End of life care Brain death Declaration Process

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Brain death Declaration Process and pitfalls

Potential donors Brain death Age < 70 Yrs No severe infection No severe chronic HT

The road to Dx of brain death 1. Essential preconditions Irremediable structural brain damage 2. Necessary exclusions Toxic metabolic causes 3. Tests Absent brainstem reflexes Apnea test

Timing The time before testing The time taken (a) To satisfy the preconditions (b) To exclude toxic and metabolic causes

Examples of observation periods in hours before testing Apnoeic coma after Major neurosurgery Second subarachnoid bleed Head injury Spontaneous hemorrhage Brain hypoxia Suspicion of drug intoxication >4 >6 >6 >24 >50

Female 56 y sudden Rt hemiparesis with confusion

Sudden change to coma with dilated fixed pupils

MALE 22 y MCA Decerebrate pupils Rt 5 Lt 3 sluggish RTL CT brain IV Manitol GCS=3 Pupils 5 mm fixed both 6 hr Decorticate pupils Rt 5 Lt 3 fixed Operate but not recover

35 y. old male, initial GCS 3 and fixed dilated pupils CT showing operable SDH 2 hr. operated Good recovery Pre op CT 3 rd d. post op. CT 3 wk post op

The tests for Dx of brain death Absent brainstem reflexes Apnea test Preoxygenation with 100%O 2 for 10 min. Reduce ventilation rate 10 ml/kg 10/min Insufflate with 100%O 2 at 6 lit/min to carina Maintain disconnection for Pa. CO 2=60 mm. Hg

O 2 canula to carina 100% 10 Lit/min