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Brain Death Role of Intensivist in Diagnosis and Preparation For Organ Retrieval
Brain Death Role of Intensivist in Diagnosis and Preparation For Organ Retrieval
1
HISTORY
1959 Coma de’passe’ (Fr.- a state beyond coma) Mollaret
and Goulon
1968 Irreversible Coma/Brain Death Harvard Medical
School Ad Hoc Committee
2
INTRODUCTION
• Traditional concept of death -life begins with the first inspiration after birth,
that death comes with the last expiration and that cardiac activity ceases
within a few minutes of the last expiration.
• BRAIN DEATH:
• Loss of Cerebral cortex and Brainstem function.
• Etiology is known and demonstrably irreversible. Spinal cord reflexes may be
preserved in some.
• Introduced by Harvard medical school in 1968
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• CEREBRAL DEATH
Cessation of function of cerebral cortices. Brainstem function controlling
respiratory centers ANS & Endocrine & immune systems are preserved
with a flat cortical EEG
• BRAINSTEM DEATH
• Does not require EEG for confirmation
• Based on rationale that brainstem and not cortices control respiration,
circulation homeostasis and reticular formation for consciousness.
4
CAUSES
• Cerebrovascular Accident
- Stroke
-Ruptured Aneurysm
• Anoxia
• Hanging, drowning, smoke inhalation, CO poisoning
• Trauma- RTA, Fall Open- Gun shot
wounds Closed- Blunt Injury
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DEAD DONOR RULE
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Brain death
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MECHANISM OF BRAIN DEATH
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Traumatic Brain Injury Generalized
Hypoxia
Cytotoxic Cerebral
Vasogenic Cerebral Edema Edema
Raised ICP
-
Exceeds Arterial BP
ICP >
MAP
Cerebral
Circulation
Ceases
-
Aseptic Brain
Necrosis
Brain 9
Liquefication
• Vasogenic edema - induced by an increase in cerebrovascular permeability after leaking
of serum proteins into the brain parenchyma.
• Cytotoxic brain edema - hypoxic and ischemic conditions. Results from disturbance of
cellular osmoregulation.
• Brain oedema – focal initially – then spreads – increase ICP – ICP > arterial BP –
cerebral circulation ceases- aseptic necrosis of brain-
Liquefied mass – respirator brain.
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Pathophysiologic changes with brain death
Cardiovascular responses:
First phase: sympathetic discharge
11
• Second phase:Loss of sympathetic tone
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RESPIRATORY RESPONSES
Increased SVR
13
• Sympathetic activity
Lung injury
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ENDOCRINE,METABOLIC AND STRESS
RESPONSES
15
HYPOTHALAMIC PITUITARY ENDOCRINE
FUCTIONS
• Preserved to a certain degree for a certain period after the
onset of brain death.
17
REVERSIBLE CAUSES ( to be ruled out)
Intoxication (alcohol)
Drugs, which depress the central nervous system
Muscle relaxants
Primary hypothermia (by measuring rectal temperature)
Hypovolaemic shock( by sequential measurement of blood
pressure)
Metabolic and endocrine disorders. Hypernatremia and
diabetes insipidus is more often the effect rather
than the cause.
18
IRREVERSIBLE CAUSE OF DEATH
19
LOSS OF CONSCIOUSNESS AND
UNRESPONSIVENESS
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Brain stem areflexia
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PUPILLARY REFLEX
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• Absent corneal reflex
[cranial nerve V and VII],
oculocephalic (also called
Doll eye movement), cough
and gag reflexes [cranial
nerve IX and X].
• The corneal reflex may be
altered as a result of facial
weakness
23
24
Oculovestibular reflex
• Cold Caloric test /Absent oculovestibular reflex [cranial nerve VIII, III
and VI]:
• The external auditory canal should be clear of cerumen and tympanic
membranes should be intact.
• Elevate the patient‟s head by 30˚.
• Twenty to fifty (20 to 50) ml of ice water irrigated into external
auditory canal and over the tympanic membrane using a soft irrigation
cannula.
• One should look for eye ball movement for which upper eyelids need
to be retracted.
• Allow 1 minute response time after injection/irrigation of fluid and at
least 5 minutes between testing on each side.
• No eye ball movements will be seen in brain dead patient .
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26
APNEA TEST
Pre-requisites:
(1) normotension (systolic blood pressure ≥100 mm Hg)
(2) normothermia (core temperature >36° C)
(3) Euvolemia
(4) eucapnia (Paco2 35 to 45 mm Hg), and no prior evidence of
carbon dioxide retention.
