This document discusses brain death, including its definition as the irreversible cessation of all brain functions including the brainstem. It outlines the diagnostic guidelines for determining brain death in children and adults. The clinical diagnosis involves demonstrating irreversible coma, absence of brainstem reflexes, and apnea. It also discusses the apnea test procedure, observation period requirements, confirmatory tests like EEG and cerebral blood flow scans, documentation standards, and providing supportive care after the diagnosis.

1. Brain Death
Dr. Abhijeet Deshmukh
Dept. of Pediatrics
Pushpagiri Institute of Medical Sciences & RC
Tiruvalla ,
Kerala.

2. • Definition:
The irreversible cessation of all functions
of the entire brain, including the brainstem.
also known as the determination of death
using neurologic criteria

3. Diagnostic Guidelines
• For children - published in 1987 by a Special
Task Force to the American Academy of
Pediatrics (Not revised yet)
• For adults - by the American Academy of
Neurology in 1995.

4. Clinical diagnosis
• Key components :
1. Demonstrations of irreversible
coma/unresponsiveness,
2. Absence of brainstem reflexes
3. Apnea

5. • Before diagnosis of B.D, rule out cause of the
coma by historical, radiologic, and laboratory
data to rule out a reversible condition.

6. • Causes of irreversible coma :
Severe head injury,
hypertensive intracerebral hemorrhage,
aneurysmal subarachnoid hemorrhage,
 hypoxic-ischemic brain insults and
fulminant hepatic failure.

7. • Causes of reversible coma :
 metabolic disorders,
 toxins,
 sedative drugs,
 paralytic agents,
 hypothermia,
 hypoxia,
 hypotension/shock,
 hypoglycemia/hyperglycemia,
 hyponatremia/hypernatremia,
 hypercalcemia,

8.  hypermagnesemia,
 nonconvulsive status epilepticus, hypothyroidism,
 hypocortisolism,
 hypercarbia,
 liver or renal failure,
 sepsis, meningitis, encephalitis,
 SAH,
 surgically remediable brainstem lesions

10. • Apnea : clinically confirmed through the
apnea test.
• performed only if the first 2 criteria
for brain death(irreversible coma and
absence of brainstem reflexes) are already
confirmed.

11. • Procedure : Preoxygenate the patient with
100% oxygen for approximately 10 min
adjust ventilation to achieve a PCO2 of
about 40 mm Hg
• During the test, oxygenation is maintained
on CPAP and 100% oxygen by means of
the ventilator circuit or a resuscitation bag
such as a Mapleson device,

12. • Child is assessed for breathing efforts
through observation and auscultation.
• A blood gas sample is obtained
approximately 10 min into the test and
every 5 min thereafter until the target
PCO2is surpassed; ventilatory support is
resumed at that time.

13. • If at any point during the test the patient
becomes hypoxic or hypotensive, the test
is aborted and ventilatory support is
resumed.
• Absence of respiratory efforts with a
PCO2 > 60 mm Hg or more than 20 mm Hg
above an elevated baseline value is
consistent with brain death.

14. Observation Period
Varies by age :
• 7 days- 2 mo:
2 examinations separated by at least 48 hr.
• 2 mo - 1 yr :
2 examinations separated by at least 24 hr
are recommended.
• >1 yr :
12-hr observation period between exams.

15. If the cause of the coma is hypoxicischemic brain injury and the first exam is
performed shortly after the insult, a period
of at least 24 hr is recommended before
the second exam.
A second exam is not needed if a
nuclear medicine cerebral flow scan
demonstrates absence of CBF.

16. Confirmatory Tests
• All children <1 yr of age.
• Where clinical exam is impossible to perform
or the results are suspected to be unreliable.
• The 2 most commonly used confirmatory
tests are :
- EEG and
- Studies to confirm the absence of CBF
eg. nuclear medicine cerebral flow scans.

17. • An EEG showing electrocerebral
silence over a 30-min supports the
diagnosis of brain death.
• Advantages : wide availability and low
risk.
• Disadvantages : artefact in the presence
of drugs like barbiturates

18. • Nuclear medicine cerebral flow scan :
Intravenous injection of a
radiopharmaceutical agent followed by
imaging of the brain
Absence of uptake in the brain
demonstrates absence of CBF and is
confirmatory of brain death
Advantages : low risk, not affected by
drug levels.

19. Documentation
1 Etiology and irreversibility of the coma
2 Absence of confounding factors: hypothermia,
hypotension, hypoxia, significant metabolic
derangement, significant drug levels
3 Absence of motor response to noxious stimulation
4 Absence of brainstem reflexes: pupillary light reflex,
oculocephalic/oculovestibular reflex, corneal
reflex, cough and gag reflex
5 Absence of respiratory effort in response to an
adequate stimulus; blood gas values should be
documented at the beginning and end of the
apnea test

20. Supportive Care
• supportive care may continue for hours to
days as the family makes decisions about
potential organ donation and comes to
terms with the diagnosis.

21. • Refereance –
Nelson Textbook of Pediatrics 19 th edition.

22. Thank You !