Faculty Bibliography

BACKGROUND: Three recent lawsuits that address declaration of brain death (BD) garnered significant media attention and threaten to limit physician power to declare BD. METHODS: We discuss these cases and their consequences including: the right to refuse an apnea test, accepted medical standards for declaration of BD, and the irreversibility of BD. RESULTS: These cases warrant discussion because they threaten to: limit physicians' power to determine death; incite families to seek injunctions to continue organ support after BD; and force hospitals to dispense valuable resources to dead patients in lieu of patients with reparable illnesses or injuries. CONCLUSIONS: Physicians, philosophers, religious officials, ethicists, and lawyers must work together to address these issues and educate both the public and medical community about BD.

BACKGROUND AND PURPOSE: The ideal strategy to prevent infections in patients with external ventricular drains (EVDs) is unclear. METHODS: We conducted a cross-sectional survey of members of the Neurocritical Care Society on infection prevention practices for patients with EVDs between April and July 2015. RESULTS: The survey was completed by 52 individuals (5% response rate). Catheter selection, use of prolonged prophylactic systemic antibiotics (PPSAs), cerebrospinal fluid (CSF) collection policies, location of EVD placement, and performance of routine EVD exchanges varied. Antibiotic-impregnated catheters (AICs) and conventional catheters (CCs) were used with similar frequency, but no respondents reported routine use of silver-impregnated catheters (SICs). The majority of respondents were either neutral or disagreed with the need for PPSA with all catheter types (CC: 75%, AIC: 85%, and SIC: 87%). Despite this, 55% of the respondents reported PPSAs were routinely administered to patients with EVDs at their institutions. The majority (80%) of the respondents reported CSF collection only on an as-needed basis. The EVD placement was restricted to the operating room at 27% of the respondents' institutions. Only 2 respondents (4%) reported that routine EVD exchanges were performed at their institution. CONCLUSION: Practice patterns demonstrate that institutions use varying strategies to prevent ventriculostomy-related infections. Identification and further study of optimum care for these patients are essential to decrease the risk of complications and to aid development of practice standards.

We sought to evaluate whether television and cinematic coverage of brain death is educational or misleading. We identified 24 accessible productions that addressed brain death using the archives of the Paley Center for Media (160 000 titles) and the Internet Movie Database (3.7 million titles). Productions were reviewed by two board-certified neurologists. Although 19 characters were pronounced brain dead, no productions demonstrated a complete examination to assess for brain death (6 included an assessment for coma, 9 included an evaluation of at least 1 brainstem reflex, but none included an assessment of every brainstem reflex, and 2 included an apnea test). Subjectively, both authors believed only a small fraction of productions (13% A.L., 13% J.W.) provided the public a complete and accurate understanding of brain death. Organ donation was addressed in 17 productions (71%), but both reviewers felt that the discussions about organ donation were professional in a paucity of productions (9% for A.L., 27% for J.W.). Because television and movies serve as a key source for public education, the quality of productions that feature brain death must be improved.

OBJECTIVE The authors sought to determine the effects of eliminating the use of prolonged prophylactic systemic antibiotics (PPSAs) in patients with subdural and subgaleal drains. METHODS Using a retrospective database, the authors collected data for patients over the age of 17 years who had undergone cranial surgery at their institution between December 2013 and July 2014 (PPSAs period) or between December 2014 and July 2015 (non-PPSAs period) and had subdural or subgaleal drains left in place postoperatively. RESULTS One hundred five patients in the PPSAs period and 80 in the non-PPSAs period were identified. The discontinuation of PPSAs did not result in an increase in the frequency of surgical site infection (SSI). The frequency of Clostridium difficile (CDI) and the growth of resistant bacteria were reduced in the non-PPSAs period in comparison with the PPSAs period. In the 8 months after the drain prophylaxis protocol was changed, $93,194.63 were saved in the costs of antibiotics and complications related to antibiotics. CONCLUSIONS After discontinuing PPSAs for patients with subdural or subgaleal drains at their institution, the authors did not observe an increase in the frequency of SSI. They did, however, note a decrease in the frequency of CDI and the growth of resistant organisms. It appears that not only can patients in this population do without PPSAs, but also that complications are avoided when antibiotic use is limited to 24 hours after surgery.

