Brain Death Its History (and Some Controversies ) Eelco F.M. Wijdicks, MD, PhD Division of Critical Care Neurology Mayo College of Medicine
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1 Brain Death Its History (and Some Controversies ) Eelco F.M. Wijdicks, MD, PhD Division of Critical Care Neurology Mayo College of Medicine 2016 MFMER
2 Brain Death or 2016 MFMER
3 Where did Brain Death Come from? 2016 MFMER
4 Sir Victor Horsley (1894) If artificial respiration is continued it would be impossible to kill an animal by increased intracranial pressure 2016 MFMER
5 The 1950s and Beginnings of Critical Care 2016 MFMER
6 Neurocatastrophies are Intubated and Ventilated ( the last rite before the end? ) 2016 MFMER
7 Where did the Diagnosis Come from? 2016 MFMER
8 2016 MFMER
9 Where did the Diagnosis Come from? 2016 MFMER
10 2016 MFMER
11 2016 MFMER
12 FRD 1 ROD TOD FRG ROG Th 1 Th MFMER
13 2016 MFMER
14 Coma Dépassé Eyeballs frozen Dilated light fixed pupils Absent blinking with stimuli Absence of swallowing reflexes Jaw droop No motor responses to stimuli No breathing Blood pressure drops progressively 2016 MFMER
15 Neurologic Exam Changes 2016 MFMER
16 No Major Publications MFMER
17 2016 MFMER
18 Henry K. Beecher 2016 MFMER
19 We should, first, abandon the ancient sign of death the cessation of the heartbeat. Beecher 2016 MFMER
20 Meetings Harvard Committee 2016 MFMER
21 Schwab and Adams 2016 MFMER
22 Harvard Criteria (1968) Unreceptivity and unresponsivity No movements or breathing No brainstem reflexes Flat electroencephalogram All of the above tests shall be repeated 24 hours with no change Exclusion of hypothermia (<90 F/32.2 C) or central nervous system depressants 2016 MFMER
23 CP MFMER
24 2016 MFMER
25 2016 MFMER
26 2016 MFMER
27 NIH Collaborative Study ( ) Comatose and no brainstem reflexes Apnea 503 patients Seen as early as 15 minutes Examined 6 hour intervals 2016 MFMER
28 A Subgroup Comatose Apnea Isoelectric EEG 189 patients 187 had cardiac arrest 2 survived (drug intoxication) 2016 MFMER
29 Heart Stops Collapse vascular tone (autonomic uncoupling) Loss of baroreceptor sensitivity and descending regulators Invariate heart rate Decrease contractility Decrease coronary perfusion Myocardial ischemia and arrhythmias Terminal arrest 2016 MFMER
30 US Collaborative Study Apnea was not tested and judged impractical >1/3 of patients had systolic blood pressures <90 mm Hg Intoxications in 15% Missing toxicology screens in 40% 2016 MFMER
31 Collaborative Study Cephalic Reflexes Untested on 503 Initial Examinations (CS) Reflex Patients with reflex untested Pupillary light 2 Corneal 2 Oculocephalic 8 Audio-ocular 12 Snout 15 Jaw jerk 24 Vestibular 44 Cough 72 Pharyngeal 79 Swalling MFMER
32 2016 MFMER
33 Coma President s Commission (1981) Absent brainstem reflexes Apnea with PaCO 2 >60 mm Hg Irreversibility Period of observation determined by clinical judgment Use of cerebral blood flow tests when Brainstem reflexes are not completely testable Sufficient cause cannot be established Shorten period of observation 2016 MFMER
34 2016 MFMER
35 Uniform Determination of Death Act [UDDA] Text of Act An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions (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 2016 MFMER
36 It is the Brainstem! 2016 MFMER
37 2016 MFMER
38 Why Brainstem? 2016 MFMER
39 2016 MFMER
40 Brainstem Death 2016 MFMER
41 Brain Death Areas of Need (AAN Guidelines 1995) Definition of clinical testing of brain stem function Description of conditions that may mimic brain death Interpretation of clinical observations that are compatible with brain death but suggest otherwise Description of apnea testing procedure Validity of confirmatory laboratory tests 2016 MFMER
42 2016 MFMER
43 2016 MFMER
44 US Pediatric Guidelines 2011 What Is Good Comprehensive review literature Useful appendices on medication checklist De-emphasize confirmatory tests 2016 MFMER
45 US Pediatric Guidelines 2011 What Is not so Good Age brackets Confounder evaluation comes after examination Ancillary tests when examination is confounded by medication 2 physicians, 2 apnea tests,12-24 wait Not all physicians (ICU specialists) 2016 MFMER
