Brain stem death, it’s diagnosis

with MLI in Organ

Transplantation

- Prepared by Group D (9052-9069)

Presenters :
Ritika Regmi (9068)
Rajan Tamang (9064)
Riya Jaiswal (9069)
Table of contents

01 Introduction

02 Diagnosis

03 Organ Transplantation
 01
Introduction
 Death
- Permanent & Irreversible cessation of the functions of the heart, lungs and brain (Medically)

- The whole body doesn’t die simultaneously .

- The concept of moment of death has changed from traditional cardiopulmonary standard
(cessation of heartbeat and breathing) to brain death nowadays .
 Brain Death
• It is defined as a irreversible destruction of the brain, with the resulting total absence of
all cortical and/or brainstem functions, although spinal cord reflexes may remain intact .

• Refers to determination of physical death by brain based, rather than cardio-pulmonary

based criteria

• It should not be confused with severe but incomplete brain damage .

 Types of Brain Death
1. Cortical or Cerebral death (with intact brain stem)
- Victim will exist in a vegetative state – the living cadaver

2. Brain Stem Death

3. Whole-brain death
- Cortical death + Brain stem death
Brain stem death
 Brainstem Death
• Brain death is now accepted as the brain stem death & Brain stem death is considered
legally as “death” in many countries .

• It is defined as the stage at which all the functions of brainstem have permanently
and irreversibly ceased .

• Loss of the vital centers that control respiration and of the ascending reticular
activating system that sustains consciousness, cause the victim to be irreversibly
comatose and incapable of spontaneous breathing .
History of establishment of Brain Death Criteria

• In 1959, concept of brain death/death by neurologic criteria (BD/DNC) was first theorized as “le
coma depasse” , by Mollaret and Goulon, who described an apneic, comatose patient without
brainstem reflexes or electroencephalographic(EEG) activity

• In 1968, a group of Harvard faculty proposed the first clinical definition as Harvard Brain death
criteria, which consisted of clinical and EEG criteria

• In 1980, the Uniform Determination of Death Act established a legal basis for a neurologic
determination of death in the U.S.
• In 1995, American Academy of Neurology (AAN) had put forth guidelines on the
determination of BD/DNC (revised 2010)

• In 1987, the American Academy of Pediatrics task force on brain death in children
published guidelines for the pediatric population (updated in 2011)
 Common causes of brain stem death

• Traumatic brain injury

• Intracranial hemorrhage
• Anoxic brain injury (usually due to cardiopulmonary arrest)
• Fulminant meningitis or encephalitis
• Fulminant hepatic failure causing cerebral edema
• Ischemic stroke with cerebral edema and herniation
 Pathophysiology of Brain Death
• Regardless of the initial cause, eventually brain death occurs via a spiral of
progressive intracranial hypertension, tissue damage and edema . This is
essentially an intracranial compartment syndrome .

• Complete brain death occurs when there is complete circulatory arrest of

the brain – no blood is entering the brain .
Final common pathway of brain death

Neuronal Cell Damage

Anoxic brain injury Tissue Edema

Reduced cerebral Increased intracranial

perfusion pressure pressure
02
Brainstem Death
Diagnosis
 Criteria for Brainstem death
A. Preconditions
i) Nature of irremediable brain stem death must be defined
ii) Apnoeic coma must not be due to the following:
1. Primary hypothermia
2. Depressant drugs
3. Neuromuscular blocking agents
4. Metabolic or endocrine disturbances

B. Clinical tests
1. Pupils do not react to light
2. Corneal reflexes absent
3. No eye movement with cold caloric test
4. No cranial nerve motor responses
5. No gag reflex
6. No respiratory movement when disconnected from a ventilator
 Apnea test
• It is based on the fact that loss of brain stem function definitely results in loss
of centrally controlled breathing with resultant apnea.

• The test requires removal of ventilator support and monitoring of PaCO2

levels.

• A positive test is total absence of respiratory efforts.

