Brain Death concepts, Its changes and life after brain death, is the body still alive?? what are the determinants of brain death and who can declare it, bio ethical dimensions of nursing care in BD
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Care of brain dead
1. Nursing Management of Brain
Dead patients
Prof. Prabhjot Saini
Professor of Medical Surgical Nursing Dept.
DMCH College of Nursing
Ludhiana, Punjab
2. It is no wonder that families of brain dead patients
frequently react to this news with denial:
How could my loved one
be dead if her heart is
still beating?
3. Brain death concepts
• Prior to the advent of mechanical respiration, death
was defined as the cessation of circulation and
breathing
• Immensely challenging concept to grasp
4. Historical perspective
• 1968 Irreversible Coma/Brain Death -Harvard Medical school
Ad Hoc Committee.
• 1981 UDDA – President’s commission for the study of ethical
problems in medicine.
• 1994 American academy of neurology Guidelines for the
determination of brain death
• Accepted by Govt. of India in 1994 as a form of death.
• 2005 NYS guidelines for determining brain death
5. Brain death: why so challenging?
• The patients look like any other patient in ICU’s
• They have vital signs, they are warm, heart is beating.
• Brain death goes against the traditional image of death in our
culture.
Nonetheless, brain death is death.
6. Why BD patients are important ??
Incidence of organ failure is increasing in India and
worldwide
Kidneys – 150,000 patients require transplants
Heart – 50,000 patients require transplants
Liver – 100,000 patients require transplants
7. Why BD patients are important ??
• Add to largest pool of donors in the world
• No wastage of organs
• Almost 95% of organ donors in western world
originate from BD donors
8. Case report
• Jahi McMath (13 yr old girl) of Oakland, Calif.,
was declared brain-dead after experiencing rare
complication from tonsil surgery.
• Hard for family to realize that she has passed
• Repeated court orders to maintain treatment,
and delay the withdrawal of ventilator, were
confusing to the McMath family and to the general
public.
10. Life after brain death: Is the body still alive???
• Distress felt by the health care provider
• Caring for these patients often elicits feelings of moral
distress and inner conflict.
• Family in denial
• Term used is “Ventilator” withdrawal, rather than “life
support” withdrawal.
11. Brain dead: What is important?
• Constantly monitoring and care of the patient’s condition
while patient is on mechanical support
At this time organ donation is presented as an option in order to
give life to others
12. What is brain death?
When and how is the patient declared
brain dead?
13. What is Brain Death?
“An individual who has sustained either irreversible
cessation of circulatory and respiratory functions, or
irreversible cessation of all functions of the entire
brain, including the brain stem.”
Uniform determination of Death Act (UDDA)
14. What is brain death?
• Brain death is irreversible and is legally and medically
recognized as death
• Total cessation of all brain function (the upper brain
structure and brain stem).
• Brain death is not a coma or persistent vegetative state.
Brain death is an actual death.
15. Causes
• Trauma to the brain
• Cerebro vascular injury (i.e. stroke or aneurysm)
• Anoxia
• Brain tumor
16. Declaration of brain dead
"No one who has met the criteria for brain
death has ever survived"
17. Determination of brain death
• Determination of death by neurologic criteria is a
clinical diagnosis.
• After certain prerequisites are met, there are three
essential components to the determination
Irreversible coma or Unresponsiveness
Absence of brainstem reflexes
Apnea
18. Prerequisites
Determination of death can be made in patients who :
• Continue to have cardiac function during
mechanical ventilation in the appropriate clinical
scenario
• A clear irreversible cause must be known based on
History
Brain imaging
CSF examination
21. 2.Absence of brainstem reflexes
Absence of:
• Pupillary response : fixed, mid-position 4-6cm diameter
• Motor response : no blink on NS adm. to cornea
• Gag & cough reflexes: absence of cough reflex during
suctioning
• Eye movements : absence of reflexes ‘doll’s eye
maneuver’ & ‘cold calorics’
22. 3. Apnea testing
After 8 min of ventilator disconnection
▫ The ABG PaCO2 >60mmHg or >20 mm Hg above
baseline
▫ Patient present with continued apnea
▫ Performed 2 times by different experts to confirm
diagnosis
24. Who can declare BD?
BD diagnosis made by the separate examinations of 2 doctors:
1. One of the doctors specialist as having knowledge in
performance of brain death certification
Intensivist/ Critical care physician/ Neurologist or neurosurgeon
2. The other medical practitioner of same qualification with
atleast 6 years of experience and possess skill and
knowledge in performance of brain death certification
26. The patho physiology of brain death is primarily related to the
secondary effects of long-standing brain edema.
