Brain death Present status YDS
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Brain death Present status YDS

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Discusses the present status of Brain Death Concept in Indian Context.

Discusses the present status of Brain Death Concept in Indian Context.

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  • 1. Dr (Brig) YD Singh MBBS, MD, FIACM, DIT Professor (Internal Medicine) SKN Medical College & Gen Hospital Pune 411 041
  • 2. Brain Death
    • Death: An Introduction
      • Genesis of Brain Death concept ?
    • Death definition under Indian Laws
    • What is brain death?
      • Scene in USA
      • Scene in India
    • Causes of Brain Death
    • Brain Death Diagnosis
    • Other Related Terms
      • Permanent Vegetative State
      • Locked in Syndrome
      • Coma
    25 September 2011 Dr (Brig) YD Singh
  • 3. Normal Brain Anatomy 25 September 2011 Dr (Brig) YD Singh Cerebral Cortex Brain Stem Reticular Activating System Receives multiple sensory inputs & Mediates Consciousness (wakefulness)
  • 4. Two Dimensions of Consciousness 25 September 2011 Dr (Brig) YD Singh
  • 5. Cerebral Cortex: Function 25 September 2011 Dr (Brig) YD Singh
    • Cognition
    • Voluntary Movement
    • Sensation
  • 6. Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh
    • Midbrain
      • Cranial Nerve III
        • Pupillary Function
        • Eye Movement
  • 7. Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh
    • Pons
    • Cranial Nerve IV, V, VI
    • Conjugate Eye Movement
    • Corneal Reflex
  • 8. Brain Stem : Functions 25 September 2011 Dr (Brig) YD Singh
    • Medulla
    • Cranial Nerve IX, X
    • Pharyngeal (Gag) Reflex
    • Tracheal (Cough) Reflex
    • Respiration
  • 9. Death : Definition
    • Thanatology
      • Branch of science dealing with study of death
    • Death is the complete and irreversible stoppage of
      • Circulation
      • Respiration
      • Brain function (Tripod of life)
        • As long as oxygenated blood reaches brain stem, Life exists ….
    • Mechanical Ventilator use in ICU
      • Brought concept of “Brain Death”
    25 September 2011 Dr (Brig) YD Singh
  • 10. Brain Death : USA
    • Uniform Determination of Death Act 1981
      • An individual who has sustained either
        • Irreversible cessation of circulatory & respiratory functions, or
        • Irreversible cessation of all functions of the entire brain, including the brain stem, is dead.
      • A determination of death must be made with accepted medical standards .
      • The Act did not define the accepted medical standards
    25 September 2011 Dr (Brig) YD Singh
  • 11. Brain Death : USA
    • The American Academy of Neurology (1995)
      • Published practice parameter to delineate medical standards for the determination of brain death (These are accepted world wide)
    • 3 clinical findings necessary to confirm irreversible cessation of all functions of the entire brain, including brain stem
      • Coma (with a known cause)
      • Absence of brainstem reflexes
      • Apnoea
    25 September 2011 Dr (Brig) YD Singh
  • 12. Death Definition : Indian Laws
    • Registration of Births & Deaths Act 1969
      • Defines death as permanent disappearance of all evidence of life at any time after live-birth has taken place. {Section 2 (1)(b) }
    • Transplantation of Human Organs Act 1994
      • “ Brain-Stem death" Means the stage at which all functions of the brain-stem have permanently and irreversibly ceased and is so certified under sub-section (6) of section 3
    25 September 2011 Dr (Brig) YD Singh
  • 13. Brain Death : Indian Laws
    • Transplantation of Human Organs act, 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 cardiopulmonary sense, at any time after live birth has taken place { Section 2(e) }
    25 September 2011 Dr (Brig) YD Singh
