This presentation consist information about Brain death with special emphasis to differences between Indian and Western Guidelines. Also consist information about Organ transplantation and related act.
This is a presentation on brain death, its background, definition, related neurological conditions, criteria of brain death, brain stem reflexes, causes of coma, confounding factors, observation compatible with brain death, ancillary test, medical record documentation, prognosis, Management of brain death patient.
You tube link of this presentation
https://www.youtube.com/watch?v=3MzE5lHfglI&t=38s
Nurses as the primary care providers would be the immediate health care professional to assess the patient's response and to determine whether he is improving or deteriorating. Signs of brain death can be identified and reported early by a nurse with adequate knowledge.
This is a presentation on brain death, its background, definition, related neurological conditions, criteria of brain death, brain stem reflexes, causes of coma, confounding factors, observation compatible with brain death, ancillary test, medical record documentation, prognosis, Management of brain death patient.
You tube link of this presentation
https://www.youtube.com/watch?v=3MzE5lHfglI&t=38s
Nurses as the primary care providers would be the immediate health care professional to assess the patient's response and to determine whether he is improving or deteriorating. Signs of brain death can be identified and reported early by a nurse with adequate knowledge.
Intracerebral hemorhage Diagnosis and managementRamesh Babu
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A detailed presentation on Brain Death and Ongan transplantation.
Criteria for Brain Death are explained in detail. Legislative laws regarding the organ transplant, organ preservation are also explained.
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Death by Neurological Criteria and Organ Donation: Bill KnightSMACC Conference
Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic.
Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care.
There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
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VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
2. Brain Death?
The death of the Brain, while the Circulation
persists.
A clinical syndrome
– First recognised over 50 years ago
– Only possible on ventilatory support
– Apnoea, unresponsiveness and other features
3.
4. Types of “Brain death”
Cerebral/ cortical death
Brainstem death
Whole brain death (cortical + brainstem)
a. Cortical death
Permanent and irreversible cessation of cerebral functions
Death of cerebral cortex
Preserved brainstem
b. Brainstem death
Cerebrum is intact
But brainstem functions lost
All essential centres like “respiratory”, “cardiac” lost
Irreversible coma, absent spontaneous breathing
Intact cerebrum --- EEG may show activity
Can have preserved intracranial blood flow
UK (and India) guidelines based on concept of Brainstem Death
USA does not follow this concept, believes in Whole Brain Concept.
6. 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,
1. By reason of Brain-stem Death or
2. In a Cardio-pulmonary Arrest at any time
after live birth has taken place.
3. ‘Brain-stem Death' means the stage at
which all functions of the brain stem have
permanently and irreversibly ceased.
Definition of Deceased Person
7. Consent for certifying brain
death
1. Any donor himself may, authorize the
removal, before death, of his body
organs for therapeutic purposes.
Donor – in writing, in presence of 2
witnesses
One of whom is a near relative
2. The person, lawfully, in possession of
the dead body
3. Parents of a person <18 years of age.
11. Rule out the following
and
AIM for near normal values
• Severe Hypothermia - core temperature of ≤32°C
• Severe Hypotension (With or Without Vasopressors) - SBP
<100 mmHg
• Drugs - Alcohol, Poisoning, Recent Use Of Sedation Or
Neuromuscular Blocking Agents
• Medical conditions - severe electrolyte abnormalities,
hypoglycemia, acid–base abnormalities
12. Brain Death Criteria
• Brain death is established by
documentation of
1. Irreversible coma
2. Irreversible loss of brain stem reflexes
3. Cessation of respiratory centre function
or
4. Demonstration of cessation of
intracranial blood flow (NOT a Part of
THOA Act)
13. Evaluation Team
Certified by a 'Board of Medical
Experts‘
(1)MS/In-Charge of the hospital in which
'brain stem' death has occurred,
(2) Specialist,
(3) a Neurologist or a Neurosurgeon
nominated by the MS, from a panel
approved by the Appropriate Authority,
(4) the Doctor under whose care the
'brain- stem' death has occurred.
14. Amendments in the THO Act 2011
Wherever Neurophysician or
Neurosurgeon is not available,
then an anaesthetist or intensivist
can be a member of board in his
place, subject to the condition that
he is not a member of the
transplant team
15. Neurological examination for diagnosing
Brain Death
This consists of three essential steps:
Documentation of coma
Documentation of the absence of brainstem
reflexes
Documentation of apnea (apnea test)
C C C C
16. Documentation of coma
Absence of motor response to a Central
Deep painful stimulus
Beware of local spinal reflexes causing
spontaneous or stimulus-related motor
movements
21. Gag Reflex and Cough Reflex
Use a tongue depressor to
stimulate each side of
oropharynx and see for any
pharyngeal/ palatal
movements
Pass a suction tube –
stimulate carina – see for
any cough/ chest or
diaphragmatic movements
22. Vestibulo- Ocular Reflex
•Many clinicians use it as a “screening” tool , If present,
don’t need to proceed for further testing.
