1. Brainstem dysfunction
- Dr. Dwayne

2. What is brain death?
 Determination of brain death in term newborns, infants
and children is a clinical diagnosis based on the
absence of neurologic function with a known irreversible
cause of coma
Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update
of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720

3.  Pre-requisites
 Physical examination
 Apnoea test
 Ancillary tests
Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update
of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720

4. Brainstem dysfunction
 PRE REQUISITES
1. Irreversible and identifiable cause – status eplepticus with anoxic brain
injury
2. Correction of contributing factors that can interfere with neurological
examination
a. Temp >95F
b. Maintainance of MAP – on inotropes
c. Sedatives/ Analgesics – NA
d. Metabolic intoxication – None via history
e. Neuromuscular blockade - none

5. Brainstem dysfunction
 PHYSICAL EXAMINATION
 Flaccid tone; patient unresponsive to deep painful stimuli
 Pupils midpostion/fully dilated and light reflexes absent
 Corneal/ cough/ gag reflexes absent
 Oculovestibular reflex absent
 Spontaneous respiratory effort whilst on mechanical ventilation is absent

6. Brainstem dysfunction
 APNOEA TEST
 Normal temp/BP. No sedation/NMB
 Preoxygenate 100% O2 5-10mins
 ABG – record PaCO2 (Pre test)
 Disconnect from vent and connect to T piece (100% FiO2)
 Monitor closely for 15 mins
 PaCO2 >60/ increase >20 from baseline with no respiratory effort –
consistent with brain death

7. Brainstem dysfunction
 ANCILLARY INVESTIGATIONS
1. EEG – features suggestive of Beta coma
2. Radionucleotide cerebral blood flow
Indications:
(i) When components of the examination or apnea testing cannot be
completed safely due to the underlying medical condition of the patient
(ii) If there is uncertainty about the results of the neurologic examination
(iii) If a medication effect may be present or
(iv) To reduce the inter-examination observation period

8. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update
of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720

9. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update
of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720

10. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update
of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720

11. Thomas A. Nakagawa et al;
Guidelines for the Determination
of Brain Death in Infants and
Children: An Update of the 1987
Task Force Recommendations.
Pediatrics 2011;128;e720

12. Why is it so important?

13. Counselling

14. Organ donation

15. Thank you