Brain death diagnosis and management

1. Presented by:
Dr.Mohammed AlSiraj
MBBS,MRCS(ed)1,MRCS(ed)2
Surgery resident

2. Definition
U.S. standard U.K. standard
 Complete and irreversible
loss of entire brain and
brainstem activity.
 Complete and irreversible
loss of brainstem function.

3. Legally,
 British physician only needs to document loss of brain
stem function.
 U.S. physician must document loss of brain (cerebral)
and brainstem functions.

4.  No one has ever recovered from such case. In other
words, till now there is no cure or treatment found
for brain dead patient.

5. “Published studies of patients meeting the criteria for brain stem
death or whole brain death – the American standard which includes
brain stem death diagnosed by similar means – record that even if
ventilation is continued after diagnosis, the heart stops beating within
only a few hours or days”

6. Adapted from Smith M. Physiologic changes during brain stem death-lessons for
management of the organ donor. J Heart Lung Transplant 2004;23:S217-22.

7.  The concept of brain death is specific.
 It does not apply to patients existing in a
 Persistent vegetative state
 other severe degrees of brain damage from causes such
as metabolic derangements, drug intoxication etc.

8. Difference between brain death
and a persistent vegetative state
Brain death Persistent vegetative state
 Irreversible coma
 Complete loss of brainstem
function
 Brain dead = Dead
 Brainstem function
unaffected
 Sleep-wake cycle (RAS)
 PVS may recover

9. Difference between persistent vegetative state
and Minimal responsive state
Persistent vegetative state Minimal responsive state
 Sleep-wake cycle (RAS)
 Brainstem function
unaffected
 No response to
environmental stimuli
 Sleep-wake cycle (RAS)
 Brainstem function
unaffected
 Variable interaction with
environmental stimuli

10. Resolution of the Council of Islamic Jurisprudence on
Resuscitation Apparatus
Decision No. (5) D 3/07/86
 The council of Islamic Jurisprudence in its third meeting held in Amman, capital of
Jordan from 8 to 13 Safar 1407 H corresponding to 11 to 16 October 1986 and after
discussing all relevant aspects of resuscitation apparatus and after hearing the detailed
explanation from specialist doctors, decide the following:
A person is pronounced legally dead and consequently, all dispositions of the Islamic law
in case of death apply if one of the two following conditions has been established:
 There is total cessation of cardiac and respiratory functions, and doctors have ruled that
such cessation is irreversible.
 There is total cessation of all cerebral functions and experienced specialized doctors have
ruled that such cessation is irreversible and that brain has started to undergo autolysins.
 In this case, it is permissible to take the person off resuscitation apparatus, even if the
function of some organs e.g., heart are still artificially maintained.

11. Saudi Center for Organ Transplantation
 Who is responsible for the diagnosis
of brain death?
 It is mandatory that a
 Neurologist,
 Neuro-surgeon,
 Internist,
 ICU physician,
 Anesthesiologist,
 Pediatrician
 consultant physician with experience
in evaluation of brain-dead patients
performs the examinations.
 Neither a nephrologist nor a transplant
surgeon should be involved in the
establishment of diagnosis of brain
death.
 Who is responsible for the care of
patients with brain death?
 The following professionals are
responsible for the care of the brain-
dead patient:
 ICU physician,
 Anesthesiologist,
 Internist,
 Neurosurgeon
 Neurophysician in cooperation with-a
nephrologist

12. Diagnosis
 Is a clinical diagnosis
 Three cardinal findings necessary for brain death:
 Irreversible coma
 Absence of brainstem reflexes
 Apnea

13. who and how ? When ?
 2 Neurological tests
 1 Apnea test
 2 Physicians and 1 should be
a consultant
 Non of them from transplant
team
 Adults :
 30 min – 12 hr
 Children :
 12 - 48 hrs

14. Irreversible coma :
 Evidence of an “acute CNS
catastrophe” that is compatible with
the clinical diagnosis of brain death
 Exclusion of complicating medical
conditions that may confound the
clinical assessment
 No severe electyrolyte, acid-
base, or endocrine disturbance
 No drug intoxication or
poisoning
 Core temperature >35 degrees
celsius

15. Absent Brainstem reflexes
 No grimace to pain
 No Pupillary responses
 No corneal reflex
 No ocular movement to
OCR or caloric testing
 No gag or cough response

16. Pupils response
 Brain dead: Mid-size (4-6mm), unreactive pupils (affecting both
sympathetic and parasympathetic)
 Pre-existing pupilary abnormality Cataract ,eye surgery. limit the test

17. • No corneal reflex
 lack of eyelid movement after
touching the cornea (not
conjunctiva) with a cotton
swab or tissue

