Brain Death

Brain Death – Amelia Muhs

Background

  • Brain death = legal death; time of death is the time of the brain death exam
  • It is not required that neurology is consulted, but they often are
  • Must complete declaration of brain death note in Epic
  • Apnea testing and brain death determination
    • An attending MUST be present for apnea testing and brain death exam
    • If loved ones are present for apnea testing, it may be helpful to explain the process to them. Family may expect that the pt’s heart will stop during testing. Explain that brain activity is not required to keep the heart beating. Explain that at the end of the test, the pt will be reconnected to the ventilator. Communication is VERY important.
  • Organ donation caveats
    • TDS number: 1-800-969-4438 – call early
    • Discussions about organ donation should take place between Tennessee Donor Services (TDS) and the surrogate. You SHOULD NOT be having extensive conversations with the surrogate about donation. Direct questions to TDS.
    • After a pt is declared brain dead, if they will be a donor, TDS will usually take over medical management of the pt. This can get confusing, so make sure to be in contact with the TDS representative with any questions

 

Checklist for Determination of Brain Death (American Academy of Neurology)

1. Prerequisites (all must be checked)

  • Coma, irreversible and cause known
  • Neuroimaging explains coma – usually CT or MRI
  • CNS depressant drug effect absent (if indicated, toxicology screen; if barbiturates given, serum level <10 μg/mL)
  • No evidence of residual paralytics (electrical stimulation if paralytics used)
  • Absence of severe acid-base, electrolyte, endocrine abnormality
  • Normothermia or mild hypothermia (core temp >36°C)
  • SBP ≥100 mm Hg
  • No spontaneous respirations

 

2. Examination (all must be checked) – Attending MUST be present for brain death exam

  • Pupils nonreactive to bright light
  • Corneal reflex absent
  • Oculocephalic reflex absent (tested only if C-spine integrity ensured)
  • Oculovestibular reflex absent
  • No facial movement to noxious stimuli at supraorbital nerve or TMJ
  • Gag reflex absent
  • Cough reflex absent to tracheal suctioning
  • Absence of motor response to noxious stimuli in all four limbs (spinal reflexes permissible)

 

3. Apnea testing (all must be checked) – The RTs know how to do this and should be at the bedside with you. Attending MUST be present.

  • Pt is hemodynamically stable
  • Ventilator adjusted to provide normocarbia (PaCO2 35–45 mm Hg)
  • Pt preoxygenated with 100% FiO2 for >10 minutes to PaO2 >200 mm Hg
  • Pt well-oxygenated with a positive end-expiratory pressure (PEEP) of 5 cm of water
  • Provide oxygen via a suction catheter to the level of the carina at 6 L/min or attach T-piece with continuous positive airway pressure (CPAP) at 10 cm H2O
  • Disconnect ventilator
  • Spontaneous respirations absent.
  • Arterial blood gas drawn at 8–10 minutes, pt reconnected to ventilator
    • PCO2 ≥60 mm Hg, or 20 mm Hg rise from normal baseline value; OR:
    • Apnea test aborted. – abort if spontaneous respirations present, pt develops hemodynamic instability, or becomes hypoxic
       

4. Ancillary testing (only one needs to be performed; to be ordered only if clinical examination cannot be fully performed due to pt factors, or if apnea testing inconclusive or aborted)

  • Cerebral angiogram
  • HMPAO SPECT (Single photon emission computed tomography)
  • EEG & TCD (transcranial Doppler)