2. ā¾ 1959 Coma deāpasseā(Fr.- a state beyond coma) Mollaret and Goulon
ā¾ 1968 Irreversible Coma/Brain Death Harvard Medical School Ad Hoc
Committee
ā¾ 1981 Uniform Determination of Death Act - Presidentās Commission
for the Study of Ethical Problems in Medicine
ā¾ 1994American Academy of Neurology Guidelines for the
determination of Brain Death
ā¾ 1994 India, Transplantation of Human OrgansAct [TOHO (Sub section
6 of Section 3)]
ā¾ 2005 NYS Guidelines for Determining Brain Death
25 January 2017 2
3. Prior to the advent of mechanical respiration,
death was defined as the cessation of
circulation and breathing
25 January 2017 3
4. āAn individual who has sustained either
irreversible cessation of circulatory and
respiratory functions, or irreversible cessation of
all functions of the entire brain, including the
brainstem. ā
Uniform Determination of DeathAct (UDDA)
25 January 2017 4
5. Neuronal Injury Neuronal Swelling
Decreased Intracranial
Blood Flow
Increased Intracranial
Pressure
25 January 2017 5
ICP>MAP is
incompatible with
life
6. Where Brain Stem Death (BSD) is suspected, it
is highly desirable to confirm this by Brain Stem
Testing:
25 January 2017 6
ā¢ To eliminate all possible doubt regarding
survivability
ā¢ To confirm diagnosis for families
ā¢ In cases subject to medico-legal scrutiny
ā¢ To provide choice regarding organ donation
8. ā¾ A determination of death must be made
with accepted medical standards
ā¾ The American Academy of Neurology
parameter to delineate the
(AAN) published a 1995 practice
medical
standards for the determination of brain
death.
ā¾ In India, brain stem death was legalized
in 1994 when The TOHO Act was
passed and the UK criteria for
brainstem death are followed.
Guidelines
25 January 2017 8
9. In India, according to the Transplantation of Human Organs Act
[TOHO 1994 (Sub section 6 of Section 3)], āBrainstem deathā
means the stage at which all functions of the brainstem have
permanently and irreversibly ceased and is so certified by a
āBoard of Medical Expertsā consisting of:
ā¾ The Medical Superintendent (MS) in charge of the hospital in
which ābrainstemā death has occurred.
ā¾ A specialist, nominated by the MS in charge of the hospital, from
a panel of names approved by theAppropriateAuthority.
ā¾ A neurologist or neurosurgeon, nominated by the MS in charge of
the hospital, from a panel of names approved by the appropriate
authority.
ā¾ The doctor under whose care the ābrain-stemā death has
25o
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17
ed. 9
10. ā¾ Clinical diagnosis of brain death
should be performed in three steps
1.Establishing the etiology of disease
2.Excluding certain potentially
reversible syndromes that may
produce signs similar to brain death
3.Demonstrating clinical signs of brain
death
ā¢ Coma
ā¢ Brainstem areflexia
ā¢ Apnea
25 January 2017 10
11. Brain death should not even be thought of until the
following reversible causes of coma have been
excluded:
ā¾ Intoxication (alcohol)
ā¾ Drugs, which depress the central nervous system
ā¾ Muscle relaxants
ā¾ Primary hypothermia (by measuring rectal temperature)
ā¾ Hypovolaemic shock (by sequential measurement of
blood pressure)
ā¾ Metabolic and endocrine disorders. Hypernatremia and
diabetes insipidus is more often the effect rather than
25 Jt
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01a
7 use. 11
12. ā¾ Neurological assessments may be unreliable in the
acute post-resuscitation phase after
cardiorespiratory arrest.
ā¾ In cases of acute hypoxic-ischemic brain injury,
clinical evaluation for NDD should be delayed for
24 h subsequent to the cardiorespiratory arrest or an
ancillary test could be performed.
ā¾ Core temperature MUST be ā„ 34Ā°C to proceed with
formal testing.
ļ§ Central blood, rectal or esophagealāgastric
ļ§ Previously was 32.2Ā°C
25 January 2017 12
13. ā¾ Brainstem
ļ§ Pupils
āŖ ā„4-9mm, unresponsive to light* (enquire about Rx given)
ļ§ Corneals
āŖ Movement of jaw or lids excludes NDD
ļ§ Vestibulo-ocular responses
āŖ OCR (Dollās)
āŖ Caution if trauma
āŖ Cold calorics
ļ§ Pharyngeal
āŖ Stimulate posterior pharynx
āŖ Suction the ETT
āŖ Depress larynx, swallow reflex
ļ§ Apnea test
25 January 2017 13
15. ā¾ Normal response = eyes always
gaze up towards roof
ā¾ Rapid, but steady movements and
observe for direction of gaze
ļ§ Activates vestibular system
ipsilateral to head thrust
horizontal gaze
āŖ Communicates with contralateral
center (CN VI)
āorchestratingā the action of the eyes
āŖ Simultaneously dampens contralateral
vestibular tone, etc.
