This document provides information about brain stem testing and organ donation. It discusses:
- The definition of death as the irreversible loss of consciousness and breathing capacity.
- The differences between donation after brain stem death (DBD) and donation after circulatory death (DCD).
- The functions of the brain stem and signs that indicate potential for brain stem death.
- The reasons brain stem testing is conducted, including to diagnose death and rule out doubt before organ donation.
- The organs that can potentially be donated and the number of lives one donor can help save.
- The process, prerequisites, and tests involved in conducting a brain stem death examination.
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.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
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.
Acute stroke management
IV thrombolysis guidelines
IV thrombolysis side effects
Early CT changes in stroke
ASPECTS scoring
AHA stroke guidelines
Thrombolysis controversies
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.
Similar to Brain Stem Death Testing and Organ Donation (20)
All the major religions and belief systems in the UK support the principles of organ donation and transplantation and accept that organ donation is an individual choice.
We understand that you may have questions about whether your faith or beliefs affect your ability to become an organ donor. We're here to help support your decision, and have provided a selection of resources to help make sure you get the information you need.
Find out more about different attitudes to organ donation by selecting a faith or belief system below, or alternatively please consult the adviser from your religion or belief group.
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
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How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
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The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
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Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
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For those battling kidney disease and exploring treatment options, understanding when to consider a kidney transplant is crucial. This guide aims to provide valuable insights into the circumstances under which a kidney transplant at the renowned Hiranandani Hospital may be the most appropriate course of action. By addressing the key indicators and factors involved, we hope to empower patients and their families to make informed decisions about their kidney care journey.
1. South Thames Regional Donor Transplant Coordinators
Brain stem testing
Shibu Chacko
Specialist Nurse Organ Donation
Email: shibu.chacko@nhs.net
2. South Thames Regional Donor Transplant Coordinators
UK Definition of Death
2
• Death entails the irreversible loss of those essential
characteristics which are necessary to the existence of a living
human person and thus the definition of death should be
regarded as the irreversible loss of the capacity for
consciousness, combined with irreversible loss of the capacity
to breathe…
(Academy of the Medical Royal Colleges- AoMRC
(2008).
3. South Thames Regional Donor Transplant Coordinators
What is DBD & DCD?
• DBD- Donation after Brain Stem Death
(Heart Beating)
• DCD – Donation after Circulatory Death
(Non Heart Beating)
6. South Thames Regional Donor Transplant Coordinators
Functions of the Brain Stem
• All motor output from the brain
• Almost all sensory input to the brain (not cranial
nerves I and II)
• Total control of breathing
• Control of Heart Rate and BP
• Control of cerebro-vascular system
• Reticular Activating System – regulates wakefulness and sleep-
wake transitions, adapts to different situations (Bouncer at the door of your mind).
7. South Thames Regional Donor Transplant Coordinators
Potential DBD patient
Patients with a catastrophic brain injury
• Ventilated with no respiratory effort
• Fixed and dilated pupils
• No cough or gag reflex
• No corneal reflex
• No reaction to painful stimuli
8. South Thames Regional Donor Transplant Coordinators
Why do we test?
A definition of human death should not be related to
organ donation / transplantation. A Code Of Practice For The Diagnosis And Confirmation Of
Death 2008
To diagnose and confirm the death of a
mechanically ventilated, severely brain injured
patient in coma, using neurological criteria.
To eliminate all possible doubt regarding
survivability
To confirm diagnosis for families
In cases subject to medico-legal scrutiny
To provide choice regarding organ donation
9. South Thames Regional Donor Transplant Coordinators
Which organs can be donated?
• Heart (DBD/DCD) <65 years
• Lungs <70 years
• Kidneys
• Liver
• Pancreas <65 years
• Bowel (DBD) <65 years
• Tissues
Possible for 1 person to help save
the lives of 9 people
10. South Thames Regional Donor Transplant Coordinators
Tumour
Trauma
Intra-cerebral
Hemorrhage
Ischemia
Brain Stem
How does brain stem death occur?
• Not enough blood & oxygen
reaching the brain
• Most common causes → Raised
ICP
• As brain stem compressed,
pressure and ischemia causes
more systemic changes.
• Initially cushing’s reflux occurs
with raised BP and a subsequent
bradycardia – attempt to restore
cerebral circulation.
• Followed by variety of arrhythmias
due to vasodilation.
• Permanent & irreversible damagePermanent & irreversible damage
occursoccurs
11. South Thames Regional Donor Transplant Coordinators
Different types of brain
herniation.
