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

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.

9. Life after brain death: Is the body
still alive???

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

19. Declaring brain death

20. 1. Unresponsiveness
• No eye movement
• No motor response to verbal/ noxious stimuli

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

23. Confirmatory testing
• Cerebral Angiography
• EEG
• Transcranial doppler blood flow
• Single photon emission computed tomography:
• Somatosensory evoked potentials
• MR angiography
• CT angiography

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

25. Physiology of brain death

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

29. Complications after brain death

30. Care of Brain dead patient &
organ donor management

31. Events in the organ donation and consent process

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

39. Protocols for donor management
•Ventilator management
•Temperature
•Hormonal management
•Fluid management
•Inotropes
•Other concerns

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

52. How to ask for organ donation
consent?

54. Possible Nursing Diagnosis

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.

58. References
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