Declaring Brain Death. Ali Salim, MD Professor of Surgery Chief, Division of Trauma, Burns, Surgical Critical Care, and Emergency General Surgery
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1 Declaring Brain Death Ali Salim, MD Professor of Surgery Chief, Division of Trauma, Burns, Surgical Critical Care, and Emergency General Surgery
2 Disclosures I have nothing to disclose
3 Why should we know about donation??
4 29,532 Transplants performed in ,416 Donors
5 The Organ Shortage Problem 140, , ,000 80,000 60,000 40,000 Waiting list 19 deaths/day 20,000 0 Transplants 7000/year
6 Did you know?? Centers for Medicare/Medicaid Services & ACS Notification process Declaration of brain death Organ procurement organization (OPO) relationship Performance Improvement (PI) program Patient/family opportunity to donate
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9 Level I, II, III Trauma Centers Must have an established relationship with a recognized OPO Must have a written policy for triggering notification of the regional OPO Must review its solid organ donation rate annually Must have written protocols defining clinical criteria and confirmatory tests for the diagnosis of brain death
10 Level I, II, III Trauma Centers Must have an established relationship with a recognized OPO Must have a written policy for triggering notification of the regional OPO Must review its solid organ donation rate annually Must have written protocols defining clinical criteria and confirmatory tests for the diagnosis of brain death
11 Cause of Death of Donors 4% 21% 35% 40%
12 Outline Types of Donors Declaration of Brain Death Critical Care Management
13 Types of Donors Living Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
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15 Types of Donors Living donors 26% Deceased donors 74%
16 Types of Donors Living Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
17 Types of Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
18 Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
19 Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
20 Pre-requisites Known proximal cause & irreversibility Absence of confounders Electrolyte, metabolic, endocrine, acidbase disturbances Intoxication/drug effects
21 Pre-requisites Known proximal cause & irreversibility Absence of confounders Electrolyte, metabolic, endocrine, acidbase disturbances Intoxication/drug effects Hypothermia > 36 C (from 32) Systolic Blood Pressure > 100 mm Hg (from 90)
22 Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
23 Clinical Exam: COMA Adapted from: Wijdicks. NEJM Motor response to painful stimuli Sternum Supraorbital nerve Nail bed
24 Clinical Exam: BRAINSTEM REFLEXES Adapted from: Wijdicks. NEJM. 2001
25 Clinical Exam: BRAINSTEM REFLEXES Pupillary Light Reflex Corneal Reflex Gag Reflex Oculocephalic Reflex (Dolls Eyes) Oculovestibular Reflex (Cold Calorics)
26 Clinical Exam: APNEA Absence of a breathing drive Tested by CO2 challenge Prerequisites Normotension Normothermia Euvolemia Eucapnia (35-45) Absence of hypoxia
27 Clinical Exam: APNEA Apneic oxygenationdiffusion technique Repeat ABG: 8 min Arterial PCO2 > 60 mm Hg OR 20 mm Hg increase over baseline Adapted from: Wijdicks. NEJM. 2001
28 Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
29 Ancillary Tests Only if clinical exam incomplete, unreliable or unsafe 1. Brain perfusion scan 2. EEG 3. Transcranial doppler 4. Conventional angiography
30 Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
31 Documentation & Donation Time of death: pco 2 reached target value Ancillary test interpretation
32 Documentation & Donation Organ donation: Federal & State law requires contact with organ procurement association OPO to approach family
33 Controversies Second exam 6 h repeat (1995) No evidence-based interval California two physicians, two exams
