Brain death presented by anaesthesiologist

how to assess brain death

1. BRAIN DEATHBRAIN DEATH
Dr. Norsham KhairatiDr. Norsham Khairati
Dept. of Anaesthesiology and ICU Dept. of Anaesthesiology and ICU
Hospital Raja Permaisuri BainunHospital Raja Permaisuri Bainun

2. Death of a person Death of a person
Cardiac deathCardiac death
irreversible cessation of circulation of blood in irreversible cessation of circulation of blood in
the body of the personthe body of the person
Brain deathBrain death
irreversible cessation of all function of the irreversible cessation of all function of the
brain of the personbrain of the person

3. Brain Death – Historical PerspectivesBrain Death – Historical Perspectives
19561956 – Lodstedt & Von Reis 1 – Lodstedt & Von Reis 1
stst
described described
ventilated patients with absent brainstem ventilated patients with absent brainstem

reflexes, absent cerebral blood flow and reflexes, absent cerebral blood flow and
cerebral necrosiscerebral necrosis
19591959 – “ le coma de passe “ – “ le coma de passe “
by Mollaret & Goulon by Mollaret & Goulon
defined death by neurologic criteriadefined death by neurologic criteria

4. 1968 –Harvard Criteria1968 –Harvard Criteria
Defines death Defines death
- irreversible loss of all brain function- irreversible loss of all brain function
Unreceptivity Unreceptivity
No movements or breathingNo movements or breathing
No reflexesNo reflexes
Flat EEGFlat EEG
All repeated at least 24 hrs with no changeAll repeated at least 24 hrs with no change
Exclusion of hypothermia ( <32.2Exclusion of hypothermia ( <32.2
00
C ) or centralC ) or central
nervous depressantsnervous depressants

5. 19711971 Mohandas & ChouMohandas & Chou
- state of irreversible damage to brainstem - state of irreversible damage to brainstem
- irrelevance of EEG - irrelevance of EEG
Minnesota CriteriaMinnesota Criteria
Known irreparable intracranial lesionKnown irreparable intracranial lesion
Metabolic factors ruled outMetabolic factors ruled out
No spontaneous movementNo spontaneous movement
Apnoea ( 4 mins )Apnoea ( 4 mins )
Absent brainstem reflexesAbsent brainstem reflexes
All findings unchanged after 12 hoursAll findings unchanged after 12 hours

6. Brain Death – Historical PerspectivesBrain Death – Historical Perspectives
1976 – UK “ Diagnosis of Brain Death “1976 – UK “ Diagnosis of Brain Death “
1995 – Concept of brain stem death in UK1995 – Concept of brain stem death in UK
1993 – Malaysian consensus on Brain Death1993 – Malaysian consensus on Brain Death
Dx of brain death now accepted throughout the Dx of brain death now accepted throughout the
worldworld

7. Brain deathBrain death
Accounts for 2-4% of all hospital deathsAccounts for 2-4% of all hospital deaths
13-15 % of deaths in Neurosurgical ICU13-15 % of deaths in Neurosurgical ICU

8. DefinitionDefinition
Death of the whole brain including the brain Death of the whole brain including the brain
stemstem
Absence of brainstem function Absence of brainstem function
Deep coma ( GCS 3 ) Deep coma ( GCS 3 )
Apnoeic , on ventilatorApnoeic , on ventilator
Known cause of irreversible brain injury / Known cause of irreversible brain injury /
pathologypathology
Other reversible causes of coma excludedOther reversible causes of coma excluded

9. Underlying causes of Brain DeathUnderlying causes of Brain Death
Intracranial injury : bleed / cerebral oedemaIntracranial injury : bleed / cerebral oedema
Spontaneous bleed : HypertensiveSpontaneous bleed : Hypertensive
AVM / AneurysmAVM / Aneurysm
Cerebral Infarct / ThrombosisCerebral Infarct / Thrombosis
TumoursTumours
Hypoxia Hypoxia
Viral infection (encephalitis ) Viral infection (encephalitis )
– – cerebral oedemacerebral oedema

10. Brain DeathBrain Death
Pathophysiological changes that follow Pathophysiological changes that follow
brain death occur irrespective of the brain death occur irrespective of the
cause of the brain deathcause of the brain death
Added to that are the other changes Added to that are the other changes
that were already present prior to brain that were already present prior to brain
death which were associated with the death which were associated with the
causal pathology causal pathology

11. Brain DeathBrain Death
Is inevitably followed by the death of the Is inevitably followed by the death of the
rest of the person within a few days rest of the person within a few days
Progressive deterioration of all the Progressive deterioration of all the
organs unless measures to maintain organs unless measures to maintain
and preserve the organ functions are and preserve the organ functions are
initiated as soon as brain death is initiated as soon as brain death is
diagnosed.diagnosed.

