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Brain Stem Death Testing and Organ Donation
- 1. South Thames Regional Donor Transplant Coordinators Brain stem testing Shibu Chacko Specialist Nurse Organ Donation Email: shibu.chacko@nhs.net
- 2. South Thames Regional Donor Transplant Coordinators UK Definition of Death 2 • Death entails the irreversible loss of those essential characteristics which are necessary to the existence of a living human person and thus the definition of death should be regarded as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe… (Academy of the Medical Royal Colleges- AoMRC (2008).
- 3. South Thames Regional Donor Transplant Coordinators What is DBD & DCD? • DBD- Donation after Brain Stem Death (Heart Beating) • DCD – Donation after Circulatory Death (Non Heart Beating)
- 4. South Thames Regional Donor Transplant Coordinators
- 5. South Thames Regional Donor Transplant Coordinators
- 6. South Thames Regional Donor Transplant Coordinators Functions of the Brain Stem • All motor output from the brain • Almost all sensory input to the brain (not cranial nerves I and II) • Total control of breathing • Control of Heart Rate and BP • Control of cerebro-vascular system • Reticular Activating System – regulates wakefulness and sleep- wake transitions, adapts to different situations (Bouncer at the door of your mind).
- 7. South Thames Regional Donor Transplant Coordinators Potential DBD patient Patients with a catastrophic brain injury • Ventilated with no respiratory effort • Fixed and dilated pupils • No cough or gag reflex • No corneal reflex • No reaction to painful stimuli
- 8. South Thames Regional Donor Transplant Coordinators Why do we test? A definition of human death should not be related to organ donation / transplantation. A Code Of Practice For The Diagnosis And Confirmation Of Death 2008 To diagnose and confirm the death of a mechanically ventilated, severely brain injured patient in coma, using neurological criteria. 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
- 9. South Thames Regional Donor Transplant Coordinators Which organs can be donated? • Heart (DBD/DCD) <65 years • Lungs <70 years • Kidneys • Liver • Pancreas <65 years • Bowel (DBD) <65 years • Tissues Possible for 1 person to help save the lives of 9 people
- 10. South Thames Regional Donor Transplant Coordinators Tumour Trauma Intra-cerebral Hemorrhage Ischemia Brain Stem How does brain stem death occur? • Not enough blood & oxygen reaching the brain • Most common causes → Raised ICP • As brain stem compressed, pressure and ischemia causes more systemic changes. • Initially cushing’s reflux occurs with raised BP and a subsequent bradycardia – attempt to restore cerebral circulation. • Followed by variety of arrhythmias due to vasodilation. • Permanent & irreversible damagePermanent & irreversible damage occursoccurs
- 11. South Thames Regional Donor Transplant Coordinators Different types of brain herniation. (1) Subfalcine ‘midline’ herniation—can cause ipsilateral anterior cerebral artery occlusion. (2) Tentorial herniation—herniation of the uncus (medial temporal lobe) through the tentorial hiatus causing compression of the occulomotor nerve and brain stem. (3) Central herniation – diffuse supratentorial swelling causing vertical displacement of the midbrain through the tentorial hiatus. (4) Tonsillar herniation—a subtentorial expanding mass or greater supratentorial pressure causes herniation of the cerebellar tonsils through the foramen magnum.