34 Controversies Second exam 6 h repeat (1995) No evidence-based interval California two physicians, two exams Newer Ancillary Tests MRI/MRA CTA Bispectral index monitoring (BIS) Insufficient Evidence
35 Organ Donor Timeline 1 st Brain death 2 nd Brain Death OPO Management Family consent Injury Organ Retrieval
36 Types of Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
37 Types of Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
38 Timeline of DCDD
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41 Who are the Candidates? Patients with severe neurological injury Intracranial hemorrhage, stroke, anoxia, trauma Patients without neurological injury Degenerative neuromuscular diseases End-stage cardiopulmonary diseases
42 Who are the Candidates? Do not meet the criteria for brain death No chance for survival off the ventilator Family and physician elect to withdraw support
43 Where Will Withdrawal of Support Occur? Operating Room Family in attendance Family not in attendance Intensive Care Unit
44 What Happens if the Patient Does Not Expire? Occurs in up to 20% of cases Pre-donation discussion with family, physicians and nurses Patient transferred to pre-determined unit Treating team remains responsible for patient care
45 Which Organs? Presently; kidney, liver, pancreas Lungs and on rare occasions heart described Abt PL et al. JACS 2006;203:
46 Outline Types of Donors Declaration of Brain Death Critical Care Management
47 Outline Types of Donors Declaration of Brain Death Critical Care Management
48 Catecholamine surge HR, BP, CO, SVR
49 arrhythmias hypotension DI DIC acidosis pulmonary edema hypothermia
50 arrhythmias hypotension DI DIC acidosis pulmonary edema hypothermia
51 Wood et al NEJM 2004;351:
52 Hemodynamic Instability Organ Loss up to 25% Cardiovascular Collapse
53 Why? Hemodynamic instability Autonomic dysfunction Hypovolemia Aerobic to anaerobic metabolism Release of vasoactive inflammatory mediators Low levels of T 3, T 4, cortisol, insulin Reversal with replacement of T 3
54 Cardiovascular Collapse?? A fluid problem. A hormonal problem An attention problem Donor management is key to preventing collapse
55 New Terminology Catastrophic Brain Injury Guidelines (CBIG s) Goal to maintain hemodynamic stability in patients with devastating brain injury
56 What are CBIG s? Hemodynamic Management Invasive monitoring with endpoints
57 Hemodynamic Management Target criteria MAP > 60 PCWP 8-12 CVP 4-12 CI > 2.4 SVR Dopamine < 10
58 What are CBIG s? Hemodynamic Management Invasive monitoring with endpoints Hormonal therapy T3 or T4 Methylprednisolone Vasopressin
59 Hormone Therapy Rapid IV bolus of: 1 amp 50% dextrose 20 units insulin 2 g Solumedrol 20 mcg T 4 Continuous T 4 infusion at 10 mcg/h T 4 only used in hemodynamically unstable donors (combined vasopresssor dose > 10mcg/kg/min)
60 Actions of T3
61 What are CBIG s? Ventilator Management Appropriate tidal volumes (10 cc/kg) Prevent atelectasis Recruitment maneuvers Fluid restriction (diuretics) Bronchoscopy (frequent suctioning) Prevent aspiration (elevate HOB)
62 What are CBIG s? Management of complications Anemia Coagulopathy DI Electrolyte imbalances Arrhythmia's
63 Salim A. J Int Care Med. 2008
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65 Critical Care Endpoint DMG 1. Mean Arterial Pressure (MAP) mmhg 2. Central Venous Pressure (CVP) 4 10 mmhg 3. Ejection Fraction (EF) > 50% 4. Vasopressor use 1 and low dose 5. Arterial Blood Gas ph PaO2:FiO2 (P:F) > 300 on PEEP = 5 7. Serum Na meq/l 8. Blood Glucose < 150 mg/dl 9. Hemoglobin (Hb) > 10 mg/dl 10. Urine Output (averaged over 4 hours) 1-3 cc/kg/hr
66 Organ Donor Timeline 1 st Brain death 2 nd Brain Death OPO Management Family consent Injury Organ Retrieval CBIG
67 Outline Types of Donors Declaration of Brain Death Critical Care Management
68 Outline Types of Donors Living, Deceased (DCD, DBD) Declaration of Brain Death Protocols need to be in place Critical Care Management Management of catastrophic brain injuries
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