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BRAIN DEATH 1_011345.pptx
- 2. BRAIN DEATH PRESENTATION BY RESHMAS R FINAL YEAR MSC NURSING (CRITICAL CARE NURSING) PD HINDUJA COLLEGE OF NURSING
- 3. Introduction Death is anirreversible, 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
- 5. History Earliest human history Neurologicalfailure (COMA) Cardiac failure (Absent Pulse, HR) Respiratory failure (Absent air entry and exit) Death
- 6. History • The lossof 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 aneed…!!! 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 ofdeath 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 Deathof 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
- 10. Normal Brain Anatomy CerebralCortex Brain Stem Reticular Activating System
- 11.
- 12. Brain Stem Midbrain Cranial NerveIII pupillary function eye movement
- 13. Brain Stem Pons Cranial NervesIV, V, VI conjugate eye movement corneal reflex
- 14. Brain Stem Medulla Cranial NervesIX, X Pharyngeal (Gag) Reflex Tracheal (Cough) Reflex Respiration
- 15. Mechanism of BrainStem Death Neuronal Injury Decreased Intracranial Blood Flow Neuronal Swelling Increased Intracranial Pressure ICP>MAP is incompatible with life
- 17.
- 18. The transplantation ofhuman 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
- 19. Indian law recognizes brainstem death
- 20. Definition of DeceasedPerson • 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 stemconsisting 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 deathv/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 Theusual 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.
- 24. • STEP..1 Establish ifthere is an underlying cause for the patient to be brain dead
- 25. Few Possible Causesmay 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
- 27. STEP..2 Look for confounders beforeproceeding for brain death verification
- 28. Rule out thefollowing 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 • Insiston 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 theTesting 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 fordiagnosing 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)
- 34. Response to painfulstimuli Within cranial nerve distribution
- 35. Documentation of theabsence 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 PupillaryReflex • 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 • Whenthe 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.
- 38. Gag Reflex andCough Reflex
- 39.
- 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
- 42.
- 43. Brain Death Confirmed Once the2 specialists complete the test the time of death is confirmed as the end of the second examination time
- 44. Radiographic Confirmation ofDeath • Testing is not complete or possible – ie facial fractures, swollen eyes etc • Or C spine fractures • Apnoea test becomes a challenge
- 45.
- 46. Pre-requisites Evaluation Pre-requisites Evaluationshould 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 Severehead 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)Exclusionof 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) Performanceof 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 wakeup 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 isa 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 Donot 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”
- 54.