- 12. South Thames Regional Donor Transplant Coordinators Stages of Brain Stem Herniation • Infarction of the Brain stem – Hypertension & Bradycardia (Cushing's Triad) – Duration varies Hypertension (SBP 300 or above / Wide Pulse pressure and Bradycardia) • Unopposed Adrenergic activity- Catecholamine storm & Cranial Diabetes Insipidus – Haemodynamic instability and vasoconstriction (Myocardial ischemia / ventricular dysfunction – Can make the heart unsuitable) – Can Treat HTN (Short acting agents like Esmolol) • Second phase: Profound hypotension and hypothermia
- 13. South Thames Regional Donor Transplant Coordinators Pre-conditions for testing • Patient’s condition is due to irreversible brain damage of known aetiology • Cardiovascular stability +/- drugs • Exclude potentially reversible causes of coma: – Depressant Drugs / paralysis influencing agents – Hypothermia – Circulatory, Metabolic and Endocrine causes (hypernatraemia, acidosis, blood sugar, Na, K+, Mg) • Exclude potentially reversible causes of apnoea – Neuromuscular Blocking Agents – High Cervical Cord Injury
- 14. South Thames Regional Donor Transplant Coordinators Equipment's • Light source, small gauze sterile swabs, Otoscope, 50ml syringe, ice cold water, a spatula, yanker sucker, Laryngoscope, ET suction catheters, Inco pad and kidney dish • Documentations
- 15. South Thames Regional Donor Transplant Coordinators Tests • 2 doctors - Consultant or senior SPR • Must conduct the tests together • Tests repeated (2 full sets of tests, including apnoea test) • Tests examine brain stem function by testing cranial nerve reflexes and respiratory drive
- 16. South Thames Regional Donor Transplant Coordinators Prerequisites • pH <7.40 • PaCO2 at least 6.0 • Core temperature above 34.0 degrees • Sodium 115-160 mmol/lit • K+ >2.0 mmol/l • Phosphate 0.5 – 3.0 mmol/l • Mg 0.5-3.0 mmol/l • Blood glucose 3.0-20.0mmol/l
- 17. South Thames Regional Donor Transplant Coordinators Testing for Brain-stem Death 17 “This form is consistent with and should be used in conjunction with, the AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of Death and has been endorsed for use by the following institutions: Faculty of Intensive Care Medicine, Intensive Care Society and the National Organ Donation Committee.” Full Abbreviated
- 18. South Thames Regional Donor Transplant Coordinators 18
- 19. South Thames Regional Donor Transplant Coordinators PUPILS FIXED AND DILATED, NOTPUPILS FIXED AND DILATED, NOT RESPONDING TO LIGHTRESPONDING TO LIGHT PUPILS FIXED AND DILATED, NOTPUPILS FIXED AND DILATED, NOT RESPONDING TO LIGHTRESPONDING TO LIGHT Cranial nerves 2,3 (Midbrain)Cranial nerves 2,3 (Midbrain)
- 20. South Thames Regional Donor Transplant Coordinators NO BLINKING TO TOUCHNO BLINKING TO TOUCH OR CORNEAL REFLEXOR CORNEAL REFLEX NO BLINKING TO TOUCHNO BLINKING TO TOUCH OR CORNEAL REFLEXOR CORNEAL REFLEX Cranial nerves 5,7 (Midbrain)Cranial nerves 5,7 (Midbrain)
- 21. South Thames Regional Donor Transplant Coordinators VESTIBULO-OCULAR REFLEXESVESTIBULO-OCULAR REFLEXES ARE ABSENT - NO EYEARE ABSENT - NO EYE MOVEMENTS ARE SEEN DURINGMOVEMENTS ARE SEEN DURING THE SLOW INJECTION OFTHE SLOW INJECTION OF 50MLS OF ICE COLD WATER.50MLS OF ICE COLD WATER. VESTIBULO-OCULAR REFLEXESVESTIBULO-OCULAR REFLEXES ARE ABSENT - NO EYEARE ABSENT - NO EYE MOVEMENTS ARE SEEN DURINGMOVEMENTS ARE SEEN DURING THE SLOW INJECTION OFTHE SLOW INJECTION OF 50MLS OF ICE COLD WATER.50MLS OF ICE COLD WATER. Cranial nerves 3,6,8 (Midbrain, Pons & Medulla)Cranial nerves 3,6,8 (Midbrain, Pons & Medulla) 66thth Nerve Palsy: OpthalmoplegiaNerve Palsy: Opthalmoplegia
