Brain death rates drop
Use of airbags and helmets and advancements in critical care credited for saving lives but change has implications for organ donations and transplants
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Fewer people are losing their lives from severe head injuries, thanks to better critical care and injury prevention, shows a new Canadian study.
“Even though there are just as many accidents on our roads as there used to be, there are fewer serious injuries from the same accidents, which implies that our roads and our cars are somewhat safer than they used to be,” says lead author Dr. Andreas Kramer, a neurological critical care specialist in Calgary, Alta.
Widespread use of airbags and helmets has helped, but so have advancements in critical care, he says. Overall recovery and outcomes have also improved.
Although this is good news, lower rates of neurologic death have implications for organ donations and transplants, the author noted. Donation after “brain death” accounts for about half of kidney transplants, three-quarters of liver transplants, 90 per cent of lung and pancreas transplants, and all heart and small bowel transplants.
The study: Incidence of neurologic death among patients with brain injury appears in the most recent Canadian Medical Association Journal.
In the study of 2,788 patients in Calgary, researchers found that the odds of patients with brain injury deteriorating to neurologic death decreased over the 10-year study period from highs of 8.1 per cent in 2002 and 9.6 per cent in 2004 to 2.2 per cent in 2010, and was most dramatic in patients with traumatic brain injury. Brain injuries can also occur from subarachnoid hemorrhage, intracerebral hemorrhage or oxygen deprivation.
Alberta Transportation reported that annual traffic-related fatalities decreased between 2006 and 2010 (from 404 to 307), as did nonfatal injury collisions (from 18,831 to 13,552), despite consistent population growth. Similar trends have been reported nationally by Transport Canada
Up until a decade ago, severe injuries from traffic collisions were increasing with the population, says Dr. Andrew Baker, critical care chief at Toronto’s St. Michael’s Hospital. “Now we’re seeing levels of trauma flatten out a little bit in the province.”
Campaigns about injury prevention and impaired and distracted driving are paying off, he believes.
“The nature of severe trauma is changing,” Baker says. “We’re not just allowing people to survive to a bad outcome, we’re having a better functional outcome.”
Early stage prevention — with procedures such as decompressive craniectomy, where part of the skull is removed for a time to allow for swelling — makes an enormous difference, Baker says.
Kramer also credits better organized trauma teams and more effective emergency transfers.
“It’s great news for our society in general,” Kramer says. “But for a patient who needs a new liver, or needs to get off dialysis with a kidney transplant, this is of course not great news.”
Until relatively recently, deceased organ donors were exclusively patients who died from neurological criteria. Doctors are now turning to death after cardiovascular criteria — where the heart stops. These patients are put on life support with hope that they can be cured, but the injuries may be too devastating for any meaningful recovery and families usually choose to withdraw treatment.
“It turns out that a lot of deaths occur that way in the ICU,” Baker says. “In those cases, they don’t become declared dead by neurologic criteria, they go on to die because they stop breathing and their heart stops.”
It’s called Donation after Cardiac Death, or DCD. Organs must be procured within 30 minutes of death and fewer organs are viable for transplant, but it still makes a difference for the approximate 1,500 Ontarians awaiting a life-saving transplant at any given time.
“Patients’ (families) began asking for this,” Baker says. “In Ontario the greatest rise in organ donation is in this category.”
Another way to shrink the gap is by focusing on the conversion rate, which is the number of actual donors divided by the number of potential donors. Critical care specialists only want organ donation to be facilitated when appropriate, Baker says. “If we can do that 30 out of 30 times, that’s great,” he says.
According to the just-released annual report from Trillium Gift of Life Network, the provincial agency mandated with organ and tissue donation and transplantation, Ontario’s conversion rate was 63 per cent in the 2012-2013 fiscal year. It was 60 per cent the previous year and 55 per cent in 2010-2011.
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