Traumatic or Cerebro vascular insult
Generalized hypoxia
Resultant Brain edema
Vasogenic cytotoxic
Brain edema (focal)
Brain edema spreads whole brain
27. Increase ICP
exceed arterial BP and decrease CBF
aseptic necrosis
Within 3-5 days, brain liquefies
“respirator brain”
Compresses brain and brainstem
Complete brain infarction
Brain deathBrain death
28. • Brain infarction leads to
▫ Ischemia of Pons: Cushing response (hypertension &
bradycardia)
▫ Ischemia of medulla : ‘catecholamine storm ‘damages
organs with severe vasoconstriction
and pro-inflammatory response
▫ Spinal cord ischemia: severe hypotension
▫ Ischemia Pituitary & hypothalamus: loss of homeostatic control
The resulting physiology is characterized by hemodynamic
instability with host of secondary complications
32. Brain death : Potential to save lives
• Awareness on maintenance of the brain dead
• Adequate care for the donor can improve graft quality for
donation.
• India still ranks low compared to the rest of the world in
deceased donation.
33. Nursing Care of Brain dead donors
Technical dimension Bioethical dimension
• Focus ongoing resuscitation to
maintain viable organs
• Post-declaration management
• Multitasking and frequent
reassessment.
▫ Family Support
▫ Bereavement care
▫ Counseling
▫ Obtaining consent for
organ donation
34. Technical dimension of nursing
care to BD patient
Initial donor resuscitation
Donor management
35. Initial donor resuscitation
Immediate goals
• Establish baseline organ function and stabilize vital signs
• Maintaining central and arterial line
• Obtain Blood, urine, and bronchial cultures and baseline
chemistries, coagulation profile, CBC
• Evaluation of lung and heart - chest x-ray, ECG, etc
36. Initial donor resuscitation
• Blood type and cross matching
• Call for OPO (organ procurement organization)
coordinator - Initial graft allocation.
• Routine serological testing
• Monitoring end organ perfusion - measuring oxygen
delivery through mechanical ventilator
• Prevent complications – aspiration, DVT
37. Follow standard ICU protocols
• DVT prophylaxis
• Administration of blood products for anemia/coagulopathy
• Aspiration precautions including following VAP bundle
• Correction of electrolytes and acidosis to prevent arrhythmias
38. Physiological end points for potential
donors
• Systolic blood pressure ≥90 mm Hg
• Mean arterial pressure ≥60 mm Hg
• Central venous pressure ≤12 mm Hg
• PCWP ≤12 mm Hg
• Urine output >1 and <4 mL/kg/h
• Core temperature >35°C
• Hematocrit ≥25%
• Oxygen saturation >95%
• pH 7.35-7.45
40. Protocols for donor management
The circulatory and biochemical variables are managed by the
general principle of the "Rule of 100" suggesting targets of
SBP ≥100 mmHg
Urine output ≥100 ml/h
PaO 2 ≥100 mmHg
Blood sugar targeted at 100% normal
41. Respiratory/ventilator management
• Minimal FiO 2 needed to maintain perfusion
PaO 2 >100 mmHg,
SpO 2 >95%,
PaCO 2 35-40 mmHg
Mode - PCV
Low Tidal vol. - 6-8 ml/kg
PEEP - 5 cm of H2O (to prevent barotrauma)
• Maintaining airway clearance –suctioning 4 hourly
• Excessive oxygen adm. should be avoided- as this can induce
the inflammatory cascade and apoptosis.
42. Temperature:
The aim is to keep the core temperature >35°C prior
to organ donation.