  • 14. Brain Death : India
    • Transplantation of Human Organs act, 1994
      • Brain death needs to be certified by a board of doctors consisting of :
        • Registered Medical Practitioner (RMP) in charge of hospital where brain death has occurred
        • An independent RMP – a specialist
        • A Neurologist / Neurosurgeon nominated by panel
        • RMP treating the patient
      • The patient must be examined by team of doctors at least twice with a reasonable gap of time in between (at least 6 hours)
    25 September 2011 Dr (Brig) YD Singh
  • 15. Brain Death : India
    • Transplantation of Human Organs act, 1994
    • Highlights:
      • Statutary sanction to the Brain Death Concept
      • Regulation of Removal, Storage and Transplantation of human organs for therapeutic purposes
      • Commercial dealings in human organs prevented
    25 September 2011 Dr (Brig) YD Singh
  • 16. Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral Anoxia
  • 17. Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral Haemorrhage
  • 18. Causes: Brain Death 25 September 2011 Dr (Brig) YD Singh Normal Cerebral Trauma
  • 19. Brain Death : Mechanism 25 September 2011 Dr (Brig) YD Singh Neuronal Injury Decreased Intracranial Blood Flow Neuronal Swelling Increased Intracranial Pressure ICP > MAP is incompatible with life
  • 20. Brain Death: Diagnosis
    • 04 Steps to diagnosis
    • (1) Clinical Evaluation (Prerequisites)
      • Establish Known Irreversible Cause of Coma
      • Exclusion of Potentially Reversible Conditions
        • Drug Intoxication or Poisoning
        • Electrolyte or Acid-Base Imbalance
        • Endocrine Disturbances
      • Achieve Body temperature > 36° C
      • Achieve Normal Systolic BP ( > 100 mm Hg)
    25 September 2011 Dr (Brig) YD Singh
  • 21. Brain Death: Diagnosis
    • 04 Steps to diagnosis
    • (2) Clinical Evaluation (Neuro assessment)
      • Establish Coma
      • Establish Absence of Brain Stem Reflexes
      • Establish Apnoea
        • Absence of Respiration drive
    • (3) Ancillary Tests
    • (4) Documentation
      • Time of death is the time the arterial PaCO2 reached the target value OR
      • When ancillary test officially interpreted
    25 September 2011 Dr (Brig) YD Singh
  • 22. Brain Death Neurologic Examination
    • COMA
    • Establish No response to noxious stimulus
      • Nail Bed pressure
      • Sternal Rub
      • Supra Orbital Ridge Pressure
    25 September 2011 Dr (Brig) YD Singh
  • 23. Brain Death Neurologic Examination
    • Absent Brain Stem Reflexes
    • Pupillary Reflex (absent)
    • Eye Movements
      • Occulo-Cephalic ( Dolls Eye Movements)
      • Occulo-Vestibular (Cold Caloric test)
    • Facial Sensation and Motor Response
    • Pharyngeal (Gag) Reflex absent
    • Tracheal (Cough) Reflex Absent
    25 September 2011 Dr (Brig) YD Singh
  • 24. Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Pupils dilated with no constriction to bright light
  • 25. Brain Death Neurologic Examination
    • Occulo Cephalic Response
    • (No Dolls Eye Movements)
    25 September 2011 Dr (Brig) YD Singh
  • 26. Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Occulo-Vestibular Response “ Cold Caloric Testing” Normal Response in Coma No Response in Brain Stem Death
  • 27. Brain Death Neurologic Examination 25 September 2011 Dr (Brig) YD Singh Facial Sensations & Motor Response
    • Absent Corneal Reflex
    • Absent Jaw reflex
    • No response to
    • Supraorbital Or
    • Temporo-Mandibular
    • Pressure
  • 28. Brain Death : Apnoea Test
    • Pre-requisites
      • Body Temperature > 36° C
      • Systolic Blood Pressure ≥ 100 mm Hg
      • Normal Electrolytes profile
      • Normal PaCO2 (35-45 mm Hg)
    • Pre-Oxygenation
      • 100% Oxygen via Tracheal Cannula for 10 min
      • Achieve PaO2 = 200 mm Hg
