Brain Death in the Adult Patient Kathrin Husmann

Brain Death in the Adult Patient Kathrin Husmann, MD Assistant Professor Medical Director, NEICU

Topics § § § History of brain death Definition and diagnosis of death Death as a legal construct AAN guidelines on diagnosis of brain death Diagnosis and pitfalls of diagnosis of death

The Fair: Those Death Takes by Surprise Marcel Roux 1905

§ § Zack Dunlap 21 y/o s/p ATV accident November 2007 Pronounced brain dead

§ Today show interview in March 2008 § “I feel pretty good…”

§ § § Jahi Mc. Math 13 y/o s/p ENT surgery December 2013 Subsequent cardiac arrest Pronounced brain dead

What is it to be dead?

Definition of Death Merriam-Webster’s on-line dictionary 1 a : a permanent cessation of all vital functions : the end of life Pronunciation: ’deth Function: noun Etymology: Middle English deeth, from Old English dēath; akin to Old Norse dauthi death

Diagnosis of Death “permanent cessation of all vital functions” § How long is permanent?

"The boundaries which divide Life from Death are at best shadowy and vague. Who shall say where the one ends, and the other begins? “ § Edgar Allan Poe, "The Premature Burial"

Diagnosis of Death “permanent cessation of all vital functions” § cardiac and respiratory function

After four years of reflection, we believe the time has come to add a new chapter in the traditional field of comas.

Le Coma Depasse § § § No spontaneous respirations No reflexes Polyuria Low blood pressure requiring norepinephrine Absence of all EEG activity

“Irreversible Coma” § Loftstedt S. von Reis G. Intracranial lesions with abolished passage of x-ray contrast through the internal carotid arteries. PACE 1956 § Wertheimer P, Jouvet M, Descotes J. A propos due diagnostic de la mort du systeme nerveux dans les comas avec arret respiratoire traites par respiration artificielle. Presse Med 1959 § Schwab RS Potts F Mathis P. EEG as an aid in determining death in the presence of cardiac activity. Electroencaphalogr Clin Neurophysiol 1963 § Appel JZ. Ethical and legal questions posed by recent advances in medicine. JAMA 1968.

Harvard criteria - 1968

“to define Irreversible Coma”

Harvard Criteria “to determine the characteristics of a permanently nonfunctioning brain” 1. Unreceptivity and unresponsitivity 2. No movements or breathing 3. No reflexes 4. Flat electroencephalogram Exclusion of hypothermia or CNS depressants All of the above 4 tests shall be repeated at, at least 24 hours, with no change.

Death by Neurologic Criteria Minnesota criteria – 1971 The United Kingdom Code – 1976 U. S Collaborative Study criteria – 1977 President’s Commission – 1981 American Academy of Neurology guidelines – 1995

Skull of a Skeleton with Burning Cigarette Vincent van Gogh 1885

Death as a legal construct § Definition of death is determined by state legislatures § Initially based on cardiac and respiratory definitions

Kansas Determination of Death § Chapter 77. --STATUTES; ADMINISTRATIVE RULES AND REGULATIONS AND PROCEDURE § Article 2. --STATUTORY CONSTRUCTION § 77 -205. Determination of death. An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards. § History: L. 1984, ch. 345, § 1; July 1.

Brain death as death § In 1970, Kansas was the first state to incorporate the brain death criteria as one determination of death. § The statute proposed by a physician legislator was adopted without substantial debate

Uniform Determination of Death Act § 1981 by National Conference of Commissioners of Uniform State Laws § Adopted by most US states § “to provide a comprehensive and medically sound basis for determining death in all situations. ”

Brain Death is Death § Uniform Determination of Death Act § Determination of Death § An individual who has sustained either § (1) irreversible cessation of circulatory and respiratory functions, or § (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. § A determination of death must be made in accordance with accepted medical standards

Missouri Revised Statutes § Chapter 194 Death--Disposition of Dead Bodies Section § 194. 005 August 28, 1999 Death, legal definition. § 194. 005. For all legal purposes, the occurrence of human death shall be determined in accordance with the usual and customary standards of medical practice, provided that death shall not be determined to have occurred unless the following minimal conditions have been met: (1) When respiration and circulation are not artificially maintained, there is an irreversible cessation of spontaneous respiration and circulation; or (2) When respiration and circulation are artificially maintained, and there is a total and irreversible cessation of all brain function, including the brain stem and that such determination is made by a licensed physician. (L. 1982 H. B. 1223 § 1)

