6Brain Death

Brain DeathBrain Death

dr. Eddy Ario Koentjoro, Sp.Sdr. Eddy Ario Koentjoro, Sp.S

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GUIDELINES FOR DECLARATION OF GUIDELINES FOR DECLARATION OF DEATH BY BRAIN CRITERIADEATH BY BRAIN CRITERIA

November 2004 November 2004

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Brain Death2* is a clinical diagnosis which can be made when there is Brain Death2* is a clinical diagnosis which can be made when there is complete and irreversible cessation of all brain function. Since it is now complete and irreversible cessation of all brain function. Since it is now technically possible to sustain cardiac, circulatory respiratory and other technically possible to sustain cardiac, circulatory respiratory and other organ function after the brain has ceased to be alive, a diagnosis of brain organ function after the brain has ceased to be alive, a diagnosis of brain death can be made before the heart beat stops.death can be made before the heart beat stops.

The diagnosis of brain death is based primarily on clinical criteria. A The diagnosis of brain death is based primarily on clinical criteria. A confirmatory laboratory test may be done to supplement the clinical confirmatory laboratory test may be done to supplement the clinical diagnosis.diagnosis.

An individual with irreversible cessation of all brain function, including An individual with irreversible cessation of all brain function, including the brain stem, is dead.the brain stem, is dead.

By Federal Law, you must notify the New England Organ Bank, 1-800-By Federal Law, you must notify the New England Organ Bank, 1-800-446-6362, as soon as you believe brain death may occur. Do not wait until 446-6362, as soon as you believe brain death may occur. Do not wait until after you have made the declaration.after you have made the declaration.

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PREREQUISITESPREREQUISITES The presence of sedative drugs, hypothermia, shock, or other potentially The presence of sedative drugs, hypothermia, shock, or other potentially

reversible conditions that may depress brain function must be excluded for reversible conditions that may depress brain function must be excluded for these clinical criteria to be valid:these clinical criteria to be valid:

Body temperature must be 32.2 degree (90 degree F) or higher.Body temperature must be 32.2 degree (90 degree F) or higher. If barbiturates are present in the blood, or were used therapeutically for If barbiturates are present in the blood, or were used therapeutically for

control of intracranial pressure or seizures, serum levels should not exceed control of intracranial pressure or seizures, serum levels should not exceed 1 mg % at the time of the clinical examination.1 mg % at the time of the clinical examination.

Screen to exclude other sedative drugs-where clinically indicated.Screen to exclude other sedative drugs-where clinically indicated. Absence of severe hypotension (shock).Absence of severe hypotension (shock).

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CLINICAL CRITERIACLINICAL CRITERIA

The clinical examination should be done by a The clinical examination should be done by a neurologist, neurosurgeon, or critical care neurologist, neurosurgeon, or critical care attending who is familiar with the neurological attending who is familiar with the neurological examination and with these criteria:examination and with these criteria:

Coma with cerebral unresponsitivityComa with cerebral unresponsitivity ApneaApnea Absent brain stem reflexesAbsent brain stem reflexes Persistence of condition for 6 to 24 hoursPersistence of condition for 6 to 24 hours

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Unresponsive ComaUnresponsive Coma

The patient should be deeply comatose with The patient should be deeply comatose with no movements, no withdrawal, seizures, or no movements, no withdrawal, seizures, or posturing (decerebrate or decorticate), posturing (decerebrate or decorticate), spontaneously or to noxious stimulation. spontaneously or to noxious stimulation. There may be spinal cord reflexesThere may be spinal cord reflexes

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ApneaApnea

Apnea may be demonstrated by the absence of spontaneous respiration Apnea may be demonstrated by the absence of spontaneous respiration in the presence of an adequate carbon dioxide (CO2) drive.in the presence of an adequate carbon dioxide (CO2) drive.

The apnea test is a clinical bedside test to determine the response of the The apnea test is a clinical bedside test to determine the response of the medullary brain stem respiratory center to a CO2 stimulus. In the medullary brain stem respiratory center to a CO2 stimulus. In the absence of significant pulmonary disease or neuromuscular paralysis, a absence of significant pulmonary disease or neuromuscular paralysis, a lack of respiratory effort to hypercarbia implies destruction of the most lack of respiratory effort to hypercarbia implies destruction of the most caudal part of the brain stem.caudal part of the brain stem.