(5)Normal PO2. Pre-oxygenation for 15min with 100% Oxygen
before carrying the apnea test, try to achieve an arterial PO2 ≥
200 mm Hg for safely conducting the test
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STEPS FOR APNEA TEST
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INTERPRETATION
• If respiratory movements are absent and arterial PCO2 is ≥ 60
mm Hg (option: 20 mm Hg increase in PCO2 over a baseline
normal PCO2), the apnea test result is positive (i.e. it supports
the diagnosis of brain death).
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• Most experts agree that a 6-hour observation period is
sufficient and reasonable in adults and children over the age of
2years.
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TROUBLE SHOOTING FOR APNEA TEST
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ANCILLARY TESTS
• Indications:
1) Patients with cranial or cervical injuries, cardiovascular
instability
2) Severe facial trauma, otorrhagia, eye agenesis,Which
preclude the performance of a portion of the clinical examination,
3) reassure family members and medical staff.
4) Panel of doctors is in doubt or disagreement of the diagnosis.
Not needed as per THOA.
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CEREBRAL ANGIOGRAPHY
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Confirmatory Testing
Cerebral Angiography
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Normal Brain Death
PET
Glucose Metabolism Studies
“Hollow-skull sign”
Normal Cerebral metabolism
of brain death
globally reduced ~50%
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COMPUTED TOMOGRAPHY
• Noninvasive test
• intravenous injection of contrast media-time density analysis
• Advantages –
1) easily accessible
2) fairly inexpensive
3)only minutes
4) can also be combined with CT perfusion imaging
5) noninvasive
6) the images are easy to interpret.
Xenon-CT cerebral blood flow method – average global flow
of less than 5 mL/dL/min confirms brain death
38
TRANSCRANIAL DOPPLER
ULTRASONOGRAPHY
• Safe,non-invasive&
inexpensive.
• Cerebral circulatory arrest can
be confirmed if the following
extracranial and intracranial
Doppler sonographic findings
have been recorded and
documented both
intracranially and
extracranially and bilaterally
on two examinations at an
interval of at least 30 minutes:
39
• “Systolic spikes” or “oscillating flow” in any cerebral artery
can be recorded by bilateral transcranial insonation of the
internal carotid artery and middle cerebral artery.
40
EEG
• Minimum of 8 scalp electrodes to be used
•Loss of bioelectrical brain activity as shown on the EEG
(i.e., isoelectric EEG) is a reliable confirmatory test for
brain death
• False positive - drug intoxication – barbiturates.
• False negative – residual electrical activity that persist
after brain death
41
Electrocerebral inactivity (ECI) or electrocerebral silence (ECS)
is defined as no electroencephalographic activity above 2 μV/mm
when recording from scalp electrode pairs placed 10 cm or more
apart and with interelectrode impedances less than 10,000 Ω but
more than 100 Ω
42
How many doctors required?
• For certification of of brainstem death requires a panel four doctors.
1.R.M.P.- Incharge of the Hospital In which brain-stem death has
occurred.
2.R.M.P. nominated from the panel of Names sent by the hospitals and
approved by the Appropriate Authority.
3.Neurologist/Neuro-Surgeon
4.R.M.P. treating the aforesaid deceased person
(where Neurologist/Neurosurgeon is not available, any Surgeon or
Physician and Anaesthetist or Intensivist, nominated by Medical
Administrator In-charge from the panel of names sent by the hospital
and approved by the Appropriate Authority shall be included)
Form 10 should be filled and signed by the medical experts certifying
brain stem death.
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44
(2) Coma
(3) Cessation of spontaneous breathing
(4) Pupillary size
(5) Pupillary light reflexes
(6) Doll’s head eye movements
(7) Corneal reflexes (Both sizes)
(8) Motor response in any cranial nerve distribution, any responses to stimulation of face, limb or trunk.
(9) Gag reflex
(10) Cough (Tracheal)
(11) Eye movements on caloric testing bilaterally
(12) Apnoea tests as specified
(13) Were any respiratory movements seen?
…………………………………………………………………………………………………………………………………………..
Date and time of first testing: ………………………………………………………………………………………………………... Date and time of second
testing: ……………………………………………………………………………………………………...
This is to certify that the patient has been carefully examined twice after an interval of about six hours and on the basis of findings recorded
above, Mr./Ms……………………………………………….is declared brain-stem dead.
Date: …………………….
Note: I. Where Neurologist/Neurosurgeon is not available, then any Surgeon or Physician and Anaesthetist or Intensivist, nominated by Medical Administrator In-charge
of the hospital shall be the member of the board of medical experts for brain-stem death certification.
