The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis

Abstract

Background: The occurrence of brain death in patients with hypoxic-ischaemic brain injury after resuscitation from cardiac arrest creates opportunities for organ donation. However, its prevalence is currently unknown.

Methods: Systematic review. MEDLINE via PubMed, ISI Web of Science and the Cochrane Database of Systematic Reviews were searched for eligible studies (2002-2016). The prevalence of brain death in adult patients resuscitated from cardiac arrest and the rate of organ donation among brain dead patients were summarised using a random effect model with double-arcsine transformation. The quality of evidence (QOE) was evaluated according to the GRADE guidelines.

Results: 26 studies [16 on conventional cardiopulmonary resuscitation (c-CPR), 10 on extracorporeal CPR (e-CPR)] included a total of 23,388 patients, 1830 of whom developed brain death at a mean time of 3.2 ± 0.4 days after recovery of circulation. The overall prevalence of brain death among patients who died before hospital discharge was 12.6 [10.2-15.2] %. Prevalence was significantly higher in e-CPR vs. c-CPR patients (27.9 [19.7-36.6] vs. 8.3 [6.5-10.4] %; p < 0.0001). The overall rate of organ donation among brain dead patients was 41.8 [20.2-51.0] % (9/26 studies, 1264 patients; range 0-100 %). The QOE was very low for both outcomes.

Conclusions: In patients with hypoxic-ischaemic brain injury following CPR, more than 10 % of deaths were due to brain death. More than 40 % of brain-dead patients could donate organs. Patients who are unconscious after resuscitation from cardiac arrest, especially when resuscitated using e-CPR, should be carefully screened for signs of brain death.

Keywords: Anoxia-ischemia, brain; Brain death; Cardiac arrest; Organ donation.

Fig. 1

Flow chart of study selection

Fig. 2

Suggested algorithm for brain death screening after cardiac arrest. In a resuscitated patient who is unresponsive after rewarming from targeted temperature management (TTM), and after having excluded confounders, brain death is suspected if brainstem reflexes are all absent. Brain death can be suspected earlier if a catastrophic brain injury is demonstrated on CT or if the patient shows signs like fixed, dilated pupils, diabetes insipidus, or cardiovascular changes suggesting herniation. Brain death is confirmed by clinical observation and/or by confirmatory tests like apnoea, a flat EEG or absent cerebral blood flow, according to local legislation or protocols. Organ donation is considered after ascertainment of brain death. In cases where circulatory death occurs, either spontaneously or as a consequence of withdrawal of life-sustaining treatment (WLST), donation after circulatory death (DCD) can be considered. For the European Resuscitation Council and the European Society of Intensive Care Medicine (ERC–ESICM) recommended neuroprognostication protocol, see Ref. [55]