Intervention:
▫ Circulating hot air blankets
▫ Warmed intravenous fluids
▫ Minimize exposure to environmental temperature
43. Hormonal replacement
The recommended replacements are:
▫ Vasopressin 1 U bolus with infusion of 0.5-4.0 U/h
▫ Methylprednisolone 15 mg/kg immediately after diagnosis and 24th hourly
thereafter. (to reduce DIC & systemic Inflammatory response)
▫ Insulin 10 U in 50% dextrose followed by an infusion 1 U/Hr
▫ Thyroxine (T4) 20 mcg bolus followed by infusions of 10 mcg/h.
▫ Tri-iodothyronine (T3) given as a 4-mcg bolus followed by an infusion of 3
mcg/h.
An analysis of 10 years data showed that the combination of thyroid hormone,
corticosteroid, insulin and ADH was the best for multiple organ
procurement.
44. Fluid management
• Polyuric and dehydrated results in central volume depletion.
• Crystalloids are the first choice and balanced salt solutions (Ringer's
lactate, Ringer's acetate, normal saline with sodium bicarbonate)
• Excessive fluid loading can result in pulmonary edema
▫ Use PAC to restrict excessive fluid use.
▫ Albuterol & diuretics can be used
• Replacement of blood and blood products to maintain Hb of 10 g/L could
improve tissue perfusion
45. Inotropes and cardiovascular system
• Dopamine is the first choice of inotrope in hypotension
unresponsive to volume
• Nor-adrenaline in doses >0.05 mcg/kg/min in
impaired cardiac contractility in heart donors
46. Preparing patient for organ donation
• Get consent signed from family members
• Prepare patient and follow all pre-operative
measures done for all patients
• Transfer to OT
47. Other concerns
• Diagnosis of BD certification needs to be safe and
confirmative
.
• Transmission of HIV and rabies from infected donors has
been documented.
• Sepsis, bacteremia or fungemia in the donor are not absolute
contraindications to donations
48. BD in Pregnancy organ donation:
▫ Controversial still
▫ A systematic review has concluded that mother
should be supported until the delivery of the fetus
and then can be considered for organ donation.
49. Bioethical dimension of nursing
care to BD patient
•Family bereavement
•Family support
•Getting consent form for organ donation
50. Family bereavement
• Family needs care and attention
• Doubts of family members to be eliminated at all stages
• Professionals/ counselors (most of the times nurses)
need to counsel in this process.
• Establish a link between the team and the family
51. Family support
The nurse needs to recognize that :
• Organ donation is an act of solidarity of the family
• Difficult to detach from the patient’s body and opt for the
donation.
• Maintain empathic behavior
• Informing family about real condition
• Helping them to understand reality
55. Possible nursing diagnosis
• Impaired gas exchange r/t need respiratory ventilation
• Potential for hemodynamic instability r/t multisystem organ failure
• Ineffective Tissue Perfusion (Cardiopulmonary) r/t decreased
circulating blood volume aeb death resulting from compression of
vital areas within the brainstem that control respiratory, vasomotor,
and cardiac function.
• Decreased Cardiac Output r/t altered stroke volume aeb arrhythmias
(tachycardia), decreased BP, cold, clammy skin, decreased peripheral
pulses, pale, grayish color of skin, and adventitious lung sounds.
• Coping for the family r/t death ( brain death has been declared).
56. Conclusion
• The recognition and acceptance of brain death is the need of
the hour
• Awareness amongst public to support the organ donor and
organ donation
• To improve the numbers and quality of donor organs
• The nurses need to care to patients who are potential donors
of organs and their families, while recognizing the complexity
of the process
• They need better qualification and emotional maturity.
57.
58. References
• Santos MJ, Massarollo MC, Moraes EL. [Family interview in the process of donating organs and tissues
for transplantation]. Acta Paul Enferm. 2012; 25(5): 788-94. Portuguese. [ Links ]
• Moraes EL, Silva LB, Moraes TC, Paixão NC, Izumi NM, Guarino AJ. [The profile of potential organ and
tissue donors]. Rev Latinoam Enferm. 2009; 17(5):716-20. Portuguese. [ Links ]
• Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. [Stressors in the nursing care delivered to
potential organ donors]. Rev Latinoam Enferm. 2009; 17(6):1023-9. Portuguese. [ Links ]
• Dalbem GC, Caregnato RC. [Organ and tissue donation for transplant: family refusal]. Texto & Contexto
Enferm. 2010; 19(4):728-35. Portuguese. [ Links ]
• Pessoa JL, Schirmer J, Roza BA. [Evaluation of the causes for family refusal to donate organs and
tissue]. Acta Paul Enferm. 2013;26(4):323-30. Portuguese. [ Links ]
• Fontanella BJ, Campos CJ, Turato ER. [Data collection in clinical-qualitative research: use of non-
directed interviews with open-ended questions by health profissionals]. Rev Latinoam Enferm.
