Question 7

College answer

Syllabus topic/section:

2.1.15 Organ and tissue Donation in Intensive Care: / Neurological determination of death: L1
2.2.15 Organ and tissue Donation in Intensive Care / Circulatory determination of death: L1

Discussion:  Part A was in general well answered and several candidates demonstrated a very high standard by taking a structured approach following the well-known and existing guidelines. A caution to candidates to be very specific in your answer e.g. detailing the value of electrolytes and temperature including a rationale with potential challenges rather than simply stating “normal electrolytes and normothermia”. Organ and tissue donation is a key core discipline area in Intensive Care and thorough explicit detail is required to demonstrate safe clinical practice.
Unfortunately, part B was poorly answered with the inability to describe the criteria for DCD highlighting a lack of familiarity with clinical experience and senior decision making. We recommend improving your answer by following the structure of the ANZICS guidelines. This topic is very clearly documented, and the answer template is a close ally of the source document.d.

Discussion

This item of core knowledge is concretely codified in fundamental CICM lore as the ANZICS statement on death and organ donation, a definitive document that does not permit any variation in practice. It is therefore not surprising that all trainees were expected to be able to answer it well, as suggested by the high Angoff cutoff. The SAQ is in fact absolutely presdcriptive, as its wording references specific sections of the Statement:

• Section 1.2.1 is where your find the criteria for neurological determination
• Section 1.31 is where your find the criteria for circulatory determination

And as the Statement itself is extremely carefully worded to avoid ambiguity, this means that any creative variation in wording, where it deviates from the Statement, would have been wasteful at best, and inaccurate at worst. To regurgitate the Statement verbatim would have therefore been the best strategy; which is another way of saying "this topic is very clearly documented, and the answer template is a close ally of the source document".

a)  Preconditions for performing neurological determination of death clinically:

• Evidence of sufficient intracranial pathology to deteriorate to loss of all brain function
• AND all of the following:
  • Normothermia ≥35 C
  • Normotension: SBP ≥90 or MAP ≥60
  • Exclusion of effects of sedative medications
  • Absence of severe electrolyte, metabolic or endocrine disturbances:
    • BSL <3 mmol/L or >25 mmol/L
    • Na⁺ <125 mmol/L or >160 mmol/L
    • PO₄ <0.5 mmol/L
    • Mg²⁺ <0.5 mmol/L
    • urea >40 mmol/L
    • Untreated severe hypothyroidism
    • Untreated severe hypoadrenalism
  • Absence of acute liver failure or decompensated chronic liver disease.
  • Absence of neuromuscular-blocking drugs
  • At least one intact ear and one intact eye
  •  Enough spinal cord function to assess the motor response in the facial nerve (VII) to painful stimulus in the upper limbs and to assess the motor response in the upper limbs to painful stimulus in the trigeminal (V) sensory region.
  • Ability to perform apnoea testing

b) Criteria for the circulatory determination of death

• Confirmation that the person is unresponsive, not breathing, is not moving and has no pulse.
• Duration: 5 minutes of circulatory arrest
• Evidence of circulatory arrest:
  •  Absent pulse on the arterial line for 5 minutes
  • OR: electrical asystole for 5
  • AND: 
  • Absent heart sounds and/or absent central pulse