Brain Death

Dr. Mohd. A. Salam

Concept of Brain Death and Organ Donation

Dr. Mohamed AbdelSalam Nurein Department of AnatomyUniversity of JubaSudan

Dr. Mohd. A. Salam

What is the problem

USA every 20 mins. A new pt is added to the national list of end stage organ failure

7 pts die every day while waiting for organ transplantation

Dr. Mohd. A. Salam

Cont ….

In Saudi Arabia the data at the end of the yr 2000 was 6696 pts were on the active waiting list for organ transplantation.

The expected number of pts with ESRF is 10.000 by the yr 2010

The incidence ESRF is 123/million pop. The rate of death is 11%

Dr. Mohd. A. Salam

Cont …

Problems of living related donors Problems of living non-related donors and

organs trading. Problems of single organs (not for donation) Cadavaric organ donation could be an exit

Dr. Mohd. A. Salam

Definition

1959 in France a pt with a known irreversible intracranial lesion, irreversible damage to the brain stem is a point of no return.

Called coma de passe (beyond coma)

Dr. Mohd. A. Salam

Cont …

Sydney declaration (1968) death is a process not an event.

It is the moment of the acceptance of irreversibility of the process leading to death which should be determined rather than the moment of death itself

Dr. Mohd. A. Salam

Cont …

In UK 1976 functional death of the brain stem means brain death.

Identification of brain death means death whether or not other organs appear functioning

Dr. Mohd. A. Salam

Cont. …

In USA 1981 a pt is considered dead if there is either

1. cessation of the all functions of the entire brain including the brain stem. OR

2. Cessation of the circulatory and the respiratory functions.

Dr. Mohd. A. Salam

Criteria

Heart rate starts to drop & no alteration in response to painful stimuli.

Steady drop of the core body temp. No pupillary responses to light No awareness about daily nursing care of the

eyes & mouth

Dr. Mohd. A. Salam

Cont …

No response to painful stimuli. Absence of spontaneous breathing.

Dr. Mohd. A. Salam

Diagnosis

Essential precondition is that a definite cause of the irreversible apnoeic coma should be well established

Essential exclusions which are

1. CNS depressant drugs

2. Metabolic disturbances like hypos or hypers (Na, K, glucose,temp. …)

Dr. Mohd. A. Salam

Anatomical Basis of Diagnosis

Brain stem reflexes tests

1. Pupillary light reflexes

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Cont …

2. Corneal reflex

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Cont …

3. Caloric test (vestibulo-ocular test)

for the integrity of the medial

longitudinal fascicules

Dr. Mohd. A. Salam

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Cont …

4. Gag reflex

Dr. Mohd. A. Salam

Dr. Mohd. A. Salam

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Apnea Test

Testing integrity of respiratory centre Preoxygenation followed by disconnection

from ventilator for 10 mins. Measure arterial blood gases PCO2 of > 60 mmHg without trial of

respiratory movement is diagnostic for brain death.

Dr. Mohd. A. Salam

Protocols for diagnosis B.D

Saudi protocol includes

1. Brain stem reflex tests . By 2 consultants

2. Interval of time (6 to 48 hours) confirmatory test to be done (EEG)

3. Repeating the B.S.R. tests

4. Apnea test.

5. Family approach for donation

Dr. Mohd. A. Salam

Criteria of Consultants

Should not be in the field of nephrology, transplant surgery or a transplant coordination

Could be an intensivest, neurologist, neurosurgeon, internist, or an anesthesiologist

Dr. Mohd. A. Salam

Cont …

In U.K. BSR tests to be done by 2 cons. At different times. confirmatory test is not essential

In Japan 3 cons. Do BSR tests 3 times with EEG 2 times

In USA certain states believe on brain stem death so no EEG. Others believe in whole brain death and EEG is mandatory here.

Dr. Mohd. A. Salam

Pitfalls of the EEG

Records electrical activities from the cortex not the brain stem.

Activities may be seen although the pt is brain dead

Chances of artifacts are high.

Dr. Mohd. A. Salam

Alternative Investigations

4 vessels angiography can replace the EEG– If the EEG is not available– If the head injury is too sever for fixing the

electrodes– There should be no flow in the four vessels i.e.

internal carotids & vertebral arteries. Other investigations like perfusion scan and

evoked potentials are supportive NOT ALTERNATIVES

Dr. Mohd. A. Salam

Approaches for Donation

In Saudi protocol family consent should be – A written consent– By a first of kin relative OR a written delegation by

him/her to some one else– withdrawn at anytime before retrieval if the family

changed their mind

Dr. Mohd. A. Salam

Other Types of Consents

Opting in – A card of accepting donation to be carried by the

individual.– When it is found organs can be harvested without

family approach

Dr. Mohd. A. Salam

Cont…

Opting out– The card is that of refusal. i.e. any one is a donor

unless he/she is carrying a card showing his/her refusal of donation

– If this card is not found organs will be taken

Dr. Mohd. A. Salam

Religion’s point of view

Purport of Senior Ulema commission resolved permissibility of organ transplantation from a living to be transplanted onto himself– Should the need arise.– There should be no harm behind that– The transplantation seems likely to be successful

Dr. Mohd. A. Salam

Cont. …

The board resolved by majority the following– Permissibility to remove an organ or part of it from

a dead person to the benefit of a muslim should– The need arise– Removal be after consent of relatives– Transplantation seems likely to be successful.

– Permissibility for the living person to donate one or part of his organs for the benefit of a Muslim in need.

Dr. Mohd. A. Salam

Cont ..

The Council of Islamic Jurisprudence in its third session held in Amman 1407H, 1986G decided the following– The pt is considered dead by Islamic shariah law

if either Complete cessation of the heart and respiration & the

doctors have decided that it is irreversible OR Cessation of the entire functions of the brain & the

doctors have decided it is irreversible.

Dr. Mohd. A. Salam

Cont …

in this condition there is permissibility to discontinue the supportive means the patient on even if some of his organs were still functioning

Dr. Mohd. A. Salam

Rationales of resolutions of scholars of Islam about transplantation

It is allowed to commit less evil in order to combat more evil.

Altruism, gifting and cooperation are principles in Islam

Necessity and great needs allows relief by using prohibited matters.

If there is conflicting benefit and harm, priority to benefits.

Dr. Mohd. A. Salam