II. The minimum time interval between the first and second testing will be six hours in adults. In case of children 6 to 12 years of age, 1 to 5 years of age and
infants, the time interval shall increase depending on the opinion of the above BSD experts.
III. No.2 and No.3 will be co-opted by the Administrator In-charge of the hospital from the Panel of experts (Nominated by the hospital
and approved by the Appropriate Authority).
45
• Clinical examination and apnea test need to be done two times
after an interval of six hours.
• After the second test the team should start counseling the
family regarding organ donation.
46
COMMUNICATION PLATFORM
• The ICU physician should communicate the confirmation of
brainstem death to transplant coordinator who in turn can
communicate to family and make request for the organ
donation.
47
• The process of consent for organ and tissue donation involves:
1) the deceased
2) Next of kin
3) Coroners consent (medico legal cases)
48
EXCLUSION CRITERIA
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AGE LIMIT FOR DECEASED ORGAN DONOR
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MANAGEMENT OF BRAIN DEAD DONOR IN ICU
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GENERAL CARE
• Hand hygiene
• Bronchial toilet
• Eye care
• Nasogastric tube insertion
• Arterial and central venous line insertion- preferably
into upper extremities.
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MONITORING
• The brain dead organ donor requires extremely close
monitoring to detect decompensation and treat it urgently. The
following monitors are required at a minimum.
1. Core temperature (Either Nasopharyngeal, esophageal, rectal
or indwelling bladder catheter)
2. ECG
3. SBP (Arterial Catheter)
4. CVP (Subclavian or IJV)
5. Arterial line
6. SpO2
7. Hourly urine output
8. Echocardiography (differential diagnosis of hypotension, and
aids in assessing the suitability of the heart for harvesting).
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ROUTINE INVESTIGATIONS
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• K. Imaging-
1.CXR
2.USG for abdominal organs-liver, kidney, pancreas
l. Microbiology-
i. Surveillance cultures of ET Asp, Blood, urine, any other fluid
eg:ascitic fluid
ii. Viral markers- 1. HBsAg 2. Anti HCV 3. HIV 1&2
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GOALS
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RULE OF 100
• Systolic arterial pressure 100 mm Hg
• PaO2 -100 mm Hg
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The medical management of organ donor can be broadly
divided into
• Management of hemodynamics
• Management of metabolic derangement
• Temperature management
• Management of respiration and hematological parameters
• Nutrition management
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MANAGEMENT OF HEMODYNAMICS
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Hypertension
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HYPOVOLEMIA
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VOLUME EXPANSION
• Crystalloids with balanced salt content so as to avoid
hypernatremia (concurrent DI), hyperchloraemic acidosis
(increases renal vascular resistance, confounds base excess)
when used as resuscitation target.
64
• Albumin solutions (20%, 4%) may be considered to reduce the
amount of volume given, although usually only moderately
effective.
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VASOPRESSORS
• Vasopressin in pressor dose (1-2 U/hr.) plays an important role
in stabilizing the hemodynamic of brain-dead patient.
Vasopressin up to 2.4 units/hour may reduce the requirement
of other ionotropes. ( First choice)
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HORMONAL REPLACEMENT
67
ARRYTHMIAS
68
HORMONAL RESUSCITATION
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METABOLIC DERANGEMENT
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PULMONARY MANAGEMENT
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TEMPERATURE MANAGEMENT
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HEMATOLOGIC MANAGEMENT:
73
INFECTION MANAGEMENT
74
NUTRITION
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SHIFTING TO OR
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PREPARATION OF OT
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ANAESTHETIC MANAGEMENT
• The main aim is to maintain haemodynamic stability for
optimal organ perfusion until organs are retrieved from brain
dead patient.
*Anaesthetic Agents:
1.Inhalational anaesthetics such as Isoflurane and sevoflurane can
cause ischemic preconditioning of organs and this may improve
graft organ function by offering protection against cold and warm
ischemia.
2.Inhalational anaesthetic may have a beneficial effect by causing
peripheral vasodilation.
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OTHER DRUGS
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GOALS OF ANAESTHETIC MANAGEMENT
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BROAD SURGICAL STEPS
82
8.The heart is arrested, the aorta is clamped at the diaphragm, and
the organs are flushed with preservative solution.
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Aishwarya Rai, Amitabh Bachhan, Jaya Bhachhan, Rajnikanth, Amir
Khan and many other film personalities have pledged their Eyes at
different times on media
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