Resuscitation 85 (2014) e63
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Lazarus phenomenon and clinical practice guidelines for death diagnosis: Regaining public trust in medical practice Sir, Gerard and colleagues as well as Greer and Soar commented1,2 on the incidence of Lazarus phenomenon or autoresuscitation (unassisted return of spontaneous circulation) and the false positive rate of the diagnosis of death with cardiorespiratory criterion after the discontinuation of cardiopulmonary resuscitation (CPR). Current scientific and clinical characterization of human autoresuscitation is derived from published case series.3 Gerard et al. reported that almost 50% of French emergency physicians have encountered autoresuscitation in clinical practice. Dhanani et al. stated that 37% of Canadian intensivists have seen at least one case of autoresuscitation in their clinical practice.4 Practice guidelines recommend the criterion of 5 min of absent arterial pulse when determining circulatory death after 30 min of unsuccessful CPR before proceeding with organ donation in uncontrolled non-heart-beating (NHB) protocol.5 There is no high quality evidence for the specificity, sensitivity, or false positive rate of this criterion in the diagnosis of death in the uncontrolled NHB protocol.6 In this protocol, CPR is resumed to maintain systemic circulation and perfusion of transplantable organs. In situ machine perfusion or extracorporeal membrane oxygenation (ECMO) with cardiopulmonary bypass is initiated with systemic anticoagulation and targeted temperature management to preserve organs for surgical procurement in potential donors. Those same interventions can be neuroprotective in this particular group. Therefore, the performance of CPR and ECMO-CPR raises concern about the accuracy of the death diagnosis in NHB protocols for the following 2 reasons. First, it may be argued that autoresuscitation is clinically irrelevant in potential donors since most cases suffer severe neurological disability and subsequently die in hospital. However, the initiation of NHB protocol was associated with spontaneous return of circulation in 3/31 of potential donors, one potential donor made good neurological recovery.5 Survival with minimal neurological disability is possible after ECMO-CPR in refractory cardiac arrest.6 Second, surgical procurement is performed on donors without general anaesthesia. It is generally assumed that absent brainstem reflexes in potential donors indicate the lack of capacity for neurological processing of external and internal noxious stimuli. However, it is clinically challenging to confirm irreversible cessation of brainstem reflexes on ECMO support without serial examinations or neuromonitoring to exclude recovery with the passage of time.
0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.09.027
In conclusion, there is paucity of evidence to support current practice guidelines recommending 5 min of absent cardiorespiratory activity to ascertain irreversible cessation of both the neurological and circulatory functions and the uniform determination of death. Public trust can only be gained when recommendations in clinical practice guidelines are grounded in high quality scientific evidence because the stakes are high for a wrongful diagnosis of death. Conflict of interest statement The authors have no conflict of interest to declare. Acknowledgement No funding source for this work. References 1. Gerard D, Vaux J, Boche T, Chollet-Xemard C, Marty J. Lazarus phenomenon: knowledge, attitude and practice. Resuscitation 2013;84:e153, http://dx.doi.org/10.1016/j.resuscitation.2013.07.030. 2. Greer R, Soar J. Lazarus phenomenon: confirmation of death after unsuccardiopulmonary resuscitation. Resuscitation 2013;84:e151, cessful http://dx.doi.org/10.1016/j.resuscitation.2013.08.015. 3. Rady MY, Verheijde JL. Autoresuscitation and determining circulatory–respiratory death in clinical practice for organ donation. Crit Care Med 2012;40:1655–6. 4. Dhanani S, Ward R, Hornby L, et al. Survey of determination of death after cardiac arrest by intensive care physicians. Crit Care Med 2012;40:1449–55. 5. Mateos-Rodríguez A, Pardillos-Ferrer L, Navalpotro-Pascual JM, Barba-Alonso C, Martin-Maldonado ME, Andrés-Belmonte A. Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions. Resuscitation 2010;81:904–7. 6. Rady MY, Verheijde JL. No-touch time in donors after cardiac death (non-heartbeating organ donation). Curr Opin Organ Transplant 2013;18:140–7.