(1) Subfalcine ‘midline’ herniation—can
cause ipsilateral anterior cerebral artery
occlusion.
(2) Tentorial herniation—herniation of the
uncus (medial temporal lobe) through the
tentorial hiatus causing compression of
the occulomotor nerve and brain stem.
(3) Central herniation – diffuse supratentorial
swelling causing vertical displacement of
the midbrain through the tentorial hiatus.
(4) Tonsillar herniation—a subtentorial
expanding mass or greater supratentorial
pressure causes herniation of the
cerebellar tonsils through the foramen
magnum.
12. South Thames Regional Donor Transplant Coordinators
Stages of Brain Stem Herniation
• Infarction of the Brain stem – Hypertension &
Bradycardia (Cushing's Triad) – Duration varies
Hypertension (SBP 300 or above / Wide Pulse pressure and
Bradycardia)
• Unopposed Adrenergic activity- Catecholamine storm
& Cranial Diabetes Insipidus – Haemodynamic
instability and vasoconstriction (Myocardial ischemia /
ventricular dysfunction – Can make the heart unsuitable) – Can
Treat HTN (Short acting agents like Esmolol)
• Second phase: Profound hypotension and
hypothermia
13. South Thames Regional Donor Transplant Coordinators
Pre-conditions for testing
• Patient’s condition is due to irreversible brain damage of
known aetiology
• Cardiovascular stability +/- drugs
• Exclude potentially reversible causes of coma:
– Depressant Drugs / paralysis influencing agents
– Hypothermia
– Circulatory, Metabolic and Endocrine causes
(hypernatraemia, acidosis, blood sugar, Na, K+, Mg)
• Exclude potentially reversible causes of apnoea
– Neuromuscular Blocking Agents
– High Cervical Cord Injury
14. South Thames Regional Donor Transplant Coordinators
Equipment's
• Light source, small gauze sterile swabs,
Otoscope, 50ml syringe, ice cold water, a
spatula, yanker sucker, Laryngoscope, ET
suction catheters, Inco pad and kidney dish
• Documentations
15. South Thames Regional Donor Transplant Coordinators
Tests
• 2 doctors - Consultant or senior SPR
• Must conduct the tests together
• Tests repeated (2 full sets of tests,
including apnoea test)
• Tests examine brain stem function by
testing cranial nerve reflexes and
respiratory drive
17. South Thames Regional Donor Transplant Coordinators
Testing for Brain-stem Death
17
“This form is consistent with and should be used in conjunction with, the
AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of
Death and has been endorsed for use by the following institutions:
Faculty of Intensive Care Medicine, Intensive Care Society and the
National Organ Donation Committee.”
Full
Abbreviated
19. South Thames Regional Donor Transplant Coordinators
PUPILS FIXED AND DILATED, NOTPUPILS FIXED AND DILATED, NOT
RESPONDING TO LIGHTRESPONDING TO LIGHT
PUPILS FIXED AND DILATED, NOTPUPILS FIXED AND DILATED, NOT
RESPONDING TO LIGHTRESPONDING TO LIGHT
Cranial nerves 2,3 (Midbrain)Cranial nerves 2,3 (Midbrain)
20. South Thames Regional Donor Transplant Coordinators
NO BLINKING TO TOUCHNO BLINKING TO TOUCH
OR CORNEAL REFLEXOR CORNEAL REFLEX
NO BLINKING TO TOUCHNO BLINKING TO TOUCH
OR CORNEAL REFLEXOR CORNEAL REFLEX
Cranial nerves 5,7 (Midbrain)Cranial nerves 5,7 (Midbrain)
21. South Thames Regional Donor Transplant Coordinators
VESTIBULO-OCULAR REFLEXESVESTIBULO-OCULAR REFLEXES
ARE ABSENT - NO EYEARE ABSENT - NO EYE
MOVEMENTS ARE SEEN DURINGMOVEMENTS ARE SEEN DURING
THE SLOW INJECTION OFTHE SLOW INJECTION OF
50MLS OF ICE COLD WATER.50MLS OF ICE COLD WATER.
VESTIBULO-OCULAR REFLEXESVESTIBULO-OCULAR REFLEXES
ARE ABSENT - NO EYEARE ABSENT - NO EYE
MOVEMENTS ARE SEEN DURINGMOVEMENTS ARE SEEN DURING
THE SLOW INJECTION OFTHE SLOW INJECTION OF
50MLS OF ICE COLD WATER.50MLS OF ICE COLD WATER.
