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February 2021; 11 (1) Research

Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death

View ORCID ProfileJoseph M. Darby, View ORCID ProfileLori A. Shutter, View ORCID ProfileJonathan Elmer, View ORCID ProfileMohammad Hirzallah, Namir Khandker, View ORCID ProfileBradley J. Molyneaux, View ORCID ProfileA. Murat Kaynar, Karen R. Nigra, Lawrence R. Wechsler
First published December 11, 2019, DOI: https://doi.org/10.1212/CPJ.0000000000000798
Joseph M. Darby
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.
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  • ORCID record for Joseph M. Darby
Lori A. Shutter
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.
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  • ORCID record for Lori A. Shutter
Jonathan Elmer
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.
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  • ORCID record for Jonathan Elmer
Mohammad Hirzallah
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.
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  • ORCID record for Mohammad Hirzallah
Namir Khandker
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.
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Bradley J. Molyneaux
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.
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  • ORCID record for Bradley J. Molyneaux
A. Murat Kaynar
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.
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Karen R. Nigra
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.
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Lawrence R. Wechsler
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.
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Citation
Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death
Joseph M. Darby, Lori A. Shutter, Jonathan Elmer, Mohammad Hirzallah, Namir Khandker, Bradley J. Molyneaux, A. Murat Kaynar, Karen R. Nigra, Lawrence R. Wechsler
Neurol Clin Pract Feb 2021, 11 (1) 13-17; DOI: 10.1212/CPJ.0000000000000798

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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.

Footnotes

  • Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.

  • Received September 17, 2019.
  • Accepted November 19, 2019.
  • © 2019 American Academy of Neurology
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The Nerve!: Rapid online correspondence

  • Reader Response: Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death
    • Calixto Machado, Senior Professor and Researcher in Neurology, Institute of Neurology and Neurosurgery, Department of Clinical Neurophysiology, Havana, Cuba
    Submitted February 10, 2021
  • Author response: Reliability of the telemedicine examination in the neurologic diagnosis of death
    • Joseph M. Darby, ICU Physician, University of Pittsburgh Department of Critical Care
    Submitted April 11, 2020
  • Reader response: Reliability of the telemedicine examination in the neurologic diagnosis of death
    • Nitin K. Sethi, Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center (New York City)
    Submitted January 30, 2020
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