ļ±Avoided in the setting of
a patient with questionable
stability of the cervical
spine
25 January 2017 15
16. ā¾ 30Ā° to the horizontal
ā¾ Minimum of 50cc of ice cold water into the
inner ear canal
ļ§ Ensure no perforated tympanic membrane before
instilling water
ļ§ Use kidney basin, prop up beside ear
ā¾ Start observing for eye deviation rapidly; eye
movements should be absent for 1 minute
ā¾ Minimum of 5 minutes before evaluating
contralateral side
25 January 2017 16
18. ā¾ Prerequisites
ļ§ Normal core body temperature
ļ§ Systolic Blood Pressure > 90
ļ§ Normal PaCO2 (~35-45 mm Hg)
āŖ So, drawABG right before starting the test.
ļ§ Absence of any other underlying conditions that
could confound diagnosis by mimicing brain death or
suppressing respiratory drive
25 January 2017 18
19. ā¾ Pre-oxygenate with 100% Oxygen for 30 min.
ā¾ Connect a pulse-ox, then disconnect ventilator.
ā¾ Place a nasal cannula at the level of the carina;
give 100% Oxygen at 6-8L/min. during test.
ā¾ Watch closely for respiratory movements (any
abdominal or chest movement that represents
respiratory effort)
ā¾ Draw ABG ~10 minutes and reconnect
ventilator.
25 January 2017 19
20. ā¾ The apnea test is POSITIVE (i.e., supports the
diagnosis of brain death) if:
ļ§ There are no respiratory efforts during the test
AND
ļ§ RepeatABG shows PCO2 > 60 mm Hg.
25 January 2017 20
21. ā¾ The apnea test is INDETERMINATE if:
ļ§ after 10 minutes, the patient demonstrates no
respiratory effort, but the PCO2 is < 60 mm Hg.
ā¾ The apnea test is NEGA
TIVE (i.e., does NOT
support the diagnosis of brain death) if:
ļ§ the patient demonstrates any respiratory effort at any
time during the test.
āŖ Cease the test and reconnect the ventilator immediately upon
observing respiratory effort.
25 January 2017 21
22. ā¾ If the patient becomes unstable at any point
during theApnea Test (i.e. SBP drops less than
90, significant desaturation on pulse-oximetry,
observance of cardiac arrhythmias, etc.), the
test should be aborted.
ļ§ TheApnea Test should not āinduce a code!ā
25 January 2017 22
23. ā¾ If severe lung disease
ļ§ Caution must be exercised in considering the
validity of the apnea test
ļ§ If in the physicianās judgment, there is a history
suggestive of chronic respiratory insufficiency
and responsiveness to only supranormal levels of
carbon dioxide, or if the patient is dependent on
hypoxic drive.
ļ§ If the physician cannot be sure of the validity of the
apnea test, an ancillary test should be administered.
25 January 2017 23
24. ā¾ The term āancillaryā should be understood to
mean an alternative test to one that otherwise,
for any reason, cannot be conducted.
ļ§ No longer called āconfirmatoryā or āsupplementalā
ļ§ Different connotations
ā¾ Gold standard = global absence of
intracerebral blood flow (only 2 tests support)
ļ§ Cerebral angiography or radio-isotope scan
25 January 2017 24
25. Cerebral Angiography
ā¾ No intracerebral filling at the level of the
carotid bifurcation or circle of Willis.
ā¾ The external carotid circulation is patent,
and filling of the superior longitudinal
sinus may be delayed.
Normal
25 January 2017
No Intracranial Flow
25
26. Normal Brain Death
Isotope scan:
ā¢Technetium-99m hexamethyl propylene amine oxime brain scan
shows no uptake of isotope in brain parenchyma (āhollow skull
phenomenonā).
ā¢Radionuclide cerebral scanning cannot document absence of flow in
the vertebrobasilar circulation.
25 January 2017 26
28. Transcranial Doppler ultrasonography:
ā¾ Assessment Subcommittee of the American
Academy of Neurology has accepted transcranial
Doppler ultrasonography as a reliable procedure for
confirmation of brain death.
ā¾ Transcranial Doppler is subject to technical
problems.
