Brain Death
ISCCM FOUNDATION DAY
Historical- What is death?
• Biology not understood before the Renaissance
Various Descriptions
• A state after the end of life
– Apnoea, unresponsiveness, immobility
– Followed by decay
– When ‘life’ or ‘the spirit’ departed from the body
• Immense cultural, religious, mystical significance
The biology of death
– Understanding possible after Harvey described the
circulation of blood and the pump function of the
heart
– “…the heart is the principle of life…from which heat
and life are dispersed to all parts…”
– Death when the heart and circulation stopped
Harvey, William. Exercitatio anatomica de motu cordis et
sanguinis in animalibus. Francof.,1628
English translation (On the motion of the heart and blood in animals) at
http://www.fordham.edu/halsall/mod/1628harvey-blood.html
Brain death?
The Death of the brain, while the circulation persists.
A clinical syndrome
– First recognised over 50 years ago
– Only possible on ventilatory support
– Revealed by intensive Care Medicine
– Apnoea, unresponsiveness and other features
Indian Law
The transplantation of human organs
act 1994 (THOA)
• Bill No. LIX-F of 1992
The Transplantation of human organs bill, 1994
• (As Passed by the Houses of Parliament Rajya Sabha on 5th May,
1993) Lok Sabha on 14th June 1994 Amendments made by the Lok
Sabha Agreed to by the Rajya Sabha on 15th June 1994) Assented to on
8-7-1994 Act No. 42 of 1994
• Bill No. LIX-F of 1992 THE TRANSPLANTATION OF HUMAN ORGANS BILL,
1994 --------------- ARRANGEMENT OF CLAUSES ------------
Indian law recognizes brain stem death
Definition of Deceased Person
The Transplantation of Human Organs Act, 1994
(Central Act 42 of 1994),- 'Deceased person'
means a person in whom permanent
disappearance of all evidence of life occurs,
1. By reason of brain-stem death or
2. In a cardio-pulmonary sense at any time after
live birth has taken place.
3. ‘Brain-stem death' means the stage at which all
functions of the brain stem have permanently and
irreversibly ceased.
Normal Brain Anatomy
Cerebral Cortex
Reticular
Activating
Brain Stem System
Brain Stem
Brain Stem
Midbrain
Cranial Nerve III
pupillary function
eye movement
Brain Stem
Pons
Cranial Nerves IV, V, VI
conjugate eye movement
corneal reflex
Brain Stem
Medulla
Cranial Nerves IX, X
Pharyngeal (Gag) Reflex
Tracheal (Cough) Reflex
Respiration
Mechanism of Brain Stem Death
Neuronal Injury
Neuronal Swelling
ICP>MAP is
incompatible with
life
Decreased Intracranial Increased Intracranial
Blood Flow Pressure
STEP..1
Establish if there is an underlying
cause for the patient to be brain dead
Few Possible Causes may progress to-
Brain Death
Cerebral Anoxia Trauma Cerebral Hemorrhage
Subarachnoid Hemorrhage
Always ask yourself- Is there a cause
for the patient to be brain dead?
• potential cause for brain stem dysfunction?
• No obvious cause or if there is any doubt about the
cause - be cautious in diagnosing brain death
• Make sure there are no confounders that mimic
brain death
STEP..2
Look for confounders before
proceeding for brain death verification
Rule out the following and aim for
near normal values- PRECONDITIONS
• Severe hypothermia - core temperature of ≤32°C
• Severe hypotension (With or Without Vasopressors) - systolic
blood pressure <100 mmHg
• Drugs - alcohol, poisoning, recent use of sedation or
neuromuscular blocking agents
• Medical conditions - severe electrolyte abnormalities,
hypoglycemia, acid–base abnormalities
Practical Tips
• Insist on core temperature measurement
• Always look in history for, drugs, overdose,
sedation, etc
• If available use a Peripheral Nerve Stimulator
for – TOF response
• Have most recent values for Sodium and
potassium available
• Insist on ABG at start of clinical testing with
100% O2 Pre-oxygenation
Brain Death Criteria
• Brain death is established by
documentation of
1. Irreversible coma
2. Irreversible loss of brain stem reflexes
3. Cessation of respiratory centre function
or
4.
