Frequency of spinal reflex movements in brain-dead patients

doi:10.1016/j.transproceed.2003.11.049

Transplantation Proceedings

Volume 36, Issue 1, January–February 2004, Pages 17-19

https://doi.org/10.1016/j.transproceed.2003.11.049 Get rights and content

Abstract

Spontaneous and reflex movements may occur in brain-dead patients. These movements originate from spinal cord neurons and do not preclude a brain-death diagnosis. In this study, we sought to determine the frequency and characteristics of motor movements in patients who fulfilled diagnostic criteria for brain death.

Patients admitted to our department between January 2000 and March 2003 and diagnosed as brain-dead were prospectively evaluated in terms of spinal reflexes. Clinical brain death was diagnosed according to our national law. We also prefer to document the diagnosis of brain death with an EEG and/or TCD. Spinal reflex movements were observed in 18 out of 134 (13.4%) brain-dead patients during the study period. Lazarus sign, the most dramatic and complex movement seen in brain-dead patients, was observed a few times in two patients during an apnea test, an oculocephalic test, after a painful stimulus, and after removal of a ventilator. The other reflex movements observed in our brain-dead patients were finger and toe jerks, extension at arms and shoulders, and flexion of arms and feet.

The occurrence of spinal reflexes in brain-dead patients may certainly delay decision making, such as starting a transplantation procedure, because of difficulties in convincing the family or even a physician taking part in the diagnosis of brain death. An awareness of spinal reflexes may prevent delays in and misinterpretations of the brain-death diagnosis.

Section snippets

Materials and methods

The spinal reflexes of patients who were diagnosed as brain dead in our department were examined prospectively between January 2000 and March 2003. Clinical brain death was diagnosed according to the national law requiring the confirmation of irreversible coma, absence of brainstem reflexes, and a positive apnea test in a normothermic, nondrugged patient. Laboratory tests were performed in all subjects to exclude metabolic causes of coma. Confirmatory tests are optional according to these

Results

During the study period, 134 patients met the criteria for brain death. Their mean age was 39.1 ± 24.6 years (range, 2 to 71). Forty-three patients had intracerebral hemorrhage; 42, traumatic brain injury; 18, subarachnoid hemorrhage; 11, cerebral infarct; 8, postcardiac arrest; 4, intoxication; 4, bleeding into a brain tumor; and 4, CNS infection. In 18 of the 134 brain-death patients (13.4%), spinal reflex movements were observed during the study period. The average age of the patients with

Discussion

The process of brain death diagnosis takes hours.⁴ During this period, some unexpected movements, considered spinal reflexes, are occasionally observed. These movements originate from spinal cord neurons and do not preclude the diagnosis of brain death. After brain death occurs, spinal cord functions can be histologically normal or may have pathologies ranging from edema to necrosis due to ischemic events.⁵

In several studies, the frequency of spinal reflexes in brain-dead patients has been

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Spinal reflexes in cerebral brain death
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Spinal man after brain death. The unilateral extension-pronation reflex of the upper limbs as an indication of brain death
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Unusual spontaneous movements in brain-dead patients
Neurology
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Practice parameters for determining brain death in adults: report of the Quality Standarts subcommittee of the American...

There are more references available in the full text version of this article.