ā¾ 10% of patients may not have temporal insonation
windows. Therefore, the initial absence of Doppler
signals
ā¾ cannot be interpreted as consistent with brain death
25 January 2017 28
29. ā¾ A silent EEG, for example, can be consistent
with brain death. It can also be consistent with
pharmacological influence (i.e., anesthesia) or
drug intoxication.
ā¾ By contrast, EEGs donāt always āconfirmā brain
death.
ļ§ There can be minor transient EEG activity even in the
setting of clinical brain death.
ļ§ Electrical artifacts on EEG in the ICU setting have
been described.
25 January 2017 29
31. Somatosensory Evoked Potentials
ļ¶In studies of patients with brain
death, most patients had no
responses to tests for somatosensory
and brain stem auditory evoked
potentials.
ļ¶It is therefore useful in
distinguishing isolated brainstem
death from high cervical transverse
cord lesions and focal bilateral
lemniscal lesions.
25 January 2017 31
32. ā¾ Key to understand is that none of these
āconfirmatory testsā is sufficient, in and of
itself, to diagnose brain death.
ā¾ They are merely adjuncts.
25 January 2017 32
33. ā¾ Children should be the same as those in adults.
ā¾ All these tests may be carried out twice, at an
interval of at least 6 hours according to the
internationally accepted protocol.
ā¾ As children are more resilient than adults, a longer
time between assessments has been advocated and
this varies according to patientās age as follows:
ā¾ Term to 2 months oldā48 hours
ā¾ Greater than 2 months to 1 year oldā24 hours
ā¾ Greater than 1 year to less than 18 year oldā12
hours
ā¾ Greater than 18 year oldāinterval optional.
25 January 2017 33
34. ā¾ The patient must demonstrate no response to
any stimulation.
ļ§ Spontaneous movement is almost always absent.
25 January 2017 34
any posturing, etc.,
function and is not
ā¾ Seizures,
indicates
consistent
shivering,
brainstem
with the determination of brain
death.
ā¾ The presence of spinal reflexes does not
exclude brain death, but if there is any doubt
then the diagnosis of brain death should be
withheld.
35. ā¾ Persistent Vegetative State
ā¾ Locked-in Syndrome
ā¾ Minimally Responsive State
25 January 2017 35
36. ā¾ Normal Sleep-Wake Cycles
ā¾ No Response to Environmental Stimuli
ā¾ Diffuse Brain Injury with Preservation of
Brain Stem Function
25 January 2017 36
37. Ventral Pontine Infarct
25 January 2017 37
ļ® Complete Paralysis
ļ® Preserved Consciousness
ļ® Preserved Eye Movement
38. ā¾ Diffuse or Multi-Focal Brain Injury
ā¾ Preserved Brain Stem Function
ā¾ Variable Interaction with Environmental
Stimuli
25 January 2017 38
39. ā¾ Sweating, Blushing
ā¾ Deep Tendon Reflexes
ā¾ Spontaneous Spinal Reflexes- Triple Flexion
ā¾ Babinski Sign
ā¾ Motor responses (āLazarus signā) may occur
spontaneously during apnea testing, often during hypoxic
or hypotensive episodes; they are of spinal origin. They
include spontaneous movements of limbs other than
pathologic flexion or extension response and
respiratorylike movements
25 January 2017 39
40. ā¾ Remember that the clinical exam is the
cornerstone of brain death determination, and
there is no test or substitute for an examinerās
judgment and skills.
25 January 2017 40
41. ā¾ Organ donation has been one of the greatest
advances of modern science that has resulted in
many patients getting a renewed lease of life.
ā¾ It means that a person pledges during his
lifetime that after death, organs from his/her
body can be used for transplantation to help
terminally ill patients and giving them a new
lease of life.
25 January 2017 41
42. ā¾ In India every year nearly 500,000 people
die because of non-availability of organs and
this number is expected to grow due to
scarcity of Organ Donors.
Organ Donation
25 January 2017 42
44. ļ¶Corneal blindness is very common in India.
ļ¶More than 3 million cases in India.
ļ¶60% are <12 years age group.
ļ¶Only 1.5 lakh/year corneal donations in India.
25 January 2017 44
46. 1)living related- donor remains alive and donates
a renewable tissue, cell, or fluid (e.g. blood,
skin), or donates an organ or part of an organ
2)living non related(brain death and cadeveric
donor)-In brain- dead organs are kept viable by
ventilators or other mechanical mechanisms
until they can be excised for transplantation.