The test is begun by pre-oxygenation with 100% oxygen via the The test is begun by pre-oxygenation with 100% oxygen via the ventilator for about 5 minutes. The ventilator is withdrawn and the ventilator for about 5 minutes. The ventilator is withdrawn and the trachea is cannulated with an oxygen catheter. A passive flow of 100% trachea is cannulated with an oxygen catheter. A passive flow of 100% oxygen at 4 1/min allows the PCO2 to rise without hypoxia. A baseline oxygen at 4 1/min allows the PCO2 to rise without hypoxia. A baseline arterial blood gas (ABG) is drawn to ensure that the PCO2 is arterial blood gas (ABG) is drawn to ensure that the PCO2 is normalized. Observe the patient's undraped chest and abdomen for normalized. Observe the patient's undraped chest and abdomen for respiratory effort. After 5 and l0 minutes an ABG is drawn and the respiratory effort. After 5 and l0 minutes an ABG is drawn and the patient returned to the ventilator. A pulse oximeter should be used.patient returned to the ventilator. A pulse oximeter should be used.

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If in the presence of a negative drug screen and in the If in the presence of a negative drug screen and in the absence of metabolic intoxication, evidence of a absence of metabolic intoxication, evidence of a paralyzing disease (e.g. Guillan-Barre, Myesthenia paralyzing disease (e.g. Guillan-Barre, Myesthenia Gravis), or of neuromuscular blockade, there is no Gravis), or of neuromuscular blockade, there is no respiratory effort after an arterial PCO2 of more than respiratory effort after an arterial PCO2 of more than 60 mm Hg has been achieved, the patient is apneic. 60 mm Hg has been achieved, the patient is apneic. Usually an ABG is drawn at baseline, 5 and 10 Usually an ABG is drawn at baseline, 5 and 10 minutes.minutes.

The apnea test is done near the end of the period of The apnea test is done near the end of the period of observation. Patients whose PO2 cannot be observation. Patients whose PO2 cannot be maintained at normal levels may be excluded from a maintained at normal levels may be excluded from a formal, apnea test.formal, apnea test.

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Recommended ProcedureRecommended Procedure

1. Prerequisites:1. Prerequisites: Core temperature should be at least 90°F (32.2o C).Core temperature should be at least 90°F (32.2o C). The patient should be hemodynamically stable.The patient should be hemodynamically stable. A baseline ABG has been obtained and the results show that the A baseline ABG has been obtained and the results show that the

PaO2 is greater than 80, or O2 saturation is at least 95% and the PaO2 is greater than 80, or O2 saturation is at least 95% and the PCO2 in 35-45mmHg.PCO2 in 35-45mmHg.

If the patient has a history of COPD or other chronic pulmonary If the patient has a history of COPD or other chronic pulmonary disease, a pulmonary consult may be obtained.disease, a pulmonary consult may be obtained.

If the patient has received medications which may interfere with If the patient has received medications which may interfere with apnea testing, consultation with a neurologist, a neurosurgeon, an apnea testing, consultation with a neurologist, a neurosurgeon, an anesthesiologist, or a toxicologist may be sought. If there is any anesthesiologist, or a toxicologist may be sought. If there is any question concerning narcotic toxicity, a narcotic antagonist should question concerning narcotic toxicity, a narcotic antagonist should be given.be given.

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2. Equipment and Personnel:2. Equipment and Personnel: Suction catheter of appropriate size with connecting Suction catheter of appropriate size with connecting

tubingtubing Sterile glovesSterile gloves Oxygen or suction connecting tubingOxygen or suction connecting tubing Oxygen flow meter with nippleOxygen flow meter with nipple ABG kits, pulse oximeterABG kits, pulse oximeter Cardiac monitorCardiac monitor Nursing and respiratory therapy personnel may be of Nursing and respiratory therapy personnel may be of

assistance in performing the procedureassistance in performing the procedure

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3.3. Suction the patient according to the standard procedure.Suction the patient according to the standard procedure.4.4. Pre-oxygenate the patient with 100% oxygen on present means of Pre-oxygenate the patient with 100% oxygen on present means of

respiratory support for five minutes.respiratory support for five minutes.5.5. Remove patient from the ventilator (if possible); observe the time Remove patient from the ventilator (if possible); observe the time

the test is started.the test is started.6.6. Insert catheter into the endotracheal or tracheostomy tube. Care must Insert catheter into the endotracheal or tracheostomy tube. Care must

be taken not to intubate a mainstem bronchus; the tip of the catheter be taken not to intubate a mainstem bronchus; the tip of the catheter should be at, or a few millimeters below, the tip of the endotracheal should be at, or a few millimeters below, the tip of the endotracheal or tracheostomy tube.or tracheostomy tube.