- 22. South Thames Regional Donor Transplant Coordinators NO MOTOR RESPONSES TONO MOTOR RESPONSES TO SUPRAORBITALSUPRAORBITAL PRESSUREPRESSURE NO MOTOR RESPONSES TONO MOTOR RESPONSES TO SUPRAORBITALSUPRAORBITAL PRESSUREPRESSURE Cranial nerves 5,7 (Pons)Cranial nerves 5,7 (Pons)
- 23. South Thames Regional Donor Transplant Coordinators NO GAG OR COUGH REFLEX TONO GAG OR COUGH REFLEX TO BRONCHIAL STIMULATIONBRONCHIAL STIMULATION NO GAG OR COUGH REFLEX TONO GAG OR COUGH REFLEX TO BRONCHIAL STIMULATIONBRONCHIAL STIMULATION Cranial nerves 9, 10, 11, 12 (Medulla)Cranial nerves 9, 10, 11, 12 (Medulla)
- 24. South Thames Regional Donor Transplant Coordinators APNOEA TEST -APNOEA TEST - NO RESPIRATORYNO RESPIRATORY MOVEMENT WHENMOVEMENT WHEN THE PATIENT ISTHE PATIENT IS DISCONNECTEDDISCONNECTED FROM MECHANICALFROM MECHANICAL VENTILATIONVENTILATION (Medulla)(Medulla) APNOEA TEST -APNOEA TEST - NO RESPIRATORYNO RESPIRATORY MOVEMENT WHENMOVEMENT WHEN THE PATIENT ISTHE PATIENT IS DISCONNECTEDDISCONNECTED FROM MECHANICALFROM MECHANICAL VENTILATIONVENTILATION (Medulla)(Medulla)
- 25. South Thames Regional Donor Transplant Coordinators Apnoea testing • Do a baseline ABG • Pre-oxygenate with 100% • Arterial Blood Gas taken to confirm PaCO2 and SaO2 correlation with EtCO2 and SpO2 levels • Reduce MV / rate to allow slow increase in EtCo2 to 6.0kPa or just above • Recheck ABG to confirm PaCO2 >6.0 and pH <7.40 • As long as cardiovascularly stable, disconnect from ventilator
- 26. South Thames Regional Donor Transplant Coordinators Apnoea Testing • Maintain oxygenation by 6 l/min via tracheal catheter or water circuit. • Observe for respiratory movements for 5 min - No respiratory effort seen • Repeat ABG after 5 mins and reconnect to ventilator – Do not wait for ABG results • ABGs : observe if CO2 risen by 0.5KPa • Ventilate, allow PaCO2 to normalise • Repeat test (Allow time between sets to allow PaCO2 to return to baseline)
- 27. South Thames Regional Donor Transplant Coordinators TWO TESTS • ALIVE • ALIVE • DECEASED TEST 1 TEST 2 TIME OFTIME OF DEATHDEATH
- 28. South Thames Regional Donor Transplant Coordinators Incidence of common physiological derangements in brain- dead patient Derangement Cause Approx incidence Hypothermia Hypothalamic damage, reduced metabolic rate, vasodilation and heat loss. Invariable if not prevented Hypotension Vasoplegia, hypovolaemia, reduced coronary blood flow, myocardial dysfunction. 81-97% DI Posterior pituitary damage 46-78% DIC Tissue factor release, coagulopathy 29-55% Arrhythmias Catecholamine storm, myocardial damage, reduced coronary blood flow 25-32% Pulmonary Oedema Acute blood flow diversion, capillary damage 13-18% McKeown, Bonser & Kellum 2012
- 29. South Thames Regional Donor Transplant Coordinators Optimising the brainstem dead donor 29
- 30. South Thames Regional Donor Transplant Coordinators Management of Brain stem dead patient in ICU • Series of pathophysiological responses / instability associated with brain stem ischemia. • This can have damaging effects on the organ systems. • If instability is not managed can lead to deterioration in organ function before retrieval. • 20% of donors dies due to CVS instability prior to donation.