25 January 2017 46
48. ā¾ Commonly donated organs from brain death
25 January 2017 48
are ākidney ,cornea ,heart, lung, liver,
pancreas, skin.
ā¾ Cadeveric donar-Tissues may be recovered
from donors up to 24 hours past the cessation
of heartbeat.
ā¾ Cadeveric donar are major source of organs
and tissues.
49. Organ Donation- types
Brain Death
ļ¼Brain dead persons are kept on artificial support
(ventilators) to maintain oxygenation of organs so
that the organs are in healthy condition until they
are removed.
ļ¼Most cases of brain death are the end result of
head injuries or brain tumor patients from
Intensive care units.
It is possible to donate all organs in the case of Brain death.
25 January 2017 49
50. Cardiac Death
ļ¶Due to the lack of circulation of blood the vital
organs quickly become unusable for
transplantation.
ļ¶However, if the person is on a ventilator and if it
is medically clear that the person cannot survive,
then the family can consider Organ donation for
certain vital organs.
Such donations typically take place in the operating room.
25 January 2017 50
Organ Donation- types
51. ā¾ Almost everywhere organ donation is voluntary-
25 January 2017 51
Two voluntary systems include ā
1.Opt In - Where the donor gives consent
2.Opt Out - Where anyone who has not refused is
considered as a donor
In India we have the Opt in system, while many
western countries practice the opt out system
52. ā¾ A patientās previously expressed preferences for
organ donation are paramount. ICU clinicians and
coordinator/ ZCCK should retrieve proof of such
authorisation.
ā¾ Another clause in from 8
ā¾ There are reasons to believe that no near relative of
the said deceased person has objection to any of
his/her organs/tissue being used for therapeutic
purposes.
For organ Retrieval
First declaration 6 hours interval
25 January 2017 52
53. changing its name from āTransplantation
25 January 2017 53
Human Organs Actā to āTransplantation
ā¾ It is proposed to amend the THO Act by
of
of
Human Organs & TissuesActā
ā¾ Law will broaden the definition of ānear relativeā
to include grandparents, grandchildren, uncles
and aunts.
ā¾ Also, not-so-close relatives who have stayed
with the patient can donate organs, provided
there is no commercial dealing.
54. ā¾ Hospital Organ Donation Registry
(HODR)coordinates the process of cadaver organ
donation
ā¾ During lifetime, a person can pledge for organ
donation by filling up a donor form in the
presence of two witnesses, one of who shall be a
near relative and send the same to HODR
ā¾ The organ donor form could be obtained from
HODR either personally or through mail
25 January 2017 54
56. ļ§ Hepatitis B or Hepatitis C may be acceptable for
HBV/C recipients
ļ§ IV drug abuse or practicing homosexual
ļ§ Untreated bacterial, fungal or viral infection (treated
infection may be considered)
ļ§ Malignancies other than primary brain tumours and
nonmelanoma skin cancers
25 January 2017 56
57. ā¾ Stabilize profound physiologic and homeostatic
derangements provoked by BD
ā¾ Balance competing management priorities
between different organs
ā¾ Avert somatic death and loss of all organs
25 January 2017 57
58. ā¾ 10-20% donors are lost to cardiovascular collapse
as patient evolves to brain death
Volume Depletion in BD
ā¾ Causes multifactorial
ļ§ Underlying medical condition ā blood loss, etc
ļ§ Prior management ā osmotic therapy for ICP
ļ§ Neuro-hormonal cascade
ļ§ Capillary Leak
ļ§ Diabetes Insipidus
ā¾ 50% of potential BD donors are volume responsive
Muragan, CCM, 200958
25 January 2017
62. Islam
ā¾ Until early 90s the religious leaders failed to approve of
organ donation
ā¾ Mid 90s the religious leader in saudi (mecca) passed a fatwa,
making organ donation after death permissible under islamic
law
Christian
ā¾ Catholics view organ donation as an act of charity
ā¾ Ethically and morally acceptable to the vatican
ā¾ Pope john paul II has given his support to organ donation
25 January 2017 62
63. ļ±All other major religions such as Sikhism,
Buddhism and Jainism do not oppose organ
donation and share similar views as that of
hinduism
LIFE ISAMAZINGā¦ PASS IT ONā¦!!!
25 January 2017 63
64. Aishwarya Rai, Amitabh Bachhan, Jaya Bhachhan, Rajnikanth, Amir
Khan and many other film personalities have pledged their Eyes at
different times on media
Anil Kumble, Sunil Shetty, Yukta Mukhi, Revathi Menon
25 January 2
a0
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dMadhavan have endorsed their views on multi-organ donation 64