Brain Death in The ICU Dr. Jonathan Goodall M62 Coloproctology Course March 22 nd 2007

JRG M62 Meeting 3/2007 Scope Development of Concepts Diagnosis of Brain Stem Death (BSD) Preconditions Preconditions Testing brain stem function Testing brain stem functionImplications Organ donation Organ donation Recent developments Non-heart beating donation Non-heart beating donation

JRG M62 Meeting 3/2007 Development of Concepts of BSD Mollaret and Goulon – ‘Le coma dépassé’ Rev Neurol 1959; 101: 3-15 Ad Hoc Committee of Harvard Medical School 1968 JAMA 1968; 205: 85-8 Minnesota Criteria ~ 1971 Notion of aetiological preconditions Notion of aetiological preconditions Conferences of Medical Royal Colleges and their Faculties Br Med J 1976;ii: ; Br Med J 1979; i: 3320 From Brain Death to Brain Stem Death Pallis C, Br. Med J 1982; 285:

JRG M62 Meeting 3/2007 Development of Concepts of BSD Cadaveric organs for transplantation: A code of practice including the diagnosis of brain death. London 1983 HMSO

JRG M62 Meeting 3/2007

Diagnosis of BSD: Preconditions The patient is deeply unconscious. There should be no doubt that the patient's condition is due to irremediable brain damage of known aetiology.

JRG M62 Meeting 3/2007

Diagnosis of BSD: Preconditions There is no evidence that this state is due to depressant drugs. Primary hypothermia as the cause of unconsciousness must have been excluded. Potentially reversible circulatory, metabolic and endocrine disturbances excluded.

JRG M62 Meeting 3/2007 Diagnosis of BSD: Preconditions The patient is being maintained on a ventilator because spontaneous ventilation has been insufficient or has ceased altogether.

JRG M62 Meeting 3/2007

Brain Stem Testing     

JRG M62 Meeting 3/2007

BST – Response to Pain No motor responses within the cranial nerve distribution can be elicited by adequate stimulation of any somatic area. There is no limb response to supra-orbital pressure.

JRG M62 Meeting 3/2007 BST- Apnoea Test No respiratory movements occur when the patient is disconnected from the mechanical ventilator. PaCO2 should reach 6.65kPa. Hypoxia prevented by apnoeic oxygenation

JRG M62 Meeting 3/2007 BST – Who? Must be made by at least two medical practitioners Registered for at least 5 years Registered for at least 5 years Are competent in this field Are competent in this field Are not members of the transplant team Are not members of the transplant team At least one must be a consultant At least one must be a consultant Repetition of testing and time of death

JRG M62 Meeting 3/2007 Organ Donation Involvement of family Legal situation Donor cards Donor cards Authorisation of removal of organs Authorisation of removal of organs Designated person In absence of relatives Involvement of HM Coroner

JRG M62 Meeting 3/2007 Retrieval of Organs & Tissues Transplant co-ordinator Practical details Practical details Screening Tests Tissue compatibilty Tissue compatibilty Viral screening Viral screening Organ retrieval and transplant

JRG M62 Meeting 3/2007 Care of the Potential Donor Good medical care Maintenance of organ perfusion Appropriate monitoring Appropriate monitoring Inotropes and vasopressors Inotropes and vasopressors Hormone replacement DDAVP DDAVP Thyroid Hormones Thyroid Hormones Steroids Steroids

JRG M62 Meeting 3/2007 Non-Heart Beating Donor Response to organ shortages Organs removed from donors in death ascertained by cardiac criteria ‘stand off period after declaration of death’ ‘stand off period after declaration of death’ Variable time of ‘warm ischaemia’ Variable time of ‘warm ischaemia’ Reasonable outcomes – delay in recovery of function

JRG M62 Meeting 3/2007 UK Donation ‘05/’06 Organs from 764 people were used in 2,195 transplants 125 non-heartbeating donors, 44% more than the previous year. At the end of March 2006, 6,698 patients were listed as actively waiting for a transplant, a 9% increase compared to the previous year.

JRG M62 Meeting 3/2007 Summary Concept of Brain death established and accepted Strict guidelines for establishing brain death – BST Organ transplantation process well organised

JRG M62 Meeting 3/2007 Almost a million more people pledged to help others after their death by registering their wishes on the NHS Organ Donor Register, bringing the total at 31 March 2006 to 13,122,056.