2006;14(5):812-20. Portuguese. [ Links ]
• Rech TH, Rodrigues Filho EM. [Care of the potential organ donor]. Rev Bras Ter Intensiva.
2012;19(2):197-204. Portuguese. [ Links ]
• Lunardi VL, Barlem EL, Bulhosa MS, Santos SS, Lunardi Filho WD, da Silveira RS, BaoI AC, DalmolinI Gde
L. [Moral distress and the ethical dimension in nursing work]. Rev Bras Enferm. 2009;62(4):599-603.
Portuguese. [ Links ]
• Mascarenhas NB, Rosa DO. [Bioethics and nursing formal education: a necessary interface]. Texto &
Contexto Enferm. 2010;19(2):366-71. Portuguese. [ Links ]
• Cinque VM, Bianchi ER. [Stressor experienced by family members in the process of organ and tissue
donation for transplant]. Rev Esc Enferm USP. 2010;44(4):996-1002. Portuguese. [ Links ]
• Lima AA. [Donation of organs for transplant: ethical conflicts in the perception of professionals].
Mundo da Saúde. 2012;36(1):27-33. Portuguese. [ Links ]
Editor's Notes
noxious stimuli on nailbeds/supraorbital nerve and temporomandibular joint
vasogenic (causing disruption of the BBB and increased leakage of protein into brain) or cytotoxic (intact BBB but increased entry of water into brain) mechanisms.
(From Organ Donation Breakthrough Collaborative best practices final report, September 2003. The Organ Donation Breakthrough Collaborative. Best practices final report; U.S. Department of Health and Human Services Health Resources and Services Administration; Office of Special Programs, Division of Transplantation Contract: 240-94-0037 Task Order No. 12, September 2003.)
A rise in pulmonary hydrostatic pressure causes damage to the pulmonary endothelium resulting in pulmonary edema that is perpetuated by endogenous epinephrine
Temperature regulation in the hypothalamus is affected, manifesting with initial hyperthermia followed by hypothermia. Hypothermia is worsened by lack of shivering, peripheral vasodilatation and a decrease in the metabolic rate. Hypothermia can worsen acidosis and coagulopathy, increase the risk for arrhythmias and cold-induced diuresis besides causing a leftward shift in the oxygen dissociation curve.
(desmopressin intranasally has a selective action on the V2 receptors and a half-life varying from 6 to 20 h). T4 improves hemodynamics and prevents cardiovascular collapse in hemodynamically unstable organ donors. [50]
isseminated intravascular coagulation occurs after brain death due to the release of tissue thromboplastin from necrotic brain tissue.
systemic inflammatory response occurs and could be quite severe. This is mediated by inflammatory mediators from an ischemic brain, ischemic reperfusion injury, metabolic changes that occur during the catecholamine storm and an inadequately restored cardiovascular state. Increased plasma levels of interleukin-6 in the donor have translated to the poorer graft utilization and graft dysfunctions. [38]
ndocrine system, stress and metabolic responsesThe endocrine responses of the body are lost with brain death and form the rationale for hormone replacement therapy for brain-dead patients.The posterior pituitary function is lost early in brain death with occurrence of diabetes insipidus with polyuria and hypernatremia. Arginine vasopressin and desmopressin can be given as replacements. The anterior pituitary functions are preserved for a slightly longer period. Thyroid hormone levels decrease and a state similar to the sick euthyroid state in critical illness can occur.In addition to the decrease in insulin levels, hyperglycemia worsens with stress, alteration in carbohydrate metabolism and use of glucose solutions. Insulin levels normalize subsequently with an increase in C peptide levels. Hyperglycemia induced pancreatic cell damage may affect the pancreatic graft and measures aimed at strict euglycemia may minimize this risk. Hyperglycemia can also affect the outcomes after renal transplantation. [37]