQR $0-$0; p<0.0001). Conclusions After discontinuing PA for patients who had instrumented spinal procedures, we did not observe an increase in the frequency of SSI. We did, however, note that there was a non-significant decrease in the frequency of growth of resistant organisms. These findings suggest that patients in this population do not need PA, and complications can be reduced if PA are withheld

Although pediatric brain death guidelines stipulate when ancillary testing should be used during brain death determination, little is known about the way these recommendations are implemented in clinical practice. We conducted a survey of pediatric intensivists and neurologists in the United States on the use of ancillary testing. Although most respondents noted they only performed an ancillary test if the clinical examination and apnea test could not be completed, 20% of 195 respondents performed an ancillary test for other reasons, including (1) to convince a family that objected to the brain death determination that a patient is truly dead (n=21), (2) personal preference (n=14), and (3) institutional requirement (n=5). Our findings suggest that pediatricians use ancillary tests for a variety of reasons during brain death determination. Medical societies and governmental regulatory bodies must reinforce the need for homogeneity in practice.

In 1968, the definition of death in the United States was expanded to include not just death by cardiopulmonary criteria, but also death by neurologic criteria. We explore the way the definition has been modified by the medical and legal communities over the past 50 years and address the medical, legal and ethical controversies associated with the definition at present, with a particular highlight on the Supreme Court of Nevada Case of Aden Hailu.

Objective: To evaluate which factors are associated with use of single brain death exam (SBD) vs two (dual) brain death exams (

Objective: To evaluate potential factors that played a role in the consent rate in a large tertiary hospital over a period of 11 years. Background: Many patient, family and hospital factors have been associated with obtaining consent for organ donation after brain death (BD), including decoupling, trained requester and translation. Design/Methods: We evaluated all BD declarations in our hospital between 2006 and 2016 regarding consent for donation. We cross-matched the hospital electronic medical records with the records of the local organ procurement organization to identify this population. Results: The Organ Procurement Organization (OPO) spoke to 199 families (58.7% African American (AA), 47.2% female, mean age of 48.2 years). Another 39 families were never approached. There was a 71.4% consent rate. There was no significant relationship between sex, admission diagnosis, ICU (neuro vs. medical vs. surgical), physician speciality (neurology vs. other), time from event to BD declaration or religion and decision to donate. Families were more likely to consent to donation if the patient was non-AA (87.3% vs 62% if AA, p<0.001), had developed diabetes insipidus (72.3% vs 27.7%, p=0.008), was younger (46.6+/-17.3 vs 52.1+/-15.6 years, p= 0.039), had a lower BUN at the time of death (17.7+/-16.7 vs 24.4+/-20.3 mg/dL, p=0.027), and had a higher PaO2 at the time of the apnea test (225.2+/-129.8 vs 185.9+/-111.8 mmHg, p=0.041). In a logistic regression model, only AA race and PaO2 independently predicted refusal of donation (odds, 95%CI, 4.9, 2-12.1, p=0.001 and 0.996, 0.993-0.999, p= 0.013, respectively). Conclusions: Although the majority of BD patients in this large series were AA, their families were almost 5 times less likely to consent for organ donation than non-AA families. There is an urgent need to explore the reasons for low donation rates in this population