3. Introduction
Death is an irreversible,
biological event that
consists of permanent
cessation of the critical
function of the organism as
a whole, especially
respiration and heartbeat.
Brain death is an
irreversible form of
unconsciousness
characterized by a loss of
brain function while the
4. Historical-
What is
death?
Various Descriptions
• Apnoea, unresponsiveness,
immobility
• Followed by decay
• When ‘life’ or ‘the spirit’ departed
from the body
A state after the end of life
Immense cultural, religious,
mystical significance
6. History
• The loss of consciousness proceeds the
respiratory and cardiopulmonary failure.
• Death of brain results in death of all other
organs.
Modern concept…
• The functions of brain cells can be taken
over by the technology even after the
brain death
• Supporting life v/s A corpse with beating
heart
Dilemma!!!!!
7. There is a need…!!!
To define death.
To determine a point on the timeline of the
death process that defines no return to life.
To harvest the organs before the
destruction.
8. The biology of death
Understanding possible after Harvey described the
circulation of blood and the pump function of the
heart
“…the heart is the principle of life…from
which heat and life are dispersed to all
parts…”
Death when the heart and circulation
stopped
9. Brain death?
The Death of the brain, while the circulation persists.
A clinical syndrome
First recognized over 50 years ago
Only possible on ventilatory support
Revealed by intensive Care Medicine
Apnoea, unresponsiveness and other
features
15. Mechanism of Brain Stem Death
Neuronal Injury
Decreased Intracranial
Blood Flow
Neuronal Swelling
Increased Intracranial
Pressure
ICP>MAP is
incompatible with
life
18. The transplantation of human organs act
1994 (THOA)
• Bill No. LIX-F of 1992
• The Transplantation of human organs bill, 1994
• (As Passed by the Houses of Parliament Rajya Sabha on 5th May 1993)
Lok Sabha on 14th June 1994 Amendments made by the Lok Sabha
Agreed to by the Rajya Sabha on 15th June 1994) Assented to on 8-7-
1994 Act No. 42 of 1994
• Bill No. LIX-F of 1992 THE TRANSPLANTATION OF HUMAN ORGANS
BILL, 1994
• ARRANGEMENT OF CLAUSES
20. Definition of Deceased Person
• The Transplantation of Human Organs Act, 1994 (Central Act 42 of
1994),- 'Deceased person' means a person in whom permanent
disappearance of all evidence of life occurs, because of brain-stem
death or
• In a cardio-pulmonary sense at any time after live birth has taken
place.
• ‘Brain-stem death' means the stage at which all brain stem
functions have permanently and irreversibly ceased.
21. Brain anatomy
Brain stem consisting of the midbrain, pons, and medulla, which extends
downwards to become the spinal cord – Controls respiration and various basic
reflexes (e.g., swallow and gag)
Cerebellum – Controls various muscle functions
Cerebrum-Controls memory, consciousness and higher mental functioning
22. Whole brain death v/s Brain stem
death
The difference lies in the results of testing.
In Brain Stem Death there are instances where blood
succeeds in reaching other areas of the cortex and
there can be measurable electrical tracings as indicated
by an EEG.
This is not necessarily indicative of brain function but
rather that some cells have electrical activity.
Even with this activity, if the patient is brain-stem dead,
there is no chance of recovering consciousness or
breathing.
23. Brain death- India
The usual clinical criteria for brain death include the
absence of brain stem reflexes including spontaneous
respiration requiring mechanical ventilation or life
support to continue cardiac function.
25. Few Possible Causes may progress to- Brain
Death
Cerebral Anoxia Trauma Cerebral Hemorrhage
Subarachnoid Hemorrhage
26. Always ask yourself- Is there a cause for the
patient to be brain dead?
• Potential cause for brain stem dysfunction?
• No obvious cause or if there is any doubt about the cause - be
cautious in diagnosing brain death
• Make sure there are no confounders that mimic brain death
28. Rule out the following and aim for near
normal values- PRECONDITIONS
• Severe hypothermia - core temperature of ≤32°C
• Severe hypotension (With or Without Vasopressors) - systolic
blood pressure <100 mmHg
• Drugs - alcohol, poisoning, recent use of sedation or
neuromuscular blocking agents
• Medical conditions - severe electrolyte abnormalities,
hypoglycemia, acid–base abnormalities
29. Practical Tips
• Insist on core temperature measurement
• Always look in history for, drugs, overdose, sedation, etc.
• If available, use a Peripheral Nerve Stimulator for – TOF response
• Have most recent values for Sodium and potassium available
• Insist on ABG at start of clinical testing with 100% O2 Pre-
oxygenation
30. Brain Death Criteria
• Brain death is established by
documentation of
• Irreversible coma
• Irreversible loss of brain stem reflexes
• Cessation of respiratory center
function
or
• Demonstration of cessation of
intracranial blood flow (NOT a Part of
THOA Act)
31. Determinatio
n of brain
death
• Nail Bed pressure
• Sternal Rub
• Supra Orbital Ridge Pressure
Establish No response to noxious stimulus
• E1 V1 M1 = 3
GLASGOW COMA SCALE (GCS)??
