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 Brain Death And Organ Donation

Dr Praveen K Tripathi25 January 2017

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Historical Perspective 1959 Coma de’passe’ (Fr.- a state beyond coma) Mollaret and Goulon

1968 Irreversible Coma/Brain Death Harvard Medical School Ad Hoc Committee

1981 Uniform Determination of Death Act - President’s Commission

for the Study of Ethical Problems in Medicine

1994 American Academy of Neurology Guidelines for the determination of Brain Death

1994 India, Transplantation of Human Organs Act [TOHO (Sub section 6 of Section 3)]

2005 NYS Guidelines for Determining Brain Death25 January 2017

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Historical Perspective

Prior to the advent of mechanical respiration, death was defined as the cessation of

circulation and breathing

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Death“An 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. “

Uniform Determination of Death Act (UDDA)

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Mechanism of Cerebral Death

Increased Intracranial Pressure

ICP>MAP is incompatible with life

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WHY TEST?

Where Brain Stem Death (BSD) is suspected, it is highly desirable to confirm this by Brain Stem Testing:

• To eliminate all possible doubt regarding survivability

• To confirm diagnosis for families• In cases subject to medico-legal scrutiny• To provide choice regarding organ donation

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Physiologic Changes with Brain Death

Neurologic

Cardiovascular

Pulmonary

EndocrineHypothermia

MetabolicProinflammatory

state

Death is a continuous ongoing process, not an isolated event. Total loss of neurophysiological functions of the brain for more than 8 minutes confirms the total and irreversible loss of brain function.

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A determination of death must be made with accepted medical standards

The American Academy of Neurology (AAN) published a 1995 practice parameter to delineate the medical standards for the determination of brain death.

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

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Who - pronouncesIn India, according to the Transplantation of Human Organs Act

[TOHO 1994 (Sub section 6 of Section 3)], “Brainstem death” means the stage at which all functions of the brainstem have permanently and irreversibly ceased and is so certified by a “Board of Medical Experts” consisting of:

The Medical Superintendent (MS) in charge of the hospital in which “brainstem” death has occurred.

A specialist, nominated by the MS in charge of the hospital, from a panel of names approved by the Appropriate Authority.

A neurologist or neurosurgeon, nominated by the MS in charge of the hospital, from a panel of names approved by the appropriate authority.

The doctor under whose care the “brain-stem” death has occurred.25 January 2017

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Steps in Determining Brain Death

Clinical diagnosis of brain death should be performed in three steps

1.Establishing the etiology of disease2.Excluding certain potentially reversible

syndromes that may produce signs similar to brain death

3.Demonstrating clinical signs of brain death• Coma• Brainstem areflexia• Apnea

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Steps in Determining Brain Death

Brain death should not even be thought of until the following reversible causes of coma have been excluded:

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.25 January 2017

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Irreversible Cause of Death

Neurological assessments may be unreliable in the acute post-resuscitation phase after cardiorespiratory arrest.

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.

Core temperature MUST be ≥ 34°C to proceed with formal testing. Central blood, rectal or esophageal–gastric Previously was 32.2°C

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Brain Death Exam Brainstem

Pupils▪ ≥4-9mm, unresponsive to light* (enquire about Rx given)

Corneals▪ Movement of jaw or lids excludes NDD

Vestibulo-ocular responses▪ OCR (Doll’s)

▪ Caution if trauma▪ Cold calorics

Pharyngeal▪ Stimulate posterior pharynx▪ Suction the ETT▪ Depress larynx, swallow reflex

Apnea test

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Vestibulo-ocular Response

Mechanical / gravitational forces stimulate vestibular

responses

Doll’s Eyes (oculo-

cephalic)

Cold CaloricsThermal energy

stimulates vestibular responses

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Doll’s Eyes Normal response = eyes always

gaze up towards roof Rapid, but steady movements and

observe for direction of gaze Activates vestibular system

ipsilateral to head thrust▪ Communicates with contralateral

horizontal gaze center (CN VI) “orchestrating” the action of the eyes

▪ Simultaneously dampens contralateral vestibular tone, etc.

Avoided in the setting of a patient with questionable stability of the cervical spine

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Cold Calorics 30° to the horizontal Minimum of 50cc of ice cold water into the inner

ear canal Ensure no perforated tympanic membrane before

instilling water Use kidney basin, prop up beside ear

Start observing for eye deviation rapidly; eye movements should be absent for 1 minute

Minimum of 5 minutes before evaluating contralateral side

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Cold Caloric TestingVestibulo-Ocular Reflex (VOR)

Attenuates resting state vestibular tone

Slow phase

Pearl: COWS mneumonic implies intact cortex (frontal eye fields). If on coma / sedated, will not get corrective nystagmus.

