Download Brain Stem Death

Brain Death in The ICU
Dr. Jonathan Goodall
M62 Coloproctology Course
March 22nd 2007
Scope
Development of Concepts
Diagnosis of Brain Stem Death (BSD)
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Preconditions
Testing brain stem function
Implications
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Organ donation
Recent developments
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Non-heart beating donation
JRG M62 Meeting 3/2007
Development of Concepts of BSD
Mollaret and Goulon – ‘Le coma dépassé’
Rev Neurol 1959; 101: 3-15
Ad Hoc Committee of Harvard Medical
School 1968 JAMA 1968; 205: 85-8
Minnesota Criteria ~ 1971
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Notion of aetiological preconditions
Conferences of Medical Royal Colleges
and their Faculties Br Med J 1976;ii: 1187-8; Br Med J
1979; i: 3320
From Brain Death to Brain Stem Death
JRG M62 Meeting 3/2007
Pallis C, Br. Med J 1982; 285: 1487-1490
Development of Concepts of BSD
Cadaveric organs for transplantation: A
code of practice including the diagnosis of
brain death. London 1983 HMSO
JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007
Diagnosis of BSD: Preconditions
The patient is deeply unconscious.
There should be no doubt that the patient's
condition is due to irremediable brain
damage of known aetiology.
JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007
Diagnosis of BSD: Preconditions
There is no evidence that this state is due
to depressant drugs.
Primary hypothermia as the cause of
unconsciousness must have been
excluded.
Potentially reversible circulatory, metabolic
and endocrine disturbances excluded.
JRG M62 Meeting 3/2007
Diagnosis of BSD: Preconditions
The patient is being
maintained on a
ventilator because
spontaneous
ventilation has been
insufficient or has
ceased altogether.
JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007
 Testing
Brain Stem
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JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007
BST – Response to Pain
No motor responses within the cranial
nerve distribution can be elicited by
adequate stimulation of any somatic area.
There is no limb response to supra-orbital
pressure.
JRG M62 Meeting 3/2007
BST- Apnoea Test
No respiratory
movements occur
when the patient is
disconnected from the
mechanical ventilator.
PaCO2 should reach
6.65kPa.
Hypoxia prevented by
apnoeic oxygenation
JRG M62 Meeting 3/2007
BST – Who?
Must be made by at least two medical
practitioners
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Registered for at least 5 years
Are competent in this field
Are not members of the transplant team
At least one must be a consultant
Repetition of testing and time of death
JRG M62 Meeting 3/2007
Organ Donation
Involvement of family
Legal situation
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Donor cards
Authorisation of removal of organs
Designated person
In absence of relatives
Involvement of HM Coroner
JRG M62 Meeting 3/2007
Retrieval of Organs & Tissues
Transplant co-ordinator
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Practical details
Screening Tests
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Tissue compatibilty
Viral screening
Organ retrieval and transplant
JRG M62 Meeting 3/2007
Care of the Potential Donor
Good medical care
Maintenance of organ perfusion
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Appropriate monitoring
Inotropes and vasopressors
Hormone replacement
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DDAVP
Thyroid Hormones
Steroids
JRG M62 Meeting 3/2007
Non-Heart Beating Donor
Response to organ shortages
Organs removed from donors in death
ascertained by cardiac criteria
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‘stand off period after declaration of death’
Variable time of ‘warm ischaemia’
Reasonable outcomes – delay in recovery
of function
JRG M62 Meeting 3/2007
UK Donation ‘05/’06
Organs from 764 people were used in
2,195 transplants
125 non-heartbeating donors, 44% more
than the previous year.
At the end of March 2006, 6,698 patients
were listed as actively waiting for a
transplant, a 9% increase compared to the
previous year.
JRG M62 Meeting 3/2007
Summary
Concept of Brain death established and
accepted
Strict guidelines for establishing brain
death – BST
Organ transplantation process well
organised
JRG M62 Meeting 3/2007
Almost a million more people pledged to
help others after their death by registering
their wishes on the NHS Organ Donor
Register, bringing the total at 31 March
2006 to 13,122,056.
JRG M62 Meeting 3/2007