Absent Brain Stem Reflexes
Pupillary Reflex (absent)
• Occulo-Cephalic ( Dolls Eye Movements)
• Occulo-Vestibular (Cold Caloric test)
Eye Movements
• Facial Sensation and Motor Responses
• Pharyngeal (Gag) Reflex absent
• Tracheal (Cough) Reflex Absent
32. Who Does the Testing and When
• Testing can be done after 4- 6 hours of NO recordable brain Stem
Signs by bed side Nurse and Doctors, provided preconditions are
met
• Testing is done by 2 Doctors- at and interval of 6 hours apart. The
doctors can be Neurologist, Intensivist, Neurosurgeon or an equally
qualified doctor who is certified to be on the hospital brain death
panel.
• 2 More persons observe the process and sign of the final document-
Primary Physician and Hospital Administrator
33. Neurological examination for diagnosing
Brain Death
C
C
C
C
This consists of three essential steps:
• Documentation of coma
• Documentation of the absence of brainstem reflexes
• Documentation of apnea (apnea test)
35. Documentation of the absence of brainstem reflexes
Brainstem reflexes are lost in a rostral-to-
caudal direction
Reflexes in medulla oblongata are the last
to cease
• Absent pupillary reflex
• Absent oculocephalic movements (doll’s eye reflex)-
• Absent oculovestibular reflex (cold calorie test)
• Absent corneal reflex
• Absent cough reflex
Tests documented are
36. Pupillary
response to light
Pupillary Reflex
• In healthy persons, both pupils
are normally equally wide; they
narrow when exposed to light.
• Brain-dead patients lack this
reflex; their pupils are no longer
reactive to light.
• Pupils dilated with no
constriction to a bright light
single beam of light.
37. Corneal reflex
• When the outer layer of the eye (cornea) comes in contact with a foreign
object, the eyes close as an automatic reflex.
• When the physician tests this reaction by touching the cornea of a brain-dead
patient with a cotton swab, this reflex is absent.
40. Documentation of apnea (apnea test)
• Done only after
• Documentation of coma
• Documentation of absence of brain stem reflexes
41. Documentation of apnea (apnea test)
• Steps
• Pre-oxygenate patient with 100% oxygen for 15 minutes
• Obtain an ABG
• Disconnect patient from mechanical ventilation
• Continue to oxygenate through a catheter placed in the trachea –
Aim for saturation above 95%- use 4-6 L/min of O2
• ABG is repeated within about 8–10 minutes
• Increase in PaCO2 (above 60mmHg or 20mmHg from base line)
and lack of respiration documented (use EtCO2) if available
43. Brain Death
Confirmed
Once the 2 specialists complete the test the
time of death is confirmed as the end of the
second examination time
44. Radiographic Confirmation of Death
• Testing is not complete or possible – ie facial fractures,
swollen eyes etc
• Or C spine fractures
• Apnoea test becomes a challenge
46. Pre-requisites Evaluation
Pre-requisites Evaluation should include clinical and
neurological imaging evidences at,
Body temperature > 36° C
Normal Systolic BP ( > 100 mm Hg)
Inclusion
Exclusio
n
Examination
Confirmatio
n
Documentation
The process
of brain
death
certification
47. The process
of brain
death
certification
Severe head
injury
Hypertensive
intracerebral
hemorrhage
Aneurysm, SAH
Hypoxemic-
ischemic brain
injury
Fulminant hepatic
failure
1)Identification of history
or physical examination
findings that provides a
clear etiology of brain
dysfunction.
48. The process
of brain
death
certification
2)Exclusion of conditions
that might confound the
subsequent examinations
of cortical or brain stem
function.
• Shock/ hypotension
• Drug known to alter
neurological, neuromuscular
functions and EEG testing
(anesthetics, neuroparalytics,
alcohols).
• Brain stem encephalitis.
• GBS Syndrome.
• Encephalopathy associated with
hepatic failure.
• Severe hypophosphatemia.
49. The
process of
brain
death
certificatio
n
3) Performance of complete neurological
examination (diagnostic testing)
• Establish Coma
• Establish Absence of Brain Stem Reflexes
• Establish Apnea (Absence of Respiration drive)
4) Ancillary testing (confirmatory testing)
5)Documentation
• Time of death is the time the arterial PaCO2
reached the target value OR
• When ancillary test is officially interpreted
50. Can a person
wake up from
brain stem
death?
No patient that was ever
diagnosed brain- stem dead by
adequate criteria has ever
woken up from brain-stem
death.
Even though the heart now
continues to beat because it is
artificially being supplied with
oxygen (by means of ventilator),
ultimately there will be complete
systemic failure and the heart
will stop beating, usually within
a few days.
51. Role of a
nurse????
• Early detection of brain death.
• Identification of reflexes.
• Assisting in determination process.
• Documentation of the events.
• Proper communication.
• Psychological support to the family.
• Initiatives for organ donation
counseling.
52. Common
misconceptio
ns
Since there is a heartbeat, he is alive
Brain dead pts have permanently lost the capacity
to think, be aware of self or surroundings,
experience, or communicate with others.
He’s in a coma
Reinforce that they are dead.
With rehab/time he’ll get better.
Irreversible, dead brain cells do not regrow
53. How to
make it
clear
Do not talk
Do not talk to the patient as if he’s still
alive.
Do not say
Do not say “kept alive” for organ
donation.
Say
Say “artificial or mechanical
ventilation”, not “life support”
Time of death = neurologic
determination.
– NOT when ventilator removed
– NOT when heartbeat ceases
Say Say “dead”, not “brain dead”