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Apnea Test

Prerequisites Normal core body temperature Systolic Blood Pressure > 90 Normal PaCO2 (~35-45 mm Hg)

▪ So, draw ABG right before starting the test. Absence of any other underlying conditions that

could confound diagnosis by mimicing brain death or suppressing respiratory drive

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Performing the Apnea Test Pre-oxygenate with 100% Oxygen for 30 min. Connect a pulse-ox, then disconnect ventilator. Place a nasal cannula at the level of the carina;

give 100% Oxygen at 6-8L/min. during test. Watch closely for respiratory movements (any

abdominal or chest movement that represents respiratory effort)

Draw ABG ~10 minutes and reconnect ventilator.

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Interpreting the test

The apnea test is POSITIVE (i.e., supports the diagnosis of brain death) if: There are no respiratory efforts during the test

AND Repeat ABG shows PCO2 > 60 mm Hg.

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Interpreting the test

The apnea test is INDETERMINATE if: after 10 minutes, the patient demonstrates no

respiratory effort, but the PCO2 is < 60 mm Hg. The apnea test is NEGATIVE (i.e., does NOT

support the diagnosis of brain death) if: the patient demonstrates any respiratory effort at any

time during the test.▪ Cease the test and reconnect the ventilator immediately upon

observing respiratory effort.

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The Apnea Test

If the patient becomes unstable at any point during the Apnea Test (i.e. SBP drops less than 90, significant desaturation on pulse-oximetry, observance of cardiac arrhythmias, etc.), the test should be aborted. The Apnea Test should not “induce a code!”

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Apnea Test (if lung disease)

If severe lung disease Caution must be exercised in considering the

validity of the apnea test If in the physician’s 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.

If the physician cannot be sure of the validity of the apnea test, an ancillary test should be administered.

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Ancillary Testing The term “ancillary” should be understood to

mean an alternative test to one that otherwise, for any reason, cannot be conducted. No longer called “confirmatory” or “supplemental” Different connotations

Gold standard = global absence of intracerebral blood flow (only 2 tests support) Cerebral angiography or radio-isotope scan

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Cerebral Angiography No intracerebral filling at the level of the carotid

bifurcation or circle of Willis. The external carotid circulation is patent, and filling

of the superior longitudinal sinus may be delayed.

NormalNo Intracranial Flow

Accepted Ancillary Test(s)

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Accepted Ancillary Test(s)

Normal Brain Death

Isotope scan: •Technetium-99m hexamethyl propylene amine oxime brain scan shows no uptake of isotope in brain parenchyma (“hollow skull phenomenon”).•Radionuclide cerebral scanning cannot document absence of flow in the vertebrobasilar circulation.

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PETGlucose Metabolism Studies

“Hollow-skull sign” of brain death Cerebral metabolism

globally reduced ~50% Normal

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Insufficient Ancillary Testing

Transcranial Doppler ultrasonography: Assessment Subcommittee of the American Academy

of Neurology has accepted transcranial Doppler ultrasonography as a reliable procedure for confirmation of brain death.

Transcranial Doppler is subject to technical problems. 10% of patients may not have temporal insonation

windows. Therefore, the initial absence of Doppler signals

cannot be interpreted as consistent with brain death25 January 2017

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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.

By contrast, EEGs don’t always “confirm” brain death. There can be minor transient EEG activity even in the

setting of clinical brain death. Electrical artifacts on EEG in the ICU setting have

been described.

Insufficient Ancillary Testing

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MR- Angiography

Insufficient Ancillary Testing

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Somatosensory Evoked Potentials

Insufficient Ancillary Testing

In studies of patients with brain death, most patients had no responses to tests for somatosensory and brain stem auditory evoked potentials.It is therefore useful in distinguishing isolated brainstem death from high cervical transverse cord lesions and focal bilateral lemniscal lesions.

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Confirmatory tests

Key to understand is that none of these “confirmatory tests” is sufficient, in and of itself, to diagnose brain death.

They are merely adjuncts.

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Special Circumstances- children

Children should be the same as those in adults. All these tests may be carried out twice, at an interval

of at least 6 hours according to the internationally accepted protocol.

As children are more resilient than adults, a longer time between assessments has been advocated and this varies according to patient’s age as follows:

Term to 2 months old—48 hours Greater than 2 months to 1 year old—24 hours Greater than 1 year to less than 18 year old—12 hours Greater than 18 year old—interval optional.

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Clinical Evaluation: Unresponsiveness

The patient must demonstrate no response to any stimulation. Spontaneous movement is almost always absent.

Seizures, shivering, any posturing, etc., indicates brainstem function and is not consistent with the determination of brain death.

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.