46 (Not so) Hypothetical Case Car accident 3 teenagers 16, 17, 18 years No brainstems reflexes and apneic 12 hours later Bed A: Bed B: Bed C: 16 yr, SCCM/ACP guidelines, wait for 2 nd exam, cardiac arrest, no organ donation 17 yr, SCCM/ACP guidelines, wait for 2 nd exam, family devastated, want closure, do not want to wait, refuse DCD, no organ donation 18 yr, AAN guidelines, 1 exam, donation follows 2016 MFMER
47 Controversies Do not accept brain death Do not accept any death 2016 MFMER
48 2016 MFMER
49 2016 MFMER
50 Critiques Against Brain Death by Physicians Author Specialty Critique Byrne Pediatrician Brain may be stunned, not dead Evans Cardiologist There is no test of cranial nerve I and II ( patient is in a visual nightmare ) Coimbra Neurologist Apnea test is dangerous and hypercapnia-acidosis may cause vasoconstriction Shewmon Pediatric neurologist Joffe Pediatric intensivist Body may remain alive without brain function and there is no cardiac arrest in several cases Recovery of brain function has been reported 2016 MFMER
51 2016 MFMER
52 2016 MFMER
53 Definition of death is not a scientific question but a social one Individuals and families should be given a choice 2016 MFMER
54 The Real Issues Expertise and competency Uniformity Ancillary tests 2016 MFMER
55 The Examiner How can we define physician competence? Are all specialties really allowed to determine brain death? 2016 MFMER
56 Simulation Brain Death 2016 MFMER
57 1 or 2 Exams? In U.S., 2 exams 8/50 states 2 independent exams? 2 full exams? (1 apnea test) 2 exams lead to marked delay (and loss of donors) 2016 MFMER
58 Mean brain death declaration interval (hr) Waiting for 2 nd exam 12% cardiac arrest Lost procurement Brain dead patients/hospital (no.) 2016 MFMER
59 Confirmatory Test in Brain Death The final judgment must be made on clinical grounds. The physician who would permit such a crucial decision to be made by a machine, ingenious as it might be, leaves himself and his patient in a highly vulnerable position. Raymond D. Adams et al, MFMER
60 2016 MFMER
61 Nuclear Scan Brain death Anterior Lateral Normal 2016 MFMER
62 TCD Brain Death 2016 MFMER
63 CTA Brain Death 2016 MFMER
64 2016 MFMER
65 T incomplete SPECT + F+ CTA + EEG- Now What? 2016 MFMER
66 CP MFMER
67 Preclinical Testing Compliance with American Academy of Neurology Guidelines Hypothermia absent Sedatives absent Electrolyte disorders absent Shock absent Established cause Sedatives and paralytics absent Acid-based disorders absent Endocrine disorders absent 89% 81% 72% 71% 63% 55% 45% 42% Greer et al: Neurology 70:1, MFMER
68 Progress in Unifying Brain Death Determination? Brain death protocols in U.S. News and World Report s Top 50 ranked neurologic institutions Comparison of 2006 with 2015 Wang et al, MFMER
69 Apnea Testing Compliance With AANPP 2015 vs 2008 (%) Absence of respirations Final pco 2 stated ABGs before starting Pre-oxygenation specified pco 2 Use of suppl O 2 Stop if unstable Repeat if inconclusive MFMER
70 2016 MFMER
71 Use of Ancillary Testing in Declaration of Brain Death Worldwide Mandatory Optional Not used EEG Transcranial Doppler MRI Nuclear medicine scan Catheter-based angiography Computed tomography with angiography Country level responders (%) 2016 MFMER
72 Uniform Criteria The Challenge Look below the tentorium There is a clinical dividing line All BSR are lost nothing returns When some is preserved recovery may occur Stick to the bare essentials Cause and confounders Neurologic examination and apnea test 2016 MFMER
73 Unsurvivable brain injury Eliminate any confounders Test brainstem reflexes and motor responses Prepare for apnea test and proceed with CO 2 challenge Note time of death Declare brain dead 2016 MFMER
74 2016 MFMER
75 2016 MFMER
76 Reasons for Decline in Brain Death Determination Reduced gun violence ( gunshot to the head)? More decompressive craniectomy? More often early withdrawal Physicians simply do not consider 2016 MFMER
77 Major Responsibilities Develop rapport with family Determine futility and irreversibility ( absolutely no hope ) Direct initial management of evolving hemodynamic instability Declare brain death (including apnea test procedure) Discussion of organ donation with organ donation agencies 2016 MFMER
78 My brain is dead but they have the rest of my body on a life-support system! 2016 MFMER
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