Introduction: Because the media plays an important role in educating the public and impacting public perception on medical topics, we sought to evaluate whether mainstream media provides education or misinformation to the public about brain death through review of articles on two recent highly publicized brain death cases: 1) the Jahi McMath case, in which a teenage girl was declared brain dead and her family refused to allow organ support to be discontinued; and 2) the Marlise Munoz case, in which a pregnant woman was declared brain dead and the hospital refused to terminate organ support until they were ordered to do so by a judge. Methods: We reviewed articles published prior to July 31, 2015 on the most shared/heavily trafficked mainstream media websites of 2014 using the search terms, "Jahi McMath" and "Marlise Munoz." Each article was evaluated to determine whether it contained 1) teaching points, or 2) misinformation, defined as misleading, incomplete, or incorrect information. Results: We reviewed 208 unique articles. The subject was referred to as being "alive" or on "life support" in 72% (149) of the articles, 97% (144) of which also described the subject as being brain dead. A definition of brain death was provided in 4% (9) of the articles. Only 7% (14) of the articles noted that organ support should be discontinued after brain death declaration unless a family has agreed to organ donation. Reference was made to well-known cases of patients in persistent vegetative states in 16% (34) of articles and 47% (16) of these implied both patients were in the same clinical state. Conclusions: Mainstream media provides poor education to the public on brain death. Because public understanding of brain death impacts organ and tissue donation, it is important for physicians, organ procurement organizations, and transplant coordinators to improve public education on this topic

Introduction: Practice guidelines recommend that practitioners should not prescribe prolonged prophylactic systemic antibiotics (PPSA) after neurosurgical procedures, even if drains are left in place. We sought to evaluate 1) current practice patterns related to PPSA administration to neurosurgical patients with drains and devices and 2) practitioner perception about the need for PPSA in this population. Methods: We surveyed members of the Neurocritical Care Society on use of PPSA (defined as maintenance antibiotics after the time of insertion) and personal perception about the need for PPSA in patients with intraparenchymal monitors, subdural drains, subgaleal drains, Jackson-Pratt spinal drains, and lumbar drains. Results: Of 52 respondents, routine institutional use of PPSA was reported by 29-52% for each drain/device. The fewest respondents reported use with subgaleal drains and the most respondents reported use with Jackson-Pratt spinal drains with instrumentation. Respondents had varying personal opinions on the need for PPSA with each drain/device. Only fifteen respondents strongly disagreed/disagreed with the need for PPSA for every drain/device. The highest percentage of respondents who agreed/strongly agreed with the need for PPSA (35%) for a given drain/device was for patients with spinal drains with instrumentation while the lowest (19%) was for patients with subgaleal drains. Conclusions: It is clear that adherence to, and knowledge of, practice guidelines varies. Because antibiotic use is associated with risk of nosocomial infections and growth of resistant bacteria, education about guidelines on the use of PPSA in patients with neurosurgical drains is necessary to optimize patient care

People die either when their heart and respiration stop or when their brain irreversibly stops functioning. This latter mode of death by neurologic criteria (also called brain death) emerged after the development of ventilators and intensive care units in the late 1950s and 1960s. Brain death is universally accepted as a modern entity, but the complex process for declaring a patient brain dead is not uniformly followed across country and state lines or even hospital policies, creating unacceptable variability and risks for falsely pronouncing a patient dead. If, however, the declaring physician has expertise and diligently follows the steps that have been published in guidelines, this risk is mitigated. In this article, the authors describe the steps for brain death declaration, discuss how to avoid pitfalls, and examine the modern controversies regarding this medical reality.