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[JAMA发表文章]:脑死亡与神经系统标准死亡的确定:世界脑死亡计划
2020年08月17日 时讯速递, 进展交流 暂无评论

Special Communication August 3, 2020

Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

David M. Greer, Sam D. Shemie, Ariane Lewis, et al

JAMA. Published online August 3, 2020. doi:10.1001/jama.2020.11586

Abstract

Importance 背景

There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

在全球范围甚至一个国家内,脑死亡/神经系统标准死亡(BD/DNC)的概念、标准、行为及记录都不尽相同。

Objective 目的

To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

根据文献综述及一个大的多学科国际专家组的专家意见,形成有关确定BD/DNC推荐意见的共识声明。

Process 过程与步骤

Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

纳入相关国际专业学会以制定有关确定BD/DNC的推荐意见。对Cochrane, Embase, 和 MEDLINE数据库进行文献检索,确定从1992年1月1日至2020年4月发表的相关论文进行审阅。由于缺乏随机对照试验或大样本观察性研究的高质量证据,因此基于专家以及代表相关学科(包括重症医学,神经内科及神经外科)的医学会之间的共识形成推荐意见。

Evidence Synthesis 证据合成

Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

根据文献综述以及大的多学科国际专家组的共识,制定不同情况下确定BD/DNC的最低临床标准。

Recommendations 推荐意见

Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

在进行BD/DNC评估之前,应当明确患者已经出现导致完全且不可逆转的全脑功能丧失的神经系统损伤,并且应当排除那些能够影响临床检查的情况以及与BD/DNC有类似表现的疾病。确定BD/DNC时,临床检查应当显示患者处于昏迷状态,无脑干反射,没有自主呼吸。这通常包括以下标准:(1) 对于最大程度的外界刺激(包括视觉、听觉和触觉刺激)没有知觉或意识;(2) 瞳孔于中立位固定或散大,对光反射消失;(3) 角膜翻身、头眼反射及前庭眼反射消失;(4) 恶性刺激时没有面部运动;(5) 双侧后咽部刺激时没有咽反射;(6) 深部气管吸痰没有咳嗽反射;(7) 对于肢体疼痛刺激没有大脑介导的运动反应;且 (8) 无自主呼吸试验达到pH <7.30 且 Paco2 ≥ 60 mm Hg时未观察到自主呼吸。如果不能完成临床检查,可以考虑进行辅助检查如血流检查或电生理检查 。对于儿童,或接受ECMO治疗,或接受治疗性低温的患者,需要特殊考虑,并要考虑宗教、社会及文化因素,法律要求以及现有资源的差异。

Conclusions and Relevance 结论与意义

This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

这个报告对于确定成人和儿童BD/DNC的最低临床标准提出了推荐意见,并对各种临床情况作出明确的指导。推荐意见得到了国际专业学会的广泛认同,可以用于指导各个专业学会及国家修订或制定确定BD/DNC的方案与步骤,从而在国家范围内和国家之间达到更好的一致性。

[评论]:

  • 脑死亡也是ICU医生经常面临的问题,ICU医生应当有能力独立进行脑死亡的判定,这一点在《中国重症医学专科医生核心知识与技能共识》中也有提及
  • 与国内不同,很多国家或地区判定脑死亡时并不要求进行脑血流或脑电图的检查,后者仅当临床检查无法全部进行时作为辅助检查帮助确定脑死亡
  • 全球范围内,尚无临床检查符合脑死亡,但辅助检查推翻诊断的例证。这就对于判断脑死亡时临床检查(主要是体格检查)的规范化与准确性提出了更高要求(这也是在高技术云集的ICU中,临床体格检查仍有其重要意义的例证之一)
  • 移植科医生不得参与脑死亡的判定,这是医学伦理的基本要求

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