Testing different cranial nerves
 Pitfalls in brainstem reflex
Reflexes not assessable on one side:
a) Injury/ trauma/ disease
b) Can test on the other side
c) Results are considered valid

Reflexes not assessable on both sides:

a) Injury/trauma disease
b) Cannot test any reflex
c) Have to do confirmatory tests

Cervical spine injury

a) Suspected/proven
b) Don't attempt VOR
 03
Organ Transplantation
and brainstem death
 Organ Transplantation
• A medical procedure in which an organ is removed from one body and placed in the
body of a recipient, to replace a damaged or missing organ.

• Organ donors may be living, brain dead or dead via circulatory death

• Brain dead persons are kept on artificial support to maintain oxygenation

ensuring healthy condition of organs until they are harvested
• It is possible to donate all organs in case of brain death (organs like lungs, liver,
heart, intestine, kidneys, pancreas ; tissues like cornea, valves, tendons, veins, skin,
bones)
 Certification of Brain death

Brainstem death needs to be certified by a board of doctors consisting of the

following:

● The RMP in charge of the hospital in which the brain stem death has occurred.
● An independent RMP being a specialist to be nominated by a RMP specified in
clause: 1 from the panel of names approved by appropriate authority.
● A neurologist or a neurosurgeon to be nominated by a RMP specified in clause.1
from the panel of names approved by an appropriate authority.
● The RMP treating the person whose brain stem death has occurred.
Laws regarding organ transplant

History

● First successful kidney transplant was done in 2008 in TUTH

● In 2000, transplantation was legalized, donor has to be a close
relative of recipient which was amended in 2016 allowed transplant
from different patients.
● Act of 1998 had limited the donor to limited family member only.
 contd

● Consent has to be given before extraction of organs.

● If brain dead individual has not given consent prior to his or her death, any
members of his or her family can give a written consent for donation.
● If donor has denied the consent while alive, the consent can be obtained
from the family member of deceased.
 Laws

The Human Body Organ Transplantation (Regulation and Prohibition) Act 2

(1998)

Regulates the extraction of an organ from a body for the purpose of treating a disease in a
systematic manner in accordance to modern medical treatment a extraction of an organ from a
body to another human body. (SPEAKER NOTE)
 Provisions
● No person shall operate or cause to be operated the activity relating to
organ transplantation without obtaining the permit pursuant to the act
● An organ transplant coordination committee includes- chairperson and
members, to formulate policies, plans and programs regarding organ
transplantation and submit the same to government of nepal.
● Any activity relating to organ transplantation for the purpose of sale and
purchase of organ or similar other act is prohibited
● It can only be done in purpose of treating a disease in a managed manner in
accordance to modern medical system
● Both donor and recipient consent is required.
● Any act done in contrary to the act is considered to be an offence.
● Advertisement and publicity regarding and availability of organ is
prohibited.
Just to know facts
• Only close relatives are eligible for organ donation (at least 2 years of continuous
relationship)

• Specific monetary compensation to the family or members of brain dead patient.

• Pair exchange provision

• Procurement and transplantation of viable organs from the brain dead patient (8
organs)

• Transplant surgeon can’t declare clinical deaths

Process of organ donation in Nepal (in
case of brain death)

● Declaration of the brain death

● Information sent to the transplant coordination unit
● A team of transplant coordinator, surgeons, anesthesiologists, nurses and other
supportive staff mobilised
● Transplant coordinators and doctors counselling the patient’s relative for organ donation and
performing necessary investigation
● A written consent taken from the family member
● The donor taken to the operation theatre and the organ harvested
● The donor’s body handed over to the donor family
● Recipient counselling and organ allocation
● Organ procurement, preservation and transport
● Necessary documentation and organ transplantation
Diagnosis involves the following steps:
● The patient is comatose and incapable of spontaneous breathing. The cause of trauma must
be irremediable structural damage.
● Exclusion of the cause of coma as due to drugs, hypothermia, or profound metabolic
disturbances
● Establishing that all the brainstem reflexes are absent and the patient fails to
breathe, even when taken off the respirator, after certain preliminary changes made in the
blood gas concentration.
● The patient must be examined by a team of doctors at least twice with a reasonable gap of
time in between-6 hrs,
● None of the doctors who participate in the diagnosis of brain stem death should have any
interest in the transplantation of an organ being removed from the cadaver.
Thank You!