The Death of the Gravedigger Carlos Schwabe 1895

Possible Brain Death § Examination shows no sign of brain function § No corneal, doll, gag, cough, grimace § Pupils are non-reactive § No response to painful stimuli § Does not over-breathe ventilator

Spectrum of Brain injury Brain function in coma, vegetative state and related disorders, Lancet 2004

AAN Practice Parameters § Definition of brain death “irreversible loss of function of the brain, including the brainstem” Practice Parameters: Determining Brain Death in Adults, 1995 Updated in 2010, www. aan. com

AAN Practice Parameters: Determining Brain Death in Adults, 1995 Updated in 2010, www. aan. com

AAN Practice Parameters

AAN Practice Parameters § Cardinal findings § Coma § Absence of brainstem reflexes § Apnea

AAN Practice Parameters § Cardinal findings § Coma § No cerebral motor response to pain

AAN Practice Parameters § Cardinal findings § Absence of brainstem reflexes

Apnea testing

Apnea Testing

Apnea Testing § If respiratory movements are absent and arterial PCO 2 is ≥ 60 mm Hg, the apnea test result is positive § i. e. , it supports the diagnosis of brain death § If respiratory movements are observed, the apnea test result is negative § i. e. , it does not support the diagnosis of brain death § Consider if the test should be repeated

Apnea Testing – problems… § If, during testing, the systolic blood pressure becomes ≤ 90 mm Hg or the pulse oximeter indicates significant oxygen desaturation and cardiac arrhythmias are present; § immediately draw an arterial blood sample § CONNECT THE VENTILATOR § If PCO 2 is ≥ 60 mm Hg or PCO 2 increase is ≥ 20 mm Hg over baseline normal PCO 2, the apnea test result is positive § if PCO 2 is < 60 mm Hg or PCO 2 increase is < 20 mm Hg over baseline normal PCO 2, the result is indeterminate § an additional confirmatory test can be considered.

AAN Practice Parameters § Confounding factors § Severe facial trauma § Preexisting pupillary abnormalities § Sleep apnea or severe pulmonary disease resulting in chronic retention of CO 2

AAN Practice Parameters

Confirmatory testing § Angiogram § No intracerebral filling at the level of the carotid bifurcation or circle of Willis.

Confirmatory testing § EEG § Electrocerebral silence “No electrical activity during at least 30 minutes of recording that adheres to the minimal technical criteria for EEG recording in suspected brain death as adopted by the American Electroencephalographic Society, including 16 channel EEG instruments. ”

Confirmatory testing § Cerebral Scintigraphy “Technetium-99 m hexamethylpropyleneamineoxime brain scan. No uptake of isotope in brain parenchyma ("hollow skull phenomenon"). ”

Confirmatory testing § TCD ultrasound

Confirmatory testing § TCD ultrasound 1. Reversal of flow in diastole aka “to-fro” flow pattern OR 2. Systolic spike waveforms Absence of flow may not be reliable.

Variability of diagnosing brain death § Preclinical prerequisites fulfilled 53. 9% § Complete neurological examinations were documented in 76. 3%. § Apnea test was completed in 39. 5%. § Overall, strict adherence to current AAN guidelines for death by neurological criteria was correctly documented in 38. 2%. Pandey et al. Variability of diagnosing brain death at an academic medical center. 2017

The Best Doctor Alfred Kubin - 1903

§ § Zack Dunlap 21 y/o s/p ATV accident November 2007 Pronounced brain dead

§ § § Jahi Mc. Math 13 y/o s/p ENT surgery December 2013 Subsequent cardiac arrest Pronounced brain dead

Spectrum of Brain injury Brain function in coma, vegetative state and related disorders, Lancet 2004

Thank you

Pork Soda by Glass Animals Pineapples are in my head (Pineapples are in my head) Got nobody 'cause I’m brain dead (Got nobody 'cause I’m brain dead)