18. Oculocephalic reflex (“Doll’s eye”) Technique:
 Check No C-spine injury
 Use both hands
 Turn head to one side and
observe for both eyes movement
 Turn head to other side and
observe for both eyes movement
 Can be done vertically and
horizontally
 Normal response: both Eyes move
contralateral to direction of head
turn
 Brain dead show no eye movement

19. Vestibulo-oculogyric reflex (Caloric test)
 Technique :
 No wax ,TM intact
 Elevate the HOB 30°
 Irrigate tympanic membranes with
50ml iced water
 Observe both eyes movement for 1
minute after ear irrigation,
 Wait 5 minute before testing the other
ear
 Normal response: both eyes deviates
towards the cold ice ear
 Brain death: no Eye movement
 Facial trauma involving the auditory
canal and petrous bone can also inhibit
these reflexes

20.  No grimace to pain
 Pressure on supra-orbital
ridge (to rule out any spinal
cord injury or spinal-
mediated reflexive motor
responses)
 Absent Gag reflex
 Tunge depressor
 Absent coughing reflex
 Insertion of suction tube
through the ETT
 Minimal movement of the
ETT

21. Apnea Testing
 Prerequisites are required:
 The core temperature needs to be > 35
 Systolic BP > 90 mmHg
 Patient should be euvolemic
 PaCO2 ~ 40-45 mmHg
 PaO2 ~ 200 mmHg (to guard against desaturation
during apnea)

22.  Technique:
 Pre-oxygenate with 100% oxygen for several min till pO2 ~
200mmHg baseline PaCO2 to be ~40 mmHg
 Disconnected from the ventilator and Advance a cannula 1-2
cm beyond the end of the ETT with 8-12 L/min humidified
O2
 Observe for respiratory effort for ~6-10 minutes
 Get ABG to determine PaCO2
• Result is positive if PaCO2 levels greater than 60 mmHg, or ≥20
mmHg over baseline and there is no respiratory effort
• Reconnect patient to Mechanical ventilator and document the
test.

23. • Stop the test at any time and
reconnect to MV if the patient
develops:
 Arrythmias,
 Hypotention,
 Desaturation
 Confirmatory tests are necessary
for patients who do not achieve
adequate levels of hypercarbia
prior to becoming unstable.

24. Ancillary Testing
 Not necessary to establish brain death in the vast majority of cases
 Not a substitute for clinical exam
 Tests not 100% sensitive or specific
 Reserve for cases where entire exam can’t be done, for example:
 Severe facial trauma
 Preexisting pupillary abnormalities (cataract,eye surgery)
 unstable patient intended for organ donation
 Children under 1 yr

25. Ancillary Testing for Brain Death
 Cerebral angiography
 EEG
 TCD
 Technecium scan
 SEP’s

26. Brain death in children
 7 days of age to 2 mo:
 two examinations + EEGs separated by 48 hr
 2 mo to 1 yr of age:
 two examinations + EEGs separated by at least 24 hrs
 initial examination + isoelectric EEG followed by nuclear
medicine study confirming no cerebral blood flow
 > 1 yr of age:
 two examinations at least 12 hrs apart, with EEG and cerebral
nuclear medicine blood flow studies optional but
recommended

27. Delivering the news
 Most families have a better understanding of the organ
donation process if the ICU staff entirely separates the
declaration of brain death from discussions about organ
donation.
 Thus, the determination of brain death is performed first
and presented to the family who are given time to digest
the information.
 Before support is withdrawn ,a request for organ donation
is made by a representative of the Organ Procurement
Organization (OPO).

28.  Say “Dead” not “brain dead”
 Say “Artificial or mechanical ventilation” not “life support”
 Time of death = Time of 1st neurological examination
 Not when ventilation removed
 Not when heart beats stop
 Don’t say ”kept alive” for organ donation
 Don’t talk as if he/she’s still alive

29.  Other than for potential organ donation, there is no
legal or medical rationale to oxygenate the cadaver.
 No family permission is required to cease ventilation
of the corpse; none should be requested.
 Physician should inform the family that the patient is
dead.
 Physician should request organ donation.
 If declined, the physician should inform ”not ask” the
family that all medical interventions will be withdrawn.
 Fallow Local hospital policy

30.  Decoupling of the process of brain death declaration from
the request for organ donation has resulted in an increase
in next of kin authorizing organ donations.

32. Question 1
 What is the posture of a brain dead patient ?
 Decerebrate
 Decorticate
 None of the above

33. Question 2
 Which of the fallowing is present in brain dead:
 Biceps reflex
 Triceps reflex
 Jaw reflex
 Knee reflex
 Superficial Abdominal reflex

34. Question 3
 Which part of the brain has the thermoregulation
center ?
 Cortex
 Thalamus
 Hypothalamus
 Midbrain
 Medulla

35. Question 4
 If thermoregulation center is in the hypothalamus
and the patient is brain dead how to maintain core
body temperature >35 ?