• Cervical spine injury: a. Suspected/ proven , DON’T
attempt VOR
24. Evaluation criteria brain death Apnoea
test:
a. Create a degree of hyper-carbia
sufficient to stimulate the respiratory
centre
b. After that also, if there is apnoea, helps
in diagnosis of brain death
Aim: Rapid increase in PaCO2 >60
mmHg (or a 20 mmHg increase from
baseline) and the corresponding decrease
in pH
Positive test Negative test
No respiratory activity Any spontaneous respiratory
activity
25. Documentation of Apnea (Apnea
Test)
Done only after
Documentation of coma
Documentation of absence of brain stem reflexes
26. Documentation of apnea (apnea
test)
Steps
a. Pre-oxygenate with 100% oxygen x 5 minutes
b. Do ABG to confirm that SaO2 and PaCO2 correlate with SpO2.
c. With SpO2 >95%, slowly reduce Resp rate to cause slow rise
in ETCO2.
d. When ETCO2 >45, do ABG to confirm PaCO2 >45 mmHg and
pH <7.4
e. The patient is disconnected from ventilator
f. Oxygen insufflated at 5 L/min via endotracheal catheter or CPAP
g. Maintain MAP >60mmHg, and SpO2 >95%.
h. Observe for 5 minutes
i. Repeat ABG to see PaCO2 >has increased >20 mmHg pre-
disconnection level
j. If after 5 minutes, no spontaneous breathing --- positive Apnea
test.
27. Apnoea test contraindicated in:-
High cervical cord injury:
a.Phrenic nerve injury
b.Phrenic nerve
dysfunction
28. Second testing
All above tests need to be
repeated
After how much time?
Determined for each patient
individually
As children are more resilient than
adults, a longer time between
assessments, of greater than 6
hours, has been advocated
29. Brain Death Confirmed
Once the 2 specialist complete the
test the time of death is confirmed
as the end of second examination
time
What is the legal time of death?
When the first test demonstrates the
absence of brainstem reflexes ,
second test is just “confirming” the
findings of the first test.
30. Observations compatible and incompatible with
Brain Death
Compatible:
• Spinal reflexes
• Sweating, blushing, tachycardia
• Normotension without pharmacologic support
Incompatible:
• Decerebrate or decorticate posturing
• Extensor or flexor motor responses to painful
stimuli
• Seizures
31. Confirmatory Tests- Not required in
India and NO mention in THOA act
• These tests are optional in adults
• Recommended in children younger than 1 year
• Certain countries mandate these tests by law to
confirm brain death
• The tests are
– Cerebral angiography (conventional or CT)
– Cerebral scintigraphy
– Electroencephalography (EEG)- NOT RECOMMENDED
– Transcranial Doppler (TCD) ultrasound- NOT RECOMMENDED
32. Confirmatory “but” optional tests
Indications: Cannot perform brainstem reflexes
d/t
a. Facial trauma/ pupillary abnormalities
b. Contra-indication to apnoea test
c. Severe pulmonary disease
d. Sleep apnoea
e. Toxic level of sedative drugs
f. Aminoglycosides – NM block
g. Toxic levels of AEDs, TCAs,
h. Anti-cholinergics, Anti-cancer drugs
37. TCD
AAN: accepted as a reliable confirmatory
test:
a. Non-invasive
b. Sensitive test
c. Absence of doppler signal
d. Small systolic peaks with no diastolic flow
or reverberating flow indicates a very high
resistance
e. But user dependant!
38.
39.
40. Criteria for Diagnosing Brain
Death in Infants and Children
The diagnosis of brain death cannot
be made in preterm infants of
gestational age of less than 37
weeks.
Children are more resilient than
adults
Longer time between assessments
has been advocated
Assessments in neonates and
41. Controversies in Confirmatory tests
a. Preserved EEG activity
b. Preserved blood flow
c. Preserved osmo-regulation, via
regulated secretion of ADH
(hypothalamic function)
Such patients, can be clinically declared dead by the absence of
brainstem reflexes, however, are NOT DEAD, if we apply a
“whole-brain death” concept.
Brain-stem death has a lower burden of proof than whole-brain
death!
42. The Transplantation Of Human
Organs Act 1994 (THOA)
The Transplantation of human organs
bill, 1994
• Rajya Sabha on 5th May, 1993
• Lok Sabha on 14th June 1994
• The Act was amended in 2011 and the
Transplantation of Human Organs (Amendment) Act
2011, has come into force on 10-1-2014
• Transplantation of Human Organs and Tissues Rules
(THOT), 2014 has many provisions to remove the
impediments to organ donation while curbing
misuse/misinterpretation of the rules.
43. National Organ Transplant
Programme
NOTTO: National Organ and Tissue Transplant Organization ROTTO: Regional Organ and Tissue Transplant
Organization
SOTTO: State Organ and Tissue Transplant Organization
T: Transplant Centre
44. References
Evidence-based guideline update:Determining brain death in
adults Report of the Quality Standards Subcommittee of the
American Academy of Neurology; Neurology® 2010;74:1911–
1918.
Brainstem death: A comprehensive review in Indian
perspective;Anant Dattatray Dhanwate; Indian J Crit Care Med.
2014 Sep; 18(9): 596–605
The diagnosis of brain death;Ajay Kumar Goila and Mridula
Pawar; Indian J Crit Care Med. 2009 JanMar; 13(1): 7–11.
Brain Death: The United Kingdom Perspective;Martin Smith,
MBBS, FRCA, FFICM; Semin Neurol 2015;35:145-151.
Plum And Posner’s Diagnosis Of Stupor And Coma fourth edition-
2007
Clinical Criteria for Diagnosis of Brain Death and its MedicoLegal
Applications (A Review Study) Author(s): Pathak Manoj Kumar,
Tripathi S K, Agrawal Prashant, Chaturvedi Rajesh, Yadav Sudhir
Vol. 6, No. 2 (2006-03 -2006-06) Indmedica MedicoLegal Update