7.7. Attach the aspirator manifold of the catheter to the oxygen flow Attach the aspirator manifold of the catheter to the oxygen flow meter via the oxygen connecting tubing. Tape over the aspirator meter via the oxygen connecting tubing. Tape over the aspirator manifold port or occlude it with your thumb throughout the manifold port or occlude it with your thumb throughout the remainder of the procedure.remainder of the procedure.

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8.8. Set the flow meter for 4 lpm. Monitor SaO2 by pulse oximeter.Set the flow meter for 4 lpm. Monitor SaO2 by pulse oximeter.9.9. It is suggested that starting PaCO2 be 35-45 Torr. The PaCO2 will It is suggested that starting PaCO2 be 35-45 Torr. The PaCO2 will

be allowed to rise while the undraped thorax and abdomen are be allowed to rise while the undraped thorax and abdomen are observed and palpated carefully for signs of spontaneous observed and palpated carefully for signs of spontaneous respirations.respirations.

10.10. An ABG should be drawn at approx. 5 minutes and 10 minutes of An ABG should be drawn at approx. 5 minutes and 10 minutes of elapsed time to establish that the PaCO2 has reached 60mm Hg.elapsed time to establish that the PaCO2 has reached 60mm Hg.

11.11. If there are any respirations or if there is a loss of vital signs or If there are any respirations or if there is a loss of vital signs or oxygen desaturation below 90%, draw ABG and discontinue the test oxygen desaturation below 90%, draw ABG and discontinue the test immediately. Reconnect the patient to ventilatory support after 10 immediately. Reconnect the patient to ventilatory support after 10 hyperinflating breaths with the resuscitation bag using 100% hyperinflating breaths with the resuscitation bag using 100% oxygen.oxygen.

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12.12. The test is over after approximately 10 minutes. If there is no The test is over after approximately 10 minutes. If there is no respiratory effort after an arterial PCO2 of more than 60mm Hg has respiratory effort after an arterial PCO2 of more than 60mm Hg has been achieved, the patient is apneic. Repeat testing for a period of been achieved, the patient is apneic. Repeat testing for a period of time longer than 10 minutes may be required if PaCO2 is below 60 time longer than 10 minutes may be required if PaCO2 is below 60 at the end of this test.at the end of this test.

13.13. Discontinue the test by hyperinflating with a resuscitation bag on Discontinue the test by hyperinflating with a resuscitation bag on 100% oxygen for a brief period until the patient's vital signs are 100% oxygen for a brief period until the patient's vital signs are stable and his/her color is normal. Resume pre-test ventilation.stable and his/her color is normal. Resume pre-test ventilation.

14.14. Document test results in progress notes and on the Patient Flow Document test results in progress notes and on the Patient Flow Sheet. Include vital signs, ABG, SaO2, clinical observations and Sheet. Include vital signs, ABG, SaO2, clinical observations and personnel performing the test.personnel performing the test.

It is recognized that on some occasions departure from the It is recognized that on some occasions departure from the above procedures may be necessary. The reasons for such above procedures may be necessary. The reasons for such departure, if taken, should be documented in the patient's departure, if taken, should be documented in the patient's recordrecord

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Absent Brain Stem ReflexesAbsent Brain Stem Reflexes

Pupils - should be mid position in size (4 mm) or dilated in the absence of Pupils - should be mid position in size (4 mm) or dilated in the absence of mydriatics and unreactive to bright light or noxious stimulation.mydriatics and unreactive to bright light or noxious stimulation.