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Conditions Distinct From Brain Death

Persistent Vegetative State

Locked-in Syndrome

Minimally Responsive State

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Persistent Vegetative State

Normal Sleep-Wake Cycles

No Response to Environmental Stimuli

Diffuse Brain Injury with Preservation of Brain Stem Function

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Locked-in Syndrome

Ventral Pontine Infarct

Complete Paralysis

Preserved Consciousness

Preserved Eye Movement

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Minimally Responsive State

Diffuse or Multi-Focal Brain Injury

Preserved Brain Stem Function

Variable Interaction with Environmental Stimuli

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Observations Compatible with Brain Death

Sweating, Blushing

Deep Tendon Reflexes

Spontaneous Spinal Reflexes- Triple Flexion

Babinski Sign

Motor responses (“Lazarus sign”) 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

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Final Thought

Remember that the clinical exam is the cornerstone of brain death determination, and there is no test or substitute for an examiner’s judgment and skills.

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Organ donation

Organ donation has been one of the greatest advances of modern science that has resulted in many patients getting a renewed lease of life.

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.

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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.

www.gather2share.org

Organ Donation

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Outcome

Common outcome Outcome Can be Changed

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What is need?

Corneal blindness is very common in India.

More than 3 million cases in India.

60% are <12 years age group.

Only 1.5 lakh/year corneal donations in India.25 January 2017

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What is need?

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Types of organ donation

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.

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What Can be Donated by living donor?

Kidney

Blood

Lungs

Part of liver Liver

Part of Pancreas

Living Donor

Bone marrow25 January 2017

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Commonly donated organs from brain death are –kidney ,cornea ,heart, lung, liver, pancreas, skin.

Cadeveric donar-Tissues may be recovered from donors up to 24 hours past the cessation of heartbeat.

Cadeveric donar are major source of organs and tissues.

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Brain 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. Most cases of brain death are the end result of head injuries or brain tumor patients from Intensive care units.  

www.gather2share.org

Organ Donation- types

It is possible to donate all organs in the case of Brain death.

Brain Death

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Due to the lack of circulation of blood the vital organs quickly become unusable for transplantation. 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.

www.gather2share.org

Such donations typically take place in the operating room.

Organ Donation- types

Cardiac Death

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Almost everywhere organ donation is voluntary- tTwo voluntary systems include –

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

Organ Donation- types

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Consent for Organ donation

A patient’s previously expressed preferences for organ donation are paramount. ICU clinicians and coordinator/ ZCCK should retrieve proof of such authorisation.

Another clause in from 8 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 RetrievalFirst declaration 6 hours interval

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Current status of organ donation act-

It is proposed to amend the THO Act by changing its name from ‘Transplantation of Human Organs Act’ to ‘Transplantation of Human Organs & Tissues Act’

Law will broaden the definition of ‘near relative’ to include grandparents, grandchildren, uncles and aunts.

Also, not-so-close relatives who have stayed with the patient can donate organs, provided there is no commercial dealing.

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Organ donation algorithm

Hospital Organ Donation Registry (HODR)coordinates the process of cadaver organ donation

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

The organ donor form could be obtained from HODR either personally or through mail

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Contraindications to donation

Hepatitis B or Hepatitis C may be acceptable for

HBV/C recipients

IV drug abuse or practicing homosexual

Untreated bacterial, fungal or viral infection (treated

infection may be considered)

Malignancies other than primary brain tumours and

nonmelanoma skin cancers 25 January 2017 56

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ICU Management of the Brain Dead Potential Donor

Stabilize profound physiologic and homeostatic derangements provoked by BD

Balance competing management priorities between different organs

Avert somatic death and loss of all organs

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Hemodynamic changes with BD

10-20% donors are lost to cardiovascular collapse as patient evolves to brain death

Volume Depletion in BD Causes multifactorial

Underlying medical condition – blood loss, etc Prior management – osmotic therapy for ICP Neuro-hormonal cascade Capillary Leak Diabetes Insipidus

50% of potential BD donors are volume responsiveMuragan, CCM, 200925 January 2017

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Critical care management of potential organ donors is crucial in maximizing the number and the quality of

transplanted organs

Goal is to provide adequate oxygen supply and tissue perfusion – Target MAP : 65-75

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Organ Preservation Time

Heart: 4-6 hours Lungs: 4-6 hours Liver: 12 hours Pancreas: 12-18

hours Kidneys: 72 hours Small Intestines: 4-6

hours

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Religious Views: Hinduism

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Religious Views:Islam Until early 90s the religious leaders failed to approve of

organ donation Mid 90s the religious leader in saudi (mecca) passed a fatwa,

making organ donation after death permissible under islamic law

Christian Catholics view organ donation as an act of charity Ethically and morally acceptable to the vatican Pope john paul II has given his support to organ donation

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Overall Religious Views

All other major religions such as Sikhism, Buddhism and Jainism do not oppose organ donation and share similar views as that of hinduism

LIFE IS AMAZING… PASS IT ON…!!!

Religious Views:

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Positive Changes

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 and Madhavan have endorsed their views on multi-organ donation25 January 2017

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Give life to others once you are no more

www.gather2share.orgTHANKYOU

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