Mohamed Y. Rady ∗ Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA Joseph L. Verheijde Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA ∗ Corresponding author. E-mail address: [email protected] (M.Y. Rady)
4 September 2013
Contents lists available at ScienceDirect
Resuscitation journal homepage: www.elsevier.com/locate/resuscitation
Letter to the Editor Lazarus phenomenon and clinical practice guidelines for death diagnosis: Regaining public trust in medical practice Sir, Gerard and colleagues as well as Greer and Soar commented1,2 on the incidence of Lazarus phenomenon or autoresuscitation (unassisted return of spontaneous circulation) and the false positive rate of the diagnosis of death with cardiorespiratory criterion after the discontinuation of cardiopulmonary resuscitation (CPR). Current scientific and clinical characterization of human autoresuscitation is derived from published case series.3 Gerard et al. reported that almost 50% of French emergency physicians have encountered autoresuscitation in clinical practice. Dhanani et al. stated that 37% of Canadian intensivists have seen at least one case of autoresuscitation in their clinical practice.4 Practice guidelines recommend the criterion of 5 min of absent arterial pulse when determining circulatory death after 30 min of unsuccessful CPR before proceeding with organ donation in uncontrolled non-heart-beating (NHB) protocol.5 There is no high quality evidence for the specificity, sensitivity, or false positive rate of this criterion in the diagnosis of death in the uncontrolled NHB protocol.6 In this protocol, CPR is resumed to maintain systemic circulation and perfusion of transplantable organs. In situ machine perfusion or extracorporeal membrane oxygenation (ECMO) with cardiopulmonary bypass is initiated with systemic anticoagulation and targeted temperature management to preserve organs for surgical procurement in potential donors. Those same interventions can be neuroprotective in this particular group. Therefore, the performance of CPR and ECMO-CPR raises concern about the accuracy of the death diagnosis in NHB protocols for the following 2 reasons. First, it may be argued that autoresuscitation is clinically irrelevant in potential donors since most cases suffer severe neurological disability and subsequently die in hospital. However, the initiation of NHB protocol was associated with spontaneous return of circulation in 3/31 of potential donors, one potential donor made good neurological recovery.5 Survival with minimal neurological disability is possible after ECMO-CPR in refractory cardiac arrest.6 Second, surgical procurement is performed on donors without general anaesthesia. It is generally assumed that absent brainstem reflexes in potential donors indicate the lack of capacity for neurological processing of external and internal noxious stimuli. However, it is clinically challenging to confirm irreversible cessation of brainstem reflexes on ECMO support without serial examinations or neuromonitoring to exclude recovery with the passage of time.
0300-9572/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.resuscitation.2013.09.027
In conclusion, there is paucity of evidence to support current practice guidelines recommending 5 min of absent cardiorespiratory activity to ascertain irreversible cessation of both the neurological and circulatory functions and the uniform determination of death. Public trust can only be gained when recommendations in clinical practice guidelines are grounded in high quality scientific evidence because the stakes are high for a wrongful diagnosis of death. Conflict of interest statement The authors have no conflict of interest to declare. Acknowledgement No funding source for this work. References 1. Gerard D, Vaux J, Boche T, Chollet-Xemard C, Marty J. Lazarus phenomenon: knowledge, attitude and practice. Resuscitation 2013;84:e153, http://dx.doi.org/10.1016/j.resuscitation.2013.07.030. 2. Greer R, Soar J. Lazarus phenomenon: confirmation of death after unsuccardiopulmonary resuscitation. Resuscitation 2013;84:e151, cessful http://dx.doi.org/10.1016/j.resuscitation.2013.08.015. 3. Rady MY, Verheijde JL. Autoresuscitation and determining circulatory–respiratory death in clinical practice for organ donation. Crit Care Med 2012;40:1655–6. 4. Dhanani S, Ward R, Hornby L, et al. Survey of determination of death after cardiac arrest by intensive care physicians. Crit Care Med 2012;40:1449–55. 5. Mateos-Rodríguez A, Pardillos-Ferrer L, Navalpotro-Pascual JM, Barba-Alonso C, Martin-Maldonado ME, Andrés-Belmonte A. Kidney transplant function using organs from non-heart-beating donors maintained by mechanical chest compressions. Resuscitation 2010;81:904–7. 6. Rady MY, Verheijde JL. No-touch time in donors after cardiac death (non-heartbeating organ donation). Curr Opin Organ Transplant 2013;18:140–7.
Mohamed Y. Rady ∗ Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA Joseph L. Verheijde Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA ∗ Corresponding author. E-mail address: [email protected] (M.Y. Rady)
4 September 2013
