The document discusses the criteria for determining brain death. It defines brain death as the irreversible loss of function of the entire brain, including the brain stem. It discusses the preconditions that must be met before determining brain death, including unresponsive coma, a cause capable of producing brain death, and determining the damage is irreversible. It also discusses the examinations and tests used in determining brain death, including clinical examinations, apnea testing, EEGs, evoked potentials, transcranial Doppler, cerebral angiography and more. Recommendations are provided about the AAN practice parameters for determining brain death and need for further evidence around certain aspects of the diagnosis.

3. *La ME se define como el cese irreversible en las
funciones de todas las estructuras neurológicas
intracraneales, tanto de los hemisferios
cerebrales como del troncoencéfalo.
*Esta situación clínica aparece cuando la presión
intracraneal (PIC) se eleva por encima de la
presión arterial sistólica (PAS) del paciente, lo
que da lugar a la parada circulatoria cerebral.

4. *The Canadian forum on NDD defined
neurologically determined death as the
irreversible loss of the capacity for
consciousness combined with the irreversible
loss of all brain stem functions, including the
capacity to breathe.
*In the United States, the Uniform Determination
of Death Act defines “brain death” as the
irreversible cessation of all functions of the
entire brain, including the brainstem.

7. *
* Pallis and Harley14 of the United Kingdom define the time of
the first assessment for brain death as the point when the
preconditions for the diagnosis of brain death have been met;
unresponsive apneic coma, a cause of coma capable of
producing brain death, and a determination that the damage
is irremediable.
* The Australian and New Zealand Intensive Care Society
guidelines recommend that no fewer than 4 hours of
documented coma should precede the first examination for
brain death.

8. * The time of the first assessment for brain death is the point
when the preconditions for the diagnosis of brain death have
been met, with the following exceptions:
* In cases of acute hypoxic-ischemic brain injury, clinical
evaluation for NDD should be delayed for 24 hours after the
cardiorespiratory arrest or when an ancillary test could be
performed.
* In cases of extreme metabolic insult, enough time should
have passed for the clinician to think that the insult is
permanent and there should be evidence of diffuse cerebral
insult on imaging (magnetic resonance imaging [MRI]). If
irreversibility remains an issue, an ancillary test should be
performed in addition to the clinical examination.

9. *
* Based on this evidence, the AAN guidelines state that a single
examination suffices to establish the diagnosis but that US
state statutes require 2 examinations, especially in the
context of organ donation.
* The Canadian guidelines state that for the purposes of a
postmortem transplant, the fact of death shall be determined
by at least 2 physicians. The examinations may be performed
concurrently. However, if the determinations are performed
at different times, a full clinical examination, including
apnea testing, must be performed at each determination. No
fixed interval of time is recommended for the second
determination except when age-related criteria apply.

10. *Estabilidad cardiocirculatoria
*Oxigenación y ventilación
adecuada
*Ausencia de hipotermia grave.
*

11. *Alteraciones metabólicas
*Intoxicaciones
*Depresores del SNC.
*Muerte tronco-encefálica aislada: Loss of ascending
reticular activating system function would lead to
the loss of consciousness the hypothalamus and
interruption of the corticothalamic tract in his
diagrams as an extended brainstem.
*

13. *COMA ARREACTIVO
*AUSENCIA DE REFLEJOS TRONCO-ENCEFALICOS.
*AUSENCIA DE AUTONOMIA RESPIRATORIA: Test
de atropina, test de apnea.
*ACTIVIDAD MOTRIZ ESPINAL
*

14. *ELECTROENCEFALOGRAMA
*POTENCIALES EVOCADOS.
*DOPPLER TRANSCRANEAL
*GAMAGRAFIA CEREBRAL
*ARTERIOGRAFIA CEREBRAL
*

15. * RECOMMENDATIONS
* The criteria for the determination of brain death given in the 1995
AAN practice parameter have not been invalidated by published
reports of neurologic recovery in patients who fulfill these criteria.
* 2. There is insufficient evidence to determine the minimally
acceptable observation period To ensure that neurologic functions
have ceased irreversibly.
* 3. Complex-spontaneous motor movements and false-positive
triggering of the ventilator may occur in patients who are brain
dead.
* 4. There is insufficient evidence to determine the comparative
safety of techniques used for apnea testing .
* 5. There is insufficient evidence to determine if newer ancillary
tests accurately confirm the cessation of function of the entire
brain.
*

17. * Capítulo VI
* De la Voluntad de Donación
* Artículo 10.- Voluntad Presunta.- Es la presunción
legal que
establece que todos los ecuatorianos y extranjeros residentes
legalmente en el país, mayores de dieciocho años, al fallecer se
convertirán en donantes a menos que en vida hubiesen
manifestado su voluntad en contrario, de acuerdo a lo
establecido en el artículo 29 de la ley.
*