Brain Death Criteria
• Brain death is established by
documentation of
1. Irreversible coma
2. Irreversible loss of brain stem reflexes
3. Cessation of respiratory centre function
or
4. Demonstration of cessation of
intracranial blood flow (NOT a Part of
THOA Act)
Who Does the Testing and When
• Testing can be done after 4- 6 hours of NO
recordable brain Stem Signs by bed side Nurse and
Doctors, provided pre conditions are met
• Testing is done by 2 Doctors- at and interval of 6
hours apart. The doctors can be Neurologist,
Intensivist, Neurosurgeon or an equally qualified
doctor who is certified to be on the hospital brain
death panel.
• 2 More persons observe the process and sign of the
final document- Primary Physician and Hospital
Administrator
Neurological examination for diagnosing Brain
Death
• This consists of three essential steps:
– Documentation of coma
– Documentation of the absence of brainstem
reflexes
– Documentation of apnea (apnea test)
CCCC
Practical Tips
• Start Pre- Oxygenation with 100% Oxygen
• Obtain a ABG- Will give you pH, Oxygen,
Carbon Di Oxide, Electrolytes, Blood Glucose
Documentation of coma
• Absence of motor response to a Central Deep painful
stimulus
• Beware of local spinal reflexes causing spontaneous
or stimulus-related motor movements
Response to painful stimuli
Within cranial nerve distribution
Documentation of the absence of brainstem
reflexes
• Brainstem reflexes are lost in a rostral-to-caudal direction
• Reflexes in medulla oblongata are the last to cease
• Tests documented are
– Absent pupillary reflex
– Absent oculocephalic movements (doll’s eye reflex)-
– Absent oculovestibular reflex (cold calorie test)
– Absent corneal reflex
– Absent cough reflex
Pupillary response to light
Corneal reflex
Gag Reflex and Cough Reflex
Vestibulo- Ocular Reflex
Documentation of apnea (apnea test)
• Done only after
– Documentation of coma
– Documentation of absence of brain stem reflexes
Documentation of apnea (apnea test)
• Steps
– Pre-oxygenate patient with 100% oxygen for 15 minutes
– Obtain an ABG
– Disconnect patient from mechanical ventilation
– Continue to oxygenate through a catheter placed in the
trachea – Aim for saturation above 95%- use 4-6 L/min of O2
– ABG is repeated within about 8–10 minutes
– Increase in PaCO2 (above 60mmHg or 20mmHg from base
line) and lack of respiration documented (use EtCO2) if
available
Apnoea Test
Practical Tips
• Pre-oxygenation with 100 % Oxygen for at
least 15min.
• Give adequate volume and Vasopressors to
keep MAP ~ 70mmHg
• CO2 rises by around 3mmHG/min of apnea, so
be prepared to test at least for 8- 10min
Brain Death Confirmed
• Once the 2 specialist complete the test the
time of death is confirmed as the end of
second examination time
Observations compatible and incompatible with
brain death
Compatible:
• Spinal reflexes
• Sweating, blushing, tachycardia
• Normotension without pharmacologic support
• Absence of diabetes insipidus
Incompatible:
• Decerebrate or decorticate posturing
• Extensor or flexor motor responses to painful stimuli
• Seizures
Confirmatory Tests- Not required in
India and NO mention in THOA act
• These tests are optional in adults
• Recommended in children younger than 1 year
• Certain countries mandate these tests by law to confirm brain
death
• The tests are
– Cerebral angiography (conventional or CT)
– Cerebral scintigraphy
– Electroencephalography (EEG)- NOT RECOMMENDED
– Transcranial Doppler (TCD) ultrasound- NOT RECOMMENDED
Radiographic Confirmation of Death
• Testing is not complete or possible – ie facial
fractures, swollen eyes etc
• Or C spine fractures
• Apnea test becomes a challenge
4 Vessel Angiography/CT angiography
Cerebral perfusion scan
Cerebral perfusion scan
Managing a Brain Dead
Patient