12. Brain DeathBrain Death
 Failure to maintain internal homeostasis Failure to maintain internal homeostasis
following the loss of brain stem functionsfollowing the loss of brain stem functions
Loss of spontaneous respirationLoss of spontaneous respiration
Loss of cardiovascular controlLoss of cardiovascular control
Loss of temperature controlLoss of temperature control
Loss of control of fluid and electrolyte balanceLoss of control of fluid and electrolyte balance
Loss of hormonal balanceLoss of hormonal balance

13. Brain Death CertificationBrain Death Certification
2 specialists trained in brain death testing - usually 2 specialists trained in brain death testing - usually
anaesthetist, neurologist, neurosurgeon, not involved in anaesthetist, neurologist, neurosurgeon, not involved in
transplantationtransplantation
2 tests performed by each specialist 2 tests performed by each specialist
Period of observation between tests – 6 hours apartPeriod of observation between tests – 6 hours apart
Test for brain stem function (cranial nerves function) and Test for brain stem function (cranial nerves function) and
cardiorespiratory centres including apnoea testcardiorespiratory centres including apnoea test
Brain death confirmed when second set of tests Brain death confirmed when second set of tests
completed by both specialistscompleted by both specialists

14. Brain Death DiagnosisBrain Death Diagnosis
1. 1. Severe and irreparable structural brain Severe and irreparable structural brain
damagedamage
ANDAND
2. Irreversible coma2. Irreversible coma
AND AND
3. (a) Irreversible loss of brain stem reflexes and 3. (a) Irreversible loss of brain stem reflexes and
respiratory function ( apnoeic )respiratory function ( apnoeic )
OROR
(b) Cessation of intracranial blood flow(b) Cessation of intracranial blood flow

15. Exclusion CriteriaExclusion Criteria
Drug intoxication / Sedative drug effectsDrug intoxication / Sedative drug effects
Neuromuscular blockadeNeuromuscular blockade
Endocrine and metabolic disturbancesEndocrine and metabolic disturbances
Severe Guillian Barre SyndromeSevere Guillian Barre Syndrome
SnakebiteSnakebite
Locked in stateLocked in state
Hypothermia ( < 35Hypothermia ( < 35
0 0
C )C )

16. NoteNote
At least six hours of therapy and At least six hours of therapy and
observation must be carried out prior observation must be carried out prior
diagnosing brain deathdiagnosing brain death
Post cerebral protection, brain death test Post cerebral protection, brain death test
can only be done after sedative drugs can only be done after sedative drugs
have stopped > 24 hourshave stopped > 24 hours

17. For BD test to be doneFor BD test to be done
NormotensiveNormotensive
Temp > 35Temp > 35
oo
CC
No acidosisNo acidosis
NormoglycemiaNormoglycemia
Normal electrolytes levelsNormal electrolytes levels
Needs close monitoring, difficult to do in Needs close monitoring, difficult to do in
general ward settinggeneral ward setting

18. Brain Death TestBrain Death Test
ClinicalClinical bedside testing of brainstem bedside testing of brainstem
functionfunction

21. Spinal reflexes
( Lazarus sign )

22. Brain Death TestBrain Death Test
Absence of reflex motor responses within the cranial Absence of reflex motor responses within the cranial
nerve distribution – e.g grimacing with supra-orbital nerve distribution – e.g grimacing with supra-orbital
pressurepressure

23. Brain Death TestBrain Death Test
Bilaterally fixed pupils with no response to strong lightBilaterally fixed pupils with no response to strong light
Need not be dilated Need not be dilated
Pitfall :Pitfall : Local eye trauma Local eye trauma
Unilateral signs Unilateral signs

24. Absent oculo-cephalic (doll’s eyes) reflex Absent oculo-cephalic (doll’s eyes) reflex
Pitfall :Pitfall : suspected cervical spine # suspected cervical spine #

25. Brain Death TestBrain Death Test
Absent corneal reflexes in response to firm Absent corneal reflexes in response to firm
pressure on the cornea using a cotton wool pressure on the cornea using a cotton wool
swabswab

26. Brain Death TestBrain Death Test
Absent vestibulo-ocular reflexes ( caloric response )Absent vestibulo-ocular reflexes ( caloric response )
no nystagmus ( eye movements) in response to stimulation no nystagmus ( eye movements) in response to stimulation
of the ear drum with 50 mls of ice cold waterof the ear drum with 50 mls of ice cold water
Pitfall :Pitfall :
needs intact tympanic membraneneeds intact tympanic membrane
inaccurate in presence of blood/ csf/ wax in ear canal inaccurate in presence of blood/ csf/ wax in ear canal

27. 
Absent gag and tracheo-bronchial reflexesAbsent gag and tracheo-bronchial reflexes

28. Brain Death TestBrain Death Test
Apnoea Test Apnoea Test

to be done only after and if the other tests showed no to be done only after and if the other tests showed no
response as the consequent hypercarbia and hypoxia response as the consequent hypercarbia and hypoxia
can worsen ICPcan worsen ICP

involves disconnecting patient from ventilator, ensuring involves disconnecting patient from ventilator, ensuring
that the PaCOthat the PaCO
22 is raised above the threshold ( 60 mmHg is raised above the threshold ( 60 mmHg
) required to stimulate the respiratory centre and ) required to stimulate the respiratory centre and
observing for respiratory movementsobserving for respiratory movements
Pitfall Pitfall :: difficult to do in the presence of bad lungs difficult to do in the presence of bad lungs

