Devastating brain injury

In patients with suspected devastating neurological injury there seems to be a consensus/recent guidance that withdrawal of treatment and subsequent assessment for organ donation be delayed for 72hrs from admission.

1. Is this specific to particular pathologies , and are any excluded?

2. What is the rationale for this change in practice?

3. In practical terms how does this now mean we admit all these patients to ITU? And if so, in addition to maintaining normal physiological parameters, are there other treatment adjuncts we should be considering?


A

Yes, there are new guidelines about to come out in relation to the patient with the devastating brain injury (DBI). This includes trauma/SAH/strokes though they are mostly trauma.There was a recent paper in JICS by Manara et al that discusses it.

In essence, there has been growing concern about extubating patients in the ED whose CT scan has been looked at by a neurosurgeon, who usually hasn’t seen the patient, and deemed the injury unsurvivable. More and more intensivists are becoming uncomfortable with this approach. We all know that an initial scan is not always correlated to outcome. There is evidence that some of these patients go on, not only to survive, but to make a good neurological recovery. This has primarily been picked up by patients who have been admitted to ICU for management prior to organ donation and started to improve.

The new guidelines that will be out soon, advises that all DBI patients be admitted to the ICU for up to 72 hours, to monitor and assess any progress. There are several benefits to this approach….

1) it allows for more accurate prognostication. There is evidence that a significant number may actually survive with good neurology

2) it allows much better end of life care. The ED is not a great place to be providing palliation, and for families who are facing a difficult time, it is less than ideal.

3) it allows for the consideration of end of life care, including organ donation, in a timely way and in an environment that is appropriate.

In terms of whether all of these patients should be admitted to neuro icu, the answer is no. They should be admitted to any ICU (DGH if thats where they are) and be provided with basic neurological care. They do not require ICP monitoring or any other specialist neurosurgical input. If they improve, they can be referred back to the neurosurgeons for a second opinion.

Just to be clear, the majority of these patients will not survive, and there is no evidence to suggest we are creating a large group of patients who survive but with poor neurological function. The point is to allow us to better prognosticate and ensure that we do not miss the small number of patients that will survive. 

In terms of the impact on bed capacity, the evidence is that the impact will be relatively low. These patients will not spend a lot of time in the ICU, unless they improve, and if at any point following their admission they deteriorate and declare themselves, then the option to withdraw at this point is still there. What the evidence does show however, is that some patients will improve and survive and that families feel that the care that they receive is of a high quality.

B

I would be cautious about suggesting all DBI patients are by default admitted as within any cohort there will be those who are very unlikely to benefit from ICU admission due to severe comorbidities, very advanced age, disseminated malignancy, their or their families wishes etc etc.  Each case should be assessed on its own merits and potential organ donation should be seen as a possible by-product not the main reason for admission.  Older staff will recall history when previous problems with the so called Exeter protocol where intensive care staff took it on themselves to start elective ventilation for the purposes of increasing the potential donor pool and fell foul of legal system.

C

Despite the fact that the proposal to admit patients for prognostication and management of the dying process does not actually differ from established practice on L6, I do have concerns with the generation of guidance which appears to be taking on the mantle of a normative standard of care.

The major issue relates the fact that not all DBI patients are equal,- rather this is a varied group that is defined by neurosurgical juniors with their personal mores and prejudices. Some individuals with DBI are clearly so damaged at presentation that survival in any capacity is simply not possible, others are much closer to the ‘this looks bad, but lets give him a spin’ end of the spectrum where we fairly routinely bump up against neurosurgical optimism that appears to be based more on faith than science. In the latter group the justification for admission is firmly rooted in prognostic uncertainty, however in the former we are drifting very close to the Exeter protocols, particularly if we write in the notes that we are admitting for consideration of organ donation (which has occurred and appears to be increasingly common in the wake of the Manara paper and the uncertainty about process that it has generated).

There are also concerns about resource allocation. The Manara paper quotes 3 survivors from a cohort of 21. Two of these are cognitively intact, the third is non rehab (I imagine that there are some on this list who could provide further information about the state of the third).

This is a relatively ‘good’ survival rate, particularly for a group who were attributed to zero survival at first assessment, and the NNT is low. However again, recognising the spectrum of DBI and the fact that some of these are manifest ‘non-survivors’ does admitting somebody at the extreme (bad) end of the spectrum really represent good value for money in the modern NHS? — I think this needs wider and more transparent debate than appears to have occurred, and is probably not something that can be dealt with by the ICS or FICM alone (never mind a small email discussion group).

Finally a word of caution- I have on three occasions- been told by trainees that they are about to intubate somebody with a DBI (scanned without tube!), so that they can be admitted according to the as-yet-unpublished-but-much-anticipated-guidance.

This was the very definition of the Exeter protocol and is not what is being proposed. As B suggests, I fear that there is a generational memory loss over this issue.

D

1)     B makes an important point about ensuring that there is clear prescription, within any DBI pathway, that patients who would not otherwise benefit from an ICU admission should be excluded and palliated – whether that’s in ICU or outside will depend on the patient, the clinician, the resources.

2)     The very fact that we are dealing with a prognostic uncertainty within the first hours of admission which could be as high as 14% (Manara’s report from their experience in SouthMead  – 3/21 survivors) mandates we do something different than remove ETT’s in ED. All other secondary outcome considerations i.e. a better death, organ donation are irrelevant in the face of such uncertainty.

3)     Nevertheless, secondary outcome measures are not irrelevant. A quote from a paper in the OOHCA literature. “Some of these non-survivors can proceed to organ donation (OD), and transplantation could be considered a secondary outcome for OHCA. The donation of these organs is beneficial to the recipient and society, cost-effective and can offer grieving families some comfort” Cheetham et al Resuscitation 2016.

4)      C’s point about patients intubated after a scan again clearly emphasises why we need a DBI protocol, so everyone understands who to admit, and why, and when and what to write in the notes.  The patient who is not intubated should remain unintubated and go to the most appropriate ward – stroke for primary ICH (probably with IVH), neurosurgery for SAH etc. If they go to the ward and deteriorate then that’s what was expected and explained to the relatives. If they go to the ward but improve, that triggers a re-referral to us/the surgeons. This is no different from the patient who has been intubated at the scene or in ED and is now on ICU.

5)     A is right. Their care should be DGH level maintenance of physiology with intermittent reassessments of neurological status.

6)     critical-care-management-of-devastating-brain-injury A statement from our own august bodies, led by Dan Harvey (?standards and quality committee ICS) to include ED college, RCoA, ICS, NCCS will be issued in the spring.

7)      C’s point on value for money. How valuable is a good death? Admission of a dying patient to the ICU for EOL care and possibly organ donation yields on average seven times more QALYs in transplant recipients per ICU bed-day compared with the average benefit for the admission of an ICU patient expected to survive. Nunnink & Cook. Crit Care Resus 2016.

8)    We admit indiscriminately OOHCA. We even transfer 93 year old from other hospitals for PCI after OOHCA (only literature in nonagenarians suggests a 1% survival). Last night we took an 84 year old with established myoclonus. Where is the difference to what we are doing with OOHCA to what is now being proposed for DBI?

9)     Resource limitation is irrelevant in the face of a 14% early prognostic uncertainty. The more activity we generate, the more beds we get commissioned in the long run.

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