Cranial nerves 3,6,8 (Midbrain, Pons & Medulla)Cranial nerves 3,6,8 (Midbrain, Pons & Medulla)
66thth
Nerve Palsy: OpthalmoplegiaNerve Palsy: Opthalmoplegia
22. South Thames Regional Donor Transplant Coordinators
NO MOTOR RESPONSES TONO MOTOR RESPONSES TO
SUPRAORBITALSUPRAORBITAL PRESSUREPRESSURE
NO MOTOR RESPONSES TONO MOTOR RESPONSES TO
SUPRAORBITALSUPRAORBITAL PRESSUREPRESSURE
Cranial nerves 5,7 (Pons)Cranial nerves 5,7 (Pons)
23. South Thames Regional Donor Transplant Coordinators
NO GAG OR COUGH REFLEX TONO GAG OR COUGH REFLEX TO
BRONCHIAL STIMULATIONBRONCHIAL STIMULATION
NO GAG OR COUGH REFLEX TONO GAG OR COUGH REFLEX TO
BRONCHIAL STIMULATIONBRONCHIAL STIMULATION
Cranial nerves 9, 10, 11, 12 (Medulla)Cranial nerves 9, 10, 11, 12 (Medulla)
24. South Thames Regional Donor Transplant Coordinators
APNOEA TEST -APNOEA TEST -
NO RESPIRATORYNO RESPIRATORY
MOVEMENT WHENMOVEMENT WHEN
THE PATIENT ISTHE PATIENT IS
DISCONNECTEDDISCONNECTED
FROM MECHANICALFROM MECHANICAL
VENTILATIONVENTILATION
(Medulla)(Medulla)
APNOEA TEST -APNOEA TEST -
NO RESPIRATORYNO RESPIRATORY
MOVEMENT WHENMOVEMENT WHEN
THE PATIENT ISTHE PATIENT IS
DISCONNECTEDDISCONNECTED
FROM MECHANICALFROM MECHANICAL
VENTILATIONVENTILATION
(Medulla)(Medulla)
25. South Thames Regional Donor Transplant Coordinators
Apnoea testing
• Do a baseline ABG
• Pre-oxygenate with 100%
• Arterial Blood Gas taken to confirm PaCO2 and SaO2
correlation with EtCO2 and SpO2 levels
• Reduce MV / rate to allow slow increase in EtCo2 to
6.0kPa or just above
• Recheck ABG to confirm PaCO2 >6.0 and pH <7.40
• As long as cardiovascularly stable, disconnect from
ventilator
26. South Thames Regional Donor Transplant Coordinators
Apnoea Testing
• Maintain oxygenation by 6 l/min via tracheal catheter
or water circuit.
• Observe for respiratory movements for 5 min - No
respiratory effort seen
• Repeat ABG after 5 mins and reconnect to ventilator –
Do not wait for ABG results
• ABGs : observe if CO2 risen by 0.5KPa
• Ventilate, allow PaCO2 to normalise
• Repeat test (Allow time between sets to allow PaCO2
to return to baseline)
27. South Thames Regional Donor Transplant Coordinators
TWO TESTS
• ALIVE
• ALIVE
• DECEASED
TEST 1
TEST 2
TIME OFTIME OF
DEATHDEATH
28. South Thames Regional Donor Transplant Coordinators
Incidence of common physiological derangements in brain-
dead patient
Derangement Cause Approx incidence
Hypothermia Hypothalamic damage, reduced metabolic
rate, vasodilation and heat loss.
Invariable if not
prevented
Hypotension Vasoplegia, hypovolaemia, reduced coronary
blood flow, myocardial dysfunction.
81-97%
DI Posterior pituitary damage 46-78%
DIC Tissue factor release, coagulopathy 29-55%
Arrhythmias Catecholamine storm, myocardial damage,
reduced coronary blood flow
25-32%
Pulmonary
Oedema
Acute blood flow diversion, capillary damage 13-18%
McKeown, Bonser & Kellum 2012
29. South Thames Regional Donor Transplant Coordinators
Optimising the
brainstem dead
donor
29
30. South Thames Regional Donor Transplant Coordinators
Management of Brain stem
dead patient in ICU
• Series of pathophysiological responses / instability
associated with brain stem ischemia.
• This can have damaging effects on the organ
systems.
• If instability is not managed can lead to deterioration
in organ function before retrieval.
• 20% of donors dies due to CVS instability prior to
donation.