30. Brain Death Test Brain Death Test
Apnoea TestApnoea Test
Ventilate patient with 100% FiO2 for 10-20 Ventilate patient with 100% FiO2 for 10-20
mins prior doing apnoea test, and keep PaCO2 mins prior doing apnoea test, and keep PaCO2
at 35-40 mmHgat 35-40 mmHg
Disconnect patient from ventilator. Deliver 6 Disconnect patient from ventilator. Deliver 6
l/min O2 via a tracheal catheter. Monitor SpO2 l/min O2 via a tracheal catheter. Monitor SpO2
and BP / HRand BP / HR
Estimate period of disconnection required to Estimate period of disconnection required to
bring PaCO2 to 60mmHg ( note PaCO2 bring PaCO2 to 60mmHg ( note PaCO2
rises by 3mmHg/min ) or do ABG at 5 and 10 rises by 3mmHg/min ) or do ABG at 5 and 10
minsmins

31. Brain Death Test Brain Death Test
Apnoea TestApnoea Test
No respiratory movements when PaCO2 is > No respiratory movements when PaCO2 is >
60mmHg consistent with brain death60mmHg consistent with brain death
Reventilate when desaturation occurs or PaCO2 Reventilate when desaturation occurs or PaCO2
reaches 60mmHgreaches 60mmHg
Test abandoned if any respiratory movements, Test abandoned if any respiratory movements,
vital signs destabilise, cyanosis, ventricular vital signs destabilise, cyanosis, ventricular
arrythmias or ECG ST depression occurs arrythmias or ECG ST depression occurs

32. Brain Death Test Brain Death Test
Apnoea TestApnoea Test
COAD patients with pre-existing hypercarbiaCOAD patients with pre-existing hypercarbia
No respiratory effort when PaCO2No respiratory effort when PaCO2
increases by > 20mmhg of baseline increases by > 20mmhg of baseline

33. Brain Death AssessmentBrain Death Assessment
Supportive TestsSupportive Tests
Four vessel intracranial angiogramFour vessel intracranial angiogram
Brain perfusion scanBrain perfusion scan
Transcranial Doppler studiesTranscranial Doppler studies
EEGEEG

34. Brain death = deathBrain death = death
On confirmation of brain death, death On confirmation of brain death, death
certificicate is signedcertificicate is signed
Time of death is the time of certification of Time of death is the time of certification of
brain death not at time of asystolebrain death not at time of asystole
Ventilator switched offVentilator switched off

35. 3rd International Conference of Islamic Jurists3rd International Conference of Islamic Jurists
( OIC ) held in Amman Oct 1986 ( 1407) ( OIC ) held in Amman Oct 1986 ( 1407)
A person is pronounced legally dead and consequently all A person is pronounced legally dead and consequently all
dispositions of the Islamic law in case of death apply if one ofdispositions of the Islamic law in case of death apply if one of
 the two following conditions has been established :the two following conditions has been established :
There is total cessation of cardiac and respiratory functions , and There is total cessation of cardiac and respiratory functions , and
doctors have ruled that such cessation is irreversibledoctors have ruled that such cessation is irreversible
There is total cessation of all cerebral functions and experienced There is total cessation of all cerebral functions and experienced
specialised doctors have ruled that such cessation is irreversible specialised doctors have ruled that such cessation is irreversible
and the brain has started to disintegrateand the brain has started to disintegrate
In this case , it is permissible to take the person offIn this case , it is permissible to take the person off
 resuscitation apparatus , even if the functions of some organsresuscitation apparatus , even if the functions of some organs
 e.g heart, are still artificially maintained e.g heart, are still artificially maintained

36. Majlis Fatwa Kebangsaan telah mengharuskan
penggunaan kaedah pemindahan organ pada
bulan Jun 1970
Dari sudut Islam, pemindahan organ diharuskan Dari sudut Islam, pemindahan organ diharuskan
dengan syarat:dengan syarat:
(i) Tidak ada alternatif lain yang boleh (i) Tidak ada alternatif lain yang boleh
menyelamatkan nyawa pesakitmenyelamatkan nyawa pesakit
(ii) Tidak mendatangkan mudarat yang lebih (ii) Tidak mendatangkan mudarat yang lebih
besar kepada penderma atau penerima organbesar kepada penderma atau penerima organ

37. (iii) Pendermaan organ dilakukan dengan ikhlas (iii) Pendermaan organ dilakukan dengan ikhlas
dengan niat untuk membantu kerana Allah s.w.t.dengan niat untuk membantu kerana Allah s.w.t.
(iv) Organ tidak diperniagakan.(iv) Organ tidak diperniagakan.
(v) Pendermaan organ mendapat keizinan (v) Pendermaan organ mendapat keizinan
penderma dan ahli keluarganya atau warisnya.penderma dan ahli keluarganya atau warisnya.

38. Thank You Thank You