Joseph M Darby1, Lori A Shutter1, Jonathan Elmer1, Mohammad Hirzallah1, Namir Khandker1, Bradley J Molyneaux1, A Murat Kaynar1, Karen R Nigra1, Lawrence R Wechsler1. 1. Department of Critical Care Medicine (JMD, LAS, JE, MH, NK, BJM, AMK), University of Pittsburgh School of Medicine; Department of Neurology (LAS, JE, BJM, LRW), University of Pittsburgh School of Medicine; Department of Emergency Medicine (JE), University of Pittsburgh School of Medicine; Department of Anesthesiology and Perioperative Medicine (AMK), University of Pittsburgh; and UPMC Presbyterian (KRN), Pittsburgh, PA.
Abstract
OBJECTIVE: To determine whether telemedicine technology can be used to reliably determine the neurologic diagnosis of death (NDD) in patients with catastrophic brain injury (CBI). METHODS: We included a convenience sample of patients with CBI at a single academic medical center from November 2016 through June 2018. We simultaneously performed brain death evaluation at the bedside and remotely via telemedicine. Remote examiners were neurointensivists who were experienced and knowledgeable in the NDD. In addition to standard clinical examination, we used quantitative pupillometry to evaluate pupil size and reactivity. We determined the proportion of agreement for each NDD examination element and the overall diagnosis of brain death between bedside and remote examiners. RESULTS: Twenty-nine patients with mean age 46 ± 18 years underwent 30 paired NDD examinations. Twenty-eight (97%) patients met the NDD criteria and were pronounced dead. One patient did not meet the NDD criteria and died after withdrawal of life support. With the exception of qualitative assessment of pupillary reactivity, we observed excellent agreement (97%-100% across NDD examination elements) between bedside and remote examiners and 97% agreement on the overall diagnosis of brain death. Unlike qualitative pupillary assessment, quantitative pupillometry was consistently interpretable by remote examiners. CONCLUSIONS: Our results suggest that remote telemedicine technology can be used to verify the findings of bedside examiners performing NDD examinations when a pupillometer is used to assess pupillary reactivity. When performed by neurocritical care experts, the telemedicine NDD examination has potential to facilitate timely and accurate certification of brain death in patients with CBI. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence on the concordance of neurologic diagnosis of death by telemedicine and bedside examiners.
OBJECTIVE: To determine whether telemedicine technology can be used to reliably determine the neurologic diagnosis of death (NDD) in patients with catastrophic brain injury (CBI). METHODS: We included a convenience sample of patients with CBI at a single academic medical center from November 2016 through June 2018. We simultaneously performed brain death evaluation at the bedside and remotely via telemedicine. Remote examiners were neurointensivists who were experienced and knowledgeable in the NDD. In addition to standard clinical examination, we used quantitative pupillometry to evaluate pupil size and reactivity. We determined the proportion of agreement for each NDD examination element and the overall diagnosis of brain death between bedside and remote examiners. RESULTS: Twenty-nine patients with mean age 46 ± 18 years underwent 30 paired NDD examinations. Twenty-eight (97%) patients met the NDD criteria and were pronounced dead. One patient did not meet the NDD criteria and died after withdrawal of life support. With the exception of qualitative assessment of pupillary reactivity, we observed excellent agreement (97%-100% across NDD examination elements) between bedside and remote examiners and 97% agreement on the overall diagnosis of brain death. Unlike qualitative pupillary assessment, quantitative pupillometry was consistently interpretable by remote examiners. CONCLUSIONS: Our results suggest that remote telemedicine technology can be used to verify the findings of bedside examiners performing NDD examinations when a pupillometer is used to assess pupillary reactivity. When performed by neurocritical care experts, the telemedicine NDD examination has potential to facilitate timely and accurate certification of brain death in patients with CBI. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence on the concordance of neurologic diagnosis of death by telemedicine and bedside examiners.
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