1. Brain Death
ISCCM FOUNDATION DAY

2. 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

3. 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

4. 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

5. Indian Law

6. 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 
Act No. 42 of 1994  
 Bill No. LIX-F of 1992  THE TRANSPLANTATION OF HUMAN ORGANS BILL, 1994
 
ARRANGEMENT OF CLAUSES 
  

7. Indian law recognizes brain stem death

8. 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,
By reason of brain-stem death or
In a cardio-pulmonary sense at any time after live birth has taken place.
‘Brain-stem death' means the stage at which all functions of the brain stem have permanently and irreversibly ceased.

9. Normal Brain Anatomy Cerebral Cortex Reticular Activating System
Brain Stem

10. Brain Stem

11. Brain Stem
Midbrain
Cranial Nerve III
pupillary function
eye movement

12. Brain Stem Pons Cranial Nerves IV, V, VI conjugate eye movement
corneal reflex

13. Brain Stem Medulla Cranial Nerves IX, X Pharyngeal (Gag) Reflex
Tracheal (Cough) Reflex
Respiration

14. Mechanism of Brain Stem Death
Neuronal Injury
Decreased Intracranial
Blood Flow
Neuronal Swelling
ICP>MAP is incompatible with life
Increased Intracranial
Pressure

15. STEP..1 Establish if there is an underlying cause for the patient to be brain dead

16. Few Possible Causes may progress to- Brain Death
Cerebral Anoxia
Trauma
Cerebral Hemorrhage
Subarachnoid Hemorrhage

17. 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

18. STEP..2 Look for confounders before proceeding for brain death verification

19. 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

20. 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

21. Brain Death Criteria Brain death is established by documentation of
Irreversible coma
Irreversible loss of brain stem reflexes
Cessation of respiratory centre function or
4. Demonstration of cessation of intracranial blood flow

22. Brain Death Criteria Brain death is established by documentation of
Irreversible coma
Irreversible loss of brain stem reflexes
Cessation of respiratory centre function or
4. Demonstration of cessation of intracranial blood flow (NOT a Part of THOA Act)

23. 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

24. 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)
C C C C

25. Practical Tips Start Pre- Oxygenation with 100% Oxygen
Obtain a ABG- Will give you pH, Oxygen, Carbon Di Oxide, Electrolytes, Blood Glucose

26. 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
Apply painful stimuli in cranial nerve distribution
C C C C

27. Response to painful stimuli
Within cranial nerve distribution

28. 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
C C C C

29. Pupillary response to light

30. Corneal reflex

31. Gag Reflex and Cough Reflex

32. Vestibulo- Ocular Reflex

33. Documentation of apnea (apnea test)
Done only after
Documentation of coma
Documentation of absence of brain stem reflexes

34. 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
C C C C

35. Apnoea Test

36. 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

37. Brain Death Confirmed
Once the 2 specialist complete the test the time of death is confirmed as the end of second examination time

38. Observations compatible and incompatible with brain death
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

39. 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

40. 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

41. 4 Vessel Angiography/CT angiography

43. Cerebral perfusion scan

44. Cerebral perfusion scan

45. Managing a Brain Dead Patient