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Organ donation after brain death is a major source for obtaining transplantable organs for patients with end-stage organ disease. However, the time from declaring brain death to organ procurement is often longer than expected. Analyzing factors that delay organ procurement may help to prevent damage to organs from marginal and unstable donors and aid in preparation for recipient operation. The aim of this study was to examine factors associated with the interval between the time of declaring brain death and organ procurement.
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Of the 77 patients which were scheduled to undergo organ procurement, 68 eventually underwent procurement of ≥1 organ. The average time interval from 1st exam for brain death to organ procurement decreased from 1,248 minutes in 2009 to 910 minutes in 2015. Although not statistically significant, during the 6-year period, the time interval decreased from 1,105 minutes to 1,075 minutes in the latter half of the period (P = .623). Organ procurement was extensively delayed most commonly owing to false negative electroencephalogram (EEG; 62.5%).
With increasing experience in dealing with brain death donors, the time interval from declaring brain death to organ procurement decreased. We suggest that an EEG be performed during the initial stages of examination for brain death to prevent unnecessary preparation of recipient operation owing to a false EEG test.
Effectiveness of tail-first dry electrical stunning, followed by immersion in ice water as a slaughter (killing) procedure for turbot (Scophthalmus maximus) and common sole (Solea solea)
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Citation Excerpt :
Positive responses to noxious stimuli were observed for only up to 5 min after LS, whereas the tap response remained active in some fish for up to 75 min. To what extent the tap response can be used to indicate (ability to regain) consciousness is uncertain (EFSA, 2009c), as it is well known that spontaneous or reflex movements can occur even in “brain-dead” human patients (Döşemeci et al., 2004; Jain and DeGeorgia, 2005). It should be noted that a distinction must be made between willful movements, involving the function of higher brain areas, and reflexes being involuntary, purposeful responses to stimuli involving integration in the spinal cord or brainstem.
To protect the welfare of fish at slaughter, these animals should be rendered unconscious and insensible prior to killing. Furthermore, the state of unconsciousness must be long enough to allow killing without recovery. The objective of this study was to determine the stunner settings for effective tail-first dry electrical stunning of turbot (Scophthalmus maximus) and common sole (Solea solea). The fish were separated in two batches (B1 and B2). The turbot and sole in B1 were subjected to a short tail-first stun lasting for 1 s and after 1 min of recovery to a second, longer (20 s) stun. The fish in B2 were exposed to a single long (20 s) stun, which was tail-first in sole, but head-first in turbot. The short stun was applied to verify that the loss of consciousness was instant (i.e. within 1 s), whereas the long stun (followed by immersion in ice water) was performed with the aim of showing that it is feasible to kill the fish without recovery. Loss of consciousness and sensibility were assessed using electrophysiological (EEG and ECG) and behavioural parameters.
After administering a current of 2.39 ± 0.91 A_rms by applying 125.5 ± 0.6 V_rms (100 Hz) in turbot and 1.22 ± 0.68 A_rms by applying 152.4 ± 0.5 V_rms in sole for 1 s, 25 out of 26 turbot and 9 out of 10 sole in B1 exhibited EEG patterns showing that the fish were rendered unconscious instantly.
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We conclude that the tail-first electrical stunning, followed by immersion in ice water can be developed into an effective stunning and killing method for turbot and sole.
Statement of relevance
The paper expedites stunning of turbot and sole in practice.
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We previously found that both turbot and sole immersed in ice water after electrical stunning were more responsive to vibration (tapping) than to needle scratches [18]. It is not clear to which extent the tap response may indicate consciousness, since spontaneous or reflex movements can occur even in “brain-dead” human patients [19,20,21]. Heart rate is often measured as a response to stressors and may show tachycardia (increased heart rate) or bradycardia (decreased heart rate).
Behavioural, neural and physiological aspects related to pre-slaughter cooling of turbot habituated to two environmental temperatures (18.7 and 12.0 °C) were investigated. Six fish in both treatments were immersed in ice water for 75 min. For control, four fish were immersed in water under their habituated environmental temperature.
Turbot did not show a quick reduction of overall power in the EEG (electroencephalogram) to less than 10%, nor did the turbot show a shift in brain wave predominance from high to low frequency waves. At 15 min after immersion in ice water at least 7 out of 12 fish still showed total power values over 10% of pre-immersion values. Significant reductions in responsiveness to needle scratches and reduced breathing after immersion in ice water were observed, but none of these parameters had dropped to 0 even after 75 min in ice water. A significant reduction in gill score was found at 2 and 5 min after immersion in ice water compared to the control fish (p < 0.05). Heart rates significantly increased immediately after immersion in ice water and then decreased to a low basal value 30 min after immersion. The heart beat did not show major changes in regularity over time. Finally, at 15 and 75 min the turbot in ice water were significantly more responsive to vibration than to needle scratches.
From these results we conclude that immersion in ice water may not induce unconsciousness, however, the brain activity does decrease to a lower level. The implication of this low brain activity with respect to welfare is not clear. Increased heart rates and maintained low brain activity and response to needle scratches during early immersion in ice water are indicative of a stress response appearing to affect welfare negatively.
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Citation Excerpt :
It has been postulated that it is the absence of cortical inhibitory and modulatory afferents to spinal cord centers that allows for the activation of basic spinal cord sequences, causing the reflex movements commonly seen in brain death.37 In addition to spinal reflexes,38,39 movements after death have been described during apnea testing and during organ procurement, as well as in the morgue.35,40,41 Movements can manifest in the head, neck, upper and lower extremities, and the trunk, and have been named “Lazarus signs” for their biblical connotation.33,39,42

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Organ donationFrequency of spinal reflex movements in brain-dead patients

Abstract

Section snippets

Materials and methods

Results

Discussion

Spinal reflexes in cerebral brain death

Neurology

Spinal man after brain death. The unilateral extension-pronation reflex of the upper limbs as an indication of brain death

Acta Neurochir

Unusual spontaneous movements in brain-dead patients

Neurology

Organ donation
Frequency of spinal reflex movements in brain-dead patients