    • Monitor PaO2 with pulse oximetry
    25 September 2011 Dr (Brig) YD Singh
  • 29. Brain Death : Apnoea Test
    • Reduce Ventilation frequency to 10/min
    • Reduce PEEP to 5 Cm H2O
    • Take 1 st Blood sample for Blood Gas analysis
    • Disconnect Ventilator
    • Deliver 100% O2 by catheter through ET tube
      • @ 6 L/min
    • Observe for Respiratory Movement
      • Atleast for 8 – 10 min
    25 September 2011 Dr (Brig) YD Singh
  • 30. Brain Death : Apnoea Test
    • Discontinue Testing
      • If BP drops to < 90 mm Hg
      • PaO2 to 85% by pulse Oxymetry for 30 Sec
    • If no respiratory drive observed after 08 min
      • Take next Blood sample for Blood gas studies
    • If respiratory movements are absent & arterial PaCO2 is 60 mm Hg OR
      • 20 mm Hg over a baseline normal PaCO2
    • The Apnea test result is POSITIVE
      • Supports the clinical diagnosis of brain death
    25 September 2011 Dr (Brig) YD Singh
  • 31. Brain Death Ancillary Confirmatory Testing
    • Recommended when
      • Proximate cause of coma is not known or
      • When confounding clinical conditions limit clinical examination
    • EEG
    • Cerebral Angiography
    • PET : Glucose Metabolic Studies
    • Dynamic Nuclear Scan
    • Somato-Sensory Evoked Potential
    25 September 2011 Dr (Brig) YD Singh
  • 32. Brain Death Confirmatory Testing 25 September 2011 Dr (Brig) YD Singh Electro-Cerebral Silence Normal EEG
  • 33. Brain Death Confirmatory Testing 25 September 2011 Dr (Brig) YD Singh No Intra- Cranial Flow Normal Cerebral Angiography
  • 34. PET Glucose Metabolism Studies 25 September 2011 Dr (Brig) YD Singh “ Hollow-skull sign” of brain death Cerebral metabolism globally reduced ~50% Normal Nature Rev Neurosci 2005;6:899-909
  • 35. Dynamic Nuclear Brain Scan 25 September 2011 Dr (Brig) YD Singh “ Hollow-skull sign” of brain death NEJM 2001;344:1215-1221
  • 36. Conditions Distinct from Brain Death
    • Coma
    • Persistent Vegetative State
    • Locked in Syndrome
    25 September 2011 Dr (Brig) YD Singh
  • 37. Coma
    • It is a sleeplike state from which patient cannot be aroused
      • It is sleep like because
        • Eyes remain closed
        • Patient is NOT aroused even by painful stimuli
    • We can simplify Coma by saying:
      • A state lacking Wakefulness and Awareness
    25 September 2011 Dr (Brig) YD Singh
  • 38. Persistent Vegetative state
    • Patient out of Coma and appears awake
      • Follows Normal Sleep-Wake Cycles
    • No Response to Environmental Stimuli
      • Not Aware of surroundings
    • Preservation of Brain Stem Function
    • Cause :
      • Diffuse Brain Injury
    25 September 2011 Dr (Brig) YD Singh
  • 39. Persistent Vegetative state 25 September 2011 Dr (Brig) YD Singh Aruna Ramachandra Shanbag Mumbai
  • 40. Locked in Syndrome 25 September 2011 Dr (Brig) YD Singh Ventral Pontine Infarct
    • Complete Paralysis
    • Consciousness is
    • Preserved
    • Preserved Eye
    • Movement
  • 41. Brain Death Conclusions
    • In the U.S., Brain death is considered death for all purposes
    • In India Brain death is defined in Organ transplantation act only
      • It is Debatable if Brain Death applicable for non organ donation?
    • We need to have Uniform Declaration of Death legislation like US to settle the issue
    25 September 2011 Dr (Brig) YD Singh
  • 42. Brain Death Conclusions
    • PVS Patient is not dead
      • In a state of wakefulness without awareness
    • Ancillary tests (EEG, PET) can help distinguish Coma, PVS & Locked-in state from Brain Death
    25 September 2011 Dr (Brig) YD Singh
  • 43. Brain Death : Present Status
    • Hippocrates said this long ago
    • (The Hippocratic Corpus)
    • “ First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless”.
    25 September 2011 Dr (Brig) YD Singh
  • 44. Thanks !! 25 September 2011 Dr (Brig) YD Singh