Eye movements - there should be no spontaneous eye movements, and the Eye movements - there should be no spontaneous eye movements, and the eyes should remain in the neutral position on testing the occulocephalic and eyes should remain in the neutral position on testing the occulocephalic and occulovestibular reflexes. The occulocephalic response is tested by rapid occulovestibular reflexes. The occulocephalic response is tested by rapid rotation of the head to either side. In eliciting the occulovestibular reflex, rotation of the head to either side. In eliciting the occulovestibular reflex, 20-30 ml of ice water are instilled into each ear external auditory canal with 20-30 ml of ice water are instilled into each ear external auditory canal with an intact tympanic membrane with the head elevated 30 degrees.an intact tympanic membrane with the head elevated 30 degrees.

Corneal Reflex - No blinking or eye movement when the cornea is touched Corneal Reflex - No blinking or eye movement when the cornea is touched lightly with cotton.lightly with cotton.

Gag Reflex - No gagging or coughing when the oropharynx or trachea is Gag Reflex - No gagging or coughing when the oropharynx or trachea is stimulated.stimulated.

Caloric testing :Caloric testing : Head is at 30Head is at 30 from horizontal from horizontal

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Brings horizontal semicircular canal into vertical and position of maximal Brings horizontal semicircular canal into vertical and position of maximal sensitivity sensitivity

Each auditory canal stimulated for 30 sec at temp of 30Each auditory canal stimulated for 30 sec at temp of 30 and 44 and 44C (7C (7 above & below body temp) with 5 minutes between each irrigation above & below body temp) with 5 minutes between each irrigation

Cold stimulation: ipsilateral tonic deviation with nystagmus away Cold stimulation: ipsilateral tonic deviation with nystagmus away Warm stimulation: nystagmus towards side of stimulation. Warm stimulation: nystagmus towards side of stimulation. Bilateral cold stimulation:Bilateral cold stimulation: tonic downward deviation with nystagmus tonic downward deviation with nystagmus

upward upward Bilateral warm stimulation:Bilateral warm stimulation: tonic upward deviation with nystagmus tonic upward deviation with nystagmus

downward.downward. The presence of deep tendon or other spinal reflexes does not preclude the The presence of deep tendon or other spinal reflexes does not preclude the

diagnosis of brain death.diagnosis of brain death.

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Duration of ObservationDuration of Observation

The clinical examination may be repeated The clinical examination may be repeated after 12-24 hours. When there is a structural after 12-24 hours. When there is a structural brain damage and the diagnosis is known brain damage and the diagnosis is known with certainty, a shorter period of with certainty, a shorter period of observation is adequate if central nervous observation is adequate if central nervous system depressant drugs, metabolic and system depressant drugs, metabolic and anoxic causes have been excludedanoxic causes have been excluded

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CONFIRMATORY TESTSCONFIRMATORY TESTS

A confimatory test supplements but is not a requirement for the clinical A confimatory test supplements but is not a requirement for the clinical diagnosis of brain death. Absence of cerebral blood flow demonstrated by diagnosis of brain death. Absence of cerebral blood flow demonstrated by radionuclide flow study or angiogram or electrocerebral silence on radionuclide flow study or angiogram or electrocerebral silence on electroencephalography is considered confirmatory.electroencephalography is considered confirmatory.

EEG recording is done for at least 30 minutes, with electrode distances of EEG recording is done for at least 30 minutes, with electrode distances of at least 10 cm and impedances between 100 and 10, 000 ohms. It is at least 10 cm and impedances between 100 and 10, 000 ohms. It is considered isoelectric if there is no cerebral activity greater than 2 micro considered isoelectric if there is no cerebral activity greater than 2 micro volts in amplitude.volts in amplitude.

Either confirmatory test should be repeated if the result is equivocal.Either confirmatory test should be repeated if the result is equivocal. In situations where there is an inability to do an adequate clinical In situations where there is an inability to do an adequate clinical

examination, such as high levels of barbiturates, or in cases of massive examination, such as high levels of barbiturates, or in cases of massive facial trauma, absence of brain circulation (to cerebral hemispheres and facial trauma, absence of brain circulation (to cerebral hemispheres and brain stem) on four vessel cerebral angiography is considered definitive of brain stem) on four vessel cerebral angiography is considered definitive of brain death. A radionuclear flow study is not sensitive for brain stem brain death. A radionuclear flow study is not sensitive for brain stem circulation and, therefore, a single scan is not adequate.circulation and, therefore, a single scan is not adequate.

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