- 31. South Thames Regional Donor Transplant Coordinators Key Points • Catastrophic Brain Injury Pathway or CBI • DBD donation BSD is followed by a predictable pattern of complex MOF Support before and after brain death can improve the number and quality of organs Increasing numbers of marginal donors are being accepted • NICE guidelines and implications
- 32. South Thames Regional Donor Transplant Coordinators
- 33. South Thames Regional Donor Transplant Coordinators DBD donation process Patient receives full treatment/Discussion & Plan Death Confirmed Organ donation Transfer to theatre (remains ventilated) Death Suspected
- 34. South Thames Regional Donor Transplant Coordinators Spinal Reflexes in BSD Patients • Movement in BSD subjects • Spontaneous body movement may occur • Generated by spinal cord • May be caused by a variety of stimuli – Apnoea / High CO2 – Incision – Movement Ranges from finger twitching to waist flexion!! Sapasnik et al, Neurology 2000 : Occurs in 39% of patients
- 35. South Thames Regional Donor Transplant Coordinators General measures • Maintain normothermia (active warming may be required) • Thrombo-embolism prophylaxis • Stockings / Sequential compression devices / LMWH • Positioning • Head-up / Side to side • Attention to cuff pressures and leaks to prevent aspiration • Continue NG feeding (may be reduced/ stopped for bowel transplant) • Antibiotics according to sensitivities or empirical according to Trust guidelines 35
- 36. South Thames Regional Donor Transplant Coordinators
Editor's Notes
- brain stem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. In humans it is usually described as including the medulla oblongata(myelencephalon), pons (part of metencephalon), and midbrain (mesencephalon). Of the twelve pairs of cranial nerves, ten pairs come from the brainstem.
- Brain herniation is a potentially deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull. Herniation can be caused by a number of factors that cause a mass effect and increase intracranial pressure (ICP): these include traumatic brain injury, intracranial hemorrhage, or brain tumor. Because herniation puts extreme pressure on parts of the brain and thereby cuts off the blood supply to various parts of the brain
- Need to be treated with careful fluids and vasopressin High-dose catecholamine infusions have been shown to worsen ischaemia and organ function and vasopressin may allow dose reduction
- Episodes where a comprehensive neurological examination cannot be carried out, for example, after severe maxillofacial trauma; when the influence of residual sedation cannot be excluded; Can be used EEG or angiogram to identify the absence of cerebral blood flow.
- (Optic & occulomotor) Dilated pupils may even occur in the presence of brain death, because sympathetic cervical pathways to the pupillary dilator muscle may still be intact. The light reflex is absent in brain death.
- 3.5th & 7th cranial nerves (trigeminal, Facial) Care should be taken to avoid any damage to the cornea. Corneal reflexes are tested here by using a cotton swab across the eye Blinking would be absent.
- 3rd, 6th, & 8th cranial nerves (caloric test, no eye movements “dolls eye”) (Occulomotor, abducens and auditory) Usually injected on to the tympanic membrane over 1 minute. No deviation of the eyes occurs Contraindication to testing is impaired integrity of the membrane. Ocular Movements can be tested Oculocephalic (dolls-eyes). No eye movements occur in response to head movements. Contraindication to testing is a suspected fracture or instability of the cervical spine
- No grimacing to pain from pressure to the supra orbital ridge or tempro- mandibular joint No limb response.
- 4.9th & 10th cranial nerves (Glossopharygeal & vagus) Suction or move the tube back and forth to stimulate a cough or gag response
- Suction or move the tube back and forth to stimulate a cough or gag response
- DIC is a pathological process characterized by the widespread activation of the clotting cascade that results in the formation of blood clots in the small blood vessels throughout the body. This leads to compromise of tissue blood flow and can ultimately lead to multiple organ damage. In addition, as the coagulation process consumes clotting factors and platelets, normal clotting is disrupted and severe bleeding can occur from various sites. DIC does not occur by itself but only as a complicating factor from another underlying condition, usually in those with a critical illness.
- Pathophysiological changes during brain stem death result in pituitary failure. Current evidence suggests that hormonal therapy may be beneficial. Methylprednisolone: 15 mg/kg bolus If urine output &gt; 4ml/kg/h then DDAVP 1-4 mcg. Maintain urine output 0.5- 2.0mls/kg/hr Vasopressin: 1 IU bolus then 0.5e5 IU/h infusion Insulin: 1 unit/h infusion minimum (titrate to blood glucose 4e8 mmol/l) Tri-iodothyronine (T 3)
- Average 12 hours
- Lazerus sign