Brain death


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Brain death

  1. 1. Brain Death Dr. Abhijeet Deshmukh Dept. of Pediatrics Pushpagiri Institute of Medical Sciences & RC Tiruvalla , Kerala.
  2. 2. • Definition: The irreversible cessation of all functions of the entire brain, including the brainstem. also known as the determination of death using neurologic criteria
  3. 3. Diagnostic Guidelines • For children - published in 1987 by a Special Task Force to the American Academy of Pediatrics (Not revised yet) • For adults - by the American Academy of Neurology in 1995.
  4. 4. Clinical diagnosis • Key components : 1. Demonstrations of irreversible coma/unresponsiveness, 2. Absence of brainstem reflexes 3. Apnea
  5. 5. • Before diagnosis of B.D, rule out cause of the coma by historical, radiologic, and laboratory data to rule out a reversible condition.
  6. 6. • Causes of irreversible coma : Severe head injury, hypertensive intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage,  hypoxic-ischemic brain insults and fulminant hepatic failure.
  7. 7. • Causes of reversible coma :  metabolic disorders,  toxins,  sedative drugs,  paralytic agents,  hypothermia,  hypoxia,  hypotension/shock,  hypoglycemia/hyperglycemia,  hyponatremia/hypernatremia,  hypercalcemia,
  8. 8.  hypermagnesemia,  nonconvulsive status epilepticus, hypothyroidism,  hypocortisolism,  hypercarbia,  liver or renal failure,  sepsis, meningitis, encephalitis,  SAH,  surgically remediable brainstem lesions
  9. 9. • Apnea : clinically confirmed through the apnea test. • performed only if the first 2 criteria for brain death(irreversible coma and absence of brainstem reflexes) are already confirmed.
  10. 10. • Procedure : Preoxygenate the patient with 100% oxygen for approximately 10 min adjust ventilation to achieve a PCO2 of about 40 mm Hg • During the test, oxygenation is maintained on CPAP and 100% oxygen by means of the ventilator circuit or a resuscitation bag such as a Mapleson device,
  11. 11. • Child is assessed for breathing efforts through observation and auscultation. • A blood gas sample is obtained approximately 10 min into the test and every 5 min thereafter until the target PCO2is surpassed; ventilatory support is resumed at that time.
  12. 12. • If at any point during the test the patient becomes hypoxic or hypotensive, the test is aborted and ventilatory support is resumed. • Absence of respiratory efforts with a PCO2 > 60 mm Hg or more than 20 mm Hg above an elevated baseline value is consistent with brain death.
  13. 13. Observation Period Varies by age : • 7 days- 2 mo: 2 examinations separated by at least 48 hr. • 2 mo - 1 yr : 2 examinations separated by at least 24 hr are recommended. • >1 yr : 12-hr observation period between exams.
  14. 14. If the cause of the coma is hypoxicischemic brain injury and the first exam is performed shortly after the insult, a period of at least 24 hr is recommended before the second exam. A second exam is not needed if a nuclear medicine cerebral flow scan demonstrates absence of CBF.
  15. 15. Confirmatory Tests • All children <1 yr of age. • Where clinical exam is impossible to perform or the results are suspected to be unreliable. • The 2 most commonly used confirmatory tests are : - EEG and - Studies to confirm the absence of CBF eg. nuclear medicine cerebral flow scans.
  16. 16. • An EEG showing electrocerebral silence over a 30-min supports the diagnosis of brain death. • Advantages : wide availability and low risk. • Disadvantages : artefact in the presence of drugs like barbiturates
  17. 17. • Nuclear medicine cerebral flow scan : Intravenous injection of a radiopharmaceutical agent followed by imaging of the brain Absence of uptake in the brain demonstrates absence of CBF and is confirmatory of brain death Advantages : low risk, not affected by drug levels.
  18. 18. Documentation 1 Etiology and irreversibility of the coma 2 Absence of confounding factors: hypothermia, hypotension, hypoxia, significant metabolic derangement, significant drug levels 3 Absence of motor response to noxious stimulation 4 Absence of brainstem reflexes: pupillary light reflex, oculocephalic/oculovestibular reflex, corneal reflex, cough and gag reflex 5 Absence of respiratory effort in response to an adequate stimulus; blood gas values should be documented at the beginning and end of the apnea test
  19. 19. Supportive Care • supportive care may continue for hours to days as the family makes decisions about potential organ donation and comes to terms with the diagnosis.
  20. 20. • Refereance – Nelson Textbook of Pediatrics 19 th edition.
  21. 21. Thank You !