healthmedicinet

The course was designed to train pediatric healthcare providers in determining BD
based on the JBD criteria practice parameters in two separate modules: a multistation
round session and a group discussion session.

Baseline knowledge assessment

All participants took 20-question pre- and post-tests. The pre-test was taken before
the keynote lectures to assess baseline knowledge, and the post-test was performed
after the group discussion to assess improvement in knowledge. All questions were
related to the entire program content.

Keynote lecture

Two lectures were provided for improving baseline knowledge; (1) the current situation
of organ donation from BD donors in Japan; and (2) the history, definition, and pathophysiology
of BD.

Multistation round

This session covered six different topics of BD determination for pediatric patients:
(1) clinical examination of LBD following the JBD criteria, (2) apnea testing, (3)
ancillary testing using electroencephalogram (EEG), (4) psychological care for family
members, (5) the process of organ donation, (6) how to detect abused children. The
participants rotated among these stations every 25 min with a predetermined time schedule.
For hands-on skill development, we used the Sim Junior 3Gâ„¢ simulation mannequin (Laerdal
Medical, Wappingers Falls, NY, USA). This model is accompanied by a monitor that can
display various vital signs such as heart rate, oxygen saturation, blood pressure,
temperature, respiratory rate, and end tidal CO
₂
.

Preparation

We intubated the mannequin with a 6.0-mm endotracheal tube and provided a flashlight
for pupillary reflex assessment, cotton swabs for corneal reflex assessment, an 18-G
needle as noxious stimuli to the neck for ciliospinal reflex assessment, a 30-cc syringe
with a suction catheter for oculovestibular reflex assessment, and a laryngoscope
and suction catheter for gag reflex assessment. A suction catheter, an oxygen tube,
and a Jackson-Rees circuit were provided for the apnea test. An EEG machine (Nihon
Kohden, Tokyo, Japan) was used for a practical presentation about the artifacts of
EEG recordings. Staff members prepared the environment in each station and the timekeeper
strictly managed the timetable for comfortable rotation. The experts conducted the
session from orientation to debriefing.

All participants were given a booklet that included copies of all session slides for
self-study, six case scenarios for group discussion, and a self-scoring sheet.

Clinical examination

After hearing a brief summary of JBD criteria, the participants were told to perform
a complete BD examination while verbalizing their thorough examination process. The
apnea test was performed last. The facilitator instructed the participants to track
the JBD criteria in the booklet and to self-evaluate their performance.

The apnea test

After a short orientation regarding the appropriate apnea testing procedure, the facilitator
demonstrated the entire procedure with a child mannequin. The participants were asked
to answer brief questions about the pitfalls of apnea testing.

EEG recording

In a hands-on session, the participants were asked to place the electrodes on a partner’s
arm to learn the effect of recording artifact on the fivefold sensitivity of the EEG.
After this demonstration, the participants could recognize that the EEG recording
requires a sophisticated technique to obtain a flat line on brain-dead patients.

Psychological care for the family

Based on the results of lecturers’ interviews with the family members of brain-dead
patients, the participants received a short lecture about the psychological process
of the patient’s family to accept the BD determination. The participants were instructed
to be aware of the importance of psychological support of medical staff.

Role of the Japan Organ Transplant Network (JOTNW)

The participants received detailed information about the role of the JOTNW and the
epidemiology of organ transplantation in Japan to understand the correct process for
contacting this organization when potential donors are identified.

How to determine a case of child abuse

Per the JBD criteria, parents who are suspected to have abused their children cannot
act as legal representatives. Therefore, organ procurement from children with a history
of child abuse will not be performed even if a clinical determination of BD is made.
The clinical approach to child abuse is not always straightforward and requires multidisciplinary
investigation. After this session, the participants were expected to have the comprehensive
knowledge necessary for diagnosis of child abuse.

Group discussion

Case presentation

A clinical vignette of a child with a history of devastating brain injury was provided
to each group for discussion of whether the patient would be an appropriate candidate
for LBD determination. The participants were required to consider various related
issues and to relay their final decision.

Example A 16-year-old girl has a long and complex history of glioblastoma multiforme that
has required four tumor resection operations and postoperative chemotherapies for
the past 12 months. The patient’s current prognosis is terminal and she has been prescribed
full-time bed rest. The patient is able to open her eyes and move her limbs but is
not able to communicate verbally. Currently, the patient does not have any evidence
of systemic organ failure. The patient experienced a seizure for 5 min and was obtunded.
She was subsequently returned to her hometown. The district emergency responders found
her in cardiopulmonary arrest status. The patient was resuscitated and transferred
to the nearest emergency center, where she was intubated and taken to the intensive
care unit for further care. The next day, the patient’s pupils were fixed and dilated,
and EEG results showed total electrocerebral silence. The patient had no advance directive,
and her family was unable to decide whether to ask you to stop current treatment.
Two days later, the patient’s family showed you a memo from her desk at her home.
The note read: “I would like to donate all my organs and tissues for patients affected
by organ failure when I become brain dead.” It was written a month ago by the patient.

Self-scoring and questionnaires

At the end of the course, all participants answered questionnaires (Fig. 1). The post-course questionnaires comprised three parts: (1) comprehension level,
(2) evaluation, and (3) feedback comments. The comprehension level was scored in five
aspects on a scale of 1–3: (1) significance of BD determination and related issues,
(2) skill in determining BD upon examination, (3) recording of EEG and apnea testing,
(4) interaction with mourning family members, and (5) knowledge of organ procurement.
For course evaluation, participants were asked to score in three aspects: value and
difficulty of the course on a scale of 1–5, duration of the course on a scale of 1–3.
Finally, the entire program of this course was scored on a scale of 1–11. In the post-course
feedback comments, we received various opinions from participants. The data were presented
as mean score ± standard deviation (SD).

Fig. 1. Post course questionnaire.

Statistical analysis

Test scores between groups were compared using Student’s t-test for continuous variables.
Statistical significance was established at p  0.05.