Definition

U.S. standard U.K. standard

 Complete and irreversible  Complete and irreversible
loss of entire brain and loss of brainstem function.
brainstem activity.
Legally
, brain stem function.
British physician only needs to document loss of

U.S. physician must document loss of brain (cerebral)

and brainstem functions.
No one has ever recovered from such case. In other
words, till now there is no cure or treatment
found for brain dead patient.
“Published studies of patients meeting the criteria for brain stem
death or whole brain death – the American standard which includes
brain stem death diagnosed by similar means – record that even if
ventilation is continued after diagnosis, the heart stops beating
within only a few hours or days”
Adapted from Smith M. Physiologic changes during brain stem death-lessons for
management of the organ donor. J Heart Lung Transplant 2004;23:S217-22.
The concept of brain death is specific.

It does not apply to patients existing in a

Persistent vegetative state
other severe degrees of brain damage from causes
such as metabolic derangements, drug intoxication
etc.
Difference between brain death
and a persistent vegetative state
Brain death Persistent vegetative state
 Irreversible coma  Brainstem function
 Complete loss of brainstem unaffected
function  Sleep-wake cycle
 Brain dead = Dead (RAS)
 PVS may recover
Difference between persistent vegetative state
and Minimal responsive state

Persistent vegetative state Minimal responsive state

 Sleep-wake cycle (RAS)
 Brainstem function
unaffected
 No response to
environmental stimuli
 Sleep-wake cycle (RAS)
 Brainstem function
unaffected
 Variable interaction with
environmental stimuli
Diagnosis
Is a clinical diagnosis
 Three cardinal findings necessary for brain death:

Irreversible coma
Absence of brainstem reflexes
Apnea
who and how ? When ?
 2 Neurological tests  Adults :
 1 Apnea test  30 min – 12 hr

 2 Physicians and 1 should

be  Children :
a consultant  12 - 48 hrs
 Non of them from transplant
team
Irreversible coma :
 Evidence of an “acute CNS
catastrophe” that is compatible with
the clinical diagnosis of brain death

 Exclusion of complicating medical

conditions that may confound the
clinical assessment
 No severe electyrolyte, acid-
base, or endocrine disturbance
 No drug intoxication or
poisoning
 Core temperature >35 degrees
celsius
 Absent Brainstem reflexes

No grimace to pain No ocular movement to

No Pupillary OCR or caloric testing
responses
No corneal reflex No gag or cough
response
Pupils response

 Brain dead: Mid-size (4-6mm), unreactive pupils (affecting both

sympathetic and parasympathetic)

 Pre-existing pupilary abnormality Cataract ,eye surgery. limit the

test
• No corneal reflex
 lack of eyelid movement after
touching the cornea (not
conjunctiva) with a cotton
swab or tissue
 Technique: Oculocephalic reflex (“Doll’s eye”)
 Check No C-spine injury
 Use both hands
 Turn head to one side and
observe for both eyes movement
 Turn head to other side and
observe for both eyes movement
 Can be done vertically and
horizontally

 Normal response: both Eyes move

contralateral to direction of head
turn

 Brain dead show no eye

movement
Vestibulo-oculogyric reflex (Caloric test)
 Technique :
 No wax ,TM intact
 Elevate the HOB 30°
 Irrigate tympanic membranes with
50ml iced water
 Observe both eyes movement for 1
minute after ear irrigation,
 Wait 5 minute before testing the other
ear

 Normal response: both eyes deviates

towards the cold ice ear

 Brain death: no Eye movement

 Facial trauma involving the auditory

canal and petrous bone can also inhibit
these reflexes
 No grimace to pain
 Pressure on supra-orbital
ridge (to rule out any
spinal cord injury or  Absent coughing reflex
spinal- mediated reflexive
motor responses)
 Absent Gag reflex
 Tunge depressor
 Insertion of suction tube
through the ETT
 Minimal movement of the
ETT
Apnea Testing
Prerequisites are required:
The core temperature needs to be > 35
Systolic BP > 90 mmHg
Patient should be euvolemic
PaCO2 ~ 40-45 mmHg
 PaO2 ~ 200 mmHg (to guard against
desaturation during apnea)
Technique:
 Pre-oxygenate with 100% oxygen for several min till pO2 ~
200mmHg baseline PaCO2 to be ~40 mmHg
 Disconnected from the ventilator and Advance a cannula 1-
2 cm beyond the end of the ETT with 8-12 L/min
humidified O2
 Observe for respiratory effort for ~6-10 minutes
 Get ABG to determine PaCO2

• Result is positive if PaCO2 levels greater than 60 mmHg, or ≥20

mmHg over baseline and there is no respiratory effort

• Reconnect patient to Mechanical ventilator and document the

test.
• Stop the test at any time and
reconnect to MV if the patient
develops:
 Arrythmias,
 Hypotention,
 Desaturation

 Confirmatory tests are necessary

for patients who do not achieve
adequate levels of hypercarbia
prior to becoming unstable.
Ancillary Testing
 Not necessary to establish brain death in the vast majority of
cases
 Not a substitute for clinical exam
 Tests not 100% sensitive or specific
 Reserve for cases where entire exam can’t be done, for example:
 Severe facial trauma
 Preexisting pupillary abnormalities (cataract,eye surgery)
 unstable patient intended for organ donation
 Children under 1 yr
Ancillary Testing for Brain Death
Cerebral angiography

EEG
Brain death in children
7 days of age to 2 mo:
 two examinations + EEGs separated by 48 hr

2 mo to 1 yr of age:
 two examinations + EEGs separated by at least 24 hrs
 initial examination + isoelectric EEG followed by
nuclear medicine study confirming no cerebral blood
flow

> 1 yr of age:
 two examinations at least 12 hrs apart, with EEG and
cerebral nuclear medicine blood flow studies optional but
recommended
Delivering the news
Most families have a better understanding of the organ
donation process if the ICU staff entirely separates the
declaration of brain death from discussions about
organ donation.

Thus, the determination of brain death is performed first

and presented to the family who are given time to digest
the information.

Before support is withdrawn ,a request for organ

donation is made by a representative of the Organ
Procurement Organization (OPO).
 Say “Dead” not “brain dead”

 Say “Artificial or mechanical ventilation” not “life support”

 Time of death = Time of 1st neurological examination

 Not when ventilation removed
 Not when heart beats stop

 Don’t say ”kept alive” for organ donation

 Don’t talk as if he/she’s still alive

Other than for potential organ donation, there is
no legal or medical rationale to oxygenate the
cadaver.

No family permission is required to cease

ventilation of the corpse; none should be
requested.
Physician should inform the family that the patient
is dead.
Physician should request organ donation.
If declined, the physician should inform ”not ask” the
family that all medical interventions will be
withdrawn.
Decoupling of the process of brain death declaration from
the request for organ donation has resulted in an
increase in next of kin authorizing organ donations.
Question 1
What is the posture of a brain dead
patient ?
Decerebrate
Decorticate
None of the above
Question 2
Which of the fallowing is present in brain
dead:
Biceps reflex
Triceps reflex
Jaw reflex
Knee reflex
Superficial Abdominal reflex
Question 3
Which part of the brain has the
thermoregulation center ?
Cortex
Thalamus
Hypothalamus
Midbrain
Medulla
Question 4
If thermoregulation center is in the hypothalamus
and the patient is brain dead how to maintain
core body temperature >35 ?