31. South Thames Regional Donor Transplant Coordinators
Key Points
• Catastrophic Brain Injury Pathway or CBI
• DBD donation
BSD is followed by a predictable pattern of
complex MOF
Support before and after brain death can improve
the number and quality of organs
Increasing numbers of marginal donors are being
accepted
• NICE guidelines and implications
33. South Thames Regional Donor Transplant Coordinators
DBD donation process
Patient receives full treatment/Discussion & Plan
Death Confirmed
Organ
donation
Transfer to theatre
(remains ventilated)
Death Suspected
34. South Thames Regional Donor Transplant Coordinators
Spinal Reflexes in BSD Patients
• Movement in BSD subjects
• Spontaneous body movement may occur
• Generated by spinal cord
• May be caused by a variety of stimuli
– Apnoea / High CO2
– Incision
– Movement
Ranges from finger twitching to waist flexion!!
Sapasnik et al, Neurology 2000 : Occurs in 39% of patients
35. South Thames Regional Donor Transplant Coordinators
General measures
• Maintain normothermia (active warming may be required)
• Thrombo-embolism prophylaxis
• Stockings / Sequential compression devices / LMWH
• Positioning
• Head-up / Side to side
• Attention to cuff pressures and leaks to prevent aspiration
• Continue NG feeding (may be reduced/ stopped for bowel
transplant)
• Antibiotics according to sensitivities or empirical according to
Trust guidelines
35
brain stem is the posterior part of the brain, adjoining and structurally continuous with the spinal cord. In humans it is usually described as including the medulla oblongata(myelencephalon), pons (part of metencephalon), and midbrain (mesencephalon).
Of the twelve pairs of cranial nerves, ten pairs come from the brainstem.
Brain herniation is a potentially deadly side effect of very high intracranial pressure that occurs when a part of the brain is squeezed across structures within the skull.
Herniation can be caused by a number of factors that cause a mass effect and increase intracranial pressure (ICP): these include traumatic brain injury, intracranial hemorrhage, or brain tumor. Because herniation puts extreme pressure on parts of the brain and thereby cuts off the blood supply to various parts of the brain
Need to be treated with careful fluids and vasopressin
High-dose catecholamine infusions have been shown to worsen ischaemia and organ function and vasopressin
may allow dose reduction
Episodes where a comprehensive neurological examination cannot be carried out, for example, after severe maxillofacial trauma;
when the influence of residual sedation cannot be excluded;
Can be used EEG or angiogram to identify the absence of cerebral blood flow.
(Optic & occulomotor)
Dilated pupils may even occur in the presence of brain death, because
sympathetic cervical pathways to the pupillary dilator muscle may still be intact.
The light reflex is absent in brain death.
3.5th & 7th cranial nerves (trigeminal, Facial)
Care should be taken to avoid any damage to the cornea.
Corneal reflexes are tested here by using a cotton swab across the eye
Blinking would be absent.
3rd, 6th, & 8th cranial nerves (caloric test, no eye movements “dolls eye”) (Occulomotor, abducens and auditory)
Usually injected on to the tympanic membrane over 1 minute.
No deviation of the eyes occurs
Contraindication to testing is impaired integrity of the membrane.
Ocular Movements can be tested Oculocephalic (dolls-eyes). No eye movements
occur in response to head movements.
Contraindication to testing is a suspected fracture or instability of the cervical spine
No grimacing to pain from pressure to the supra orbital ridge or tempro-
mandibular joint
No limb response.
4.9th & 10th cranial nerves (Glossopharygeal & vagus)
Suction or move the tube back and forth to stimulate a cough
or gag response
Suction or move the tube back and forth to stimulate a cough
or gag response
DIC is a pathological process characterized by the widespread activation of the clotting cascade that results in the formation of blood clots in the small blood vessels throughout the body. This leads to compromise of tissue blood flow and can ultimately lead to multiple organ damage. In addition, as the coagulation process consumes clotting factors and platelets, normal clotting is disrupted and severe bleeding can occur from various sites. DIC does not occur by itself but only as a complicating factor from another underlying condition, usually in those with a critical illness.
Pathophysiological changes during brain stem death result in pituitary failure.
Current evidence suggests that hormonal therapy may be beneficial.
Methylprednisolone: 15 mg/kg bolus
If urine output &gt; 4ml/kg/h then DDAVP 1-4 mcg. Maintain urine output 0.5- 2.0mls/kg/hr
Vasopressin: 1 IU bolus then 0.5e5 IU/h infusion
Insulin: 1 unit/h infusion minimum (titrate to blood glucose 4e8 mmol/l)
Tri-iodothyronine (T 3)