The Determination The Determination ofof

Brain DeathBrain Death

James Zisfein, M.D.James Zisfein, M.D.Chief, Division of Chief, Division of

NeurologyNeurologyLincoln Hospital, Bronx, Lincoln Hospital, Bronx,

NYNY

Brain death: the early yearsBrain death: the early years

• 1950's: ACLS and ventilators saved lives1950's: ACLS and ventilators saved lives But there were also unanticipated outcomesBut there were also unanticipated outcomes

• Physicians saw things they never saw beforePhysicians saw things they never saw before Clinicians saw patients in a state "beyond coma"Clinicians saw patients in a state "beyond coma" EEGers saw electrocerebral silenceEEGers saw electrocerebral silence Pathologists saw the "respirator brain"Pathologists saw the "respirator brain"

• 1960's: term "brain death" comes into use1960's: term "brain death" comes into use

• 1968: Harvard Criteria for brain death1968: Harvard Criteria for brain death Loss of animation, brainstem reflexes, and respirationLoss of animation, brainstem reflexes, and respiration Electrocerebral silenceElectrocerebral silence Persistence of the condition for 24 hoursPersistence of the condition for 24 hours

Published guidelinesPublished guidelines

• Harvard Criteria (1968)Harvard Criteria (1968)

• President's Commission Criteria (1981)President's Commission Criteria (1981)

• American Academy of Pediatrics (1987)American Academy of Pediatrics (1987)

• American Academy of Neurology (1995, 2010)American Academy of Neurology (1995, 2010) This presentation is based on the AAN 2010 guidelineThis presentation is based on the AAN 2010 guideline

• New York State Department of Health (2005)New York State Department of Health (2005) NYSDOH is aware of the AAN 2010 update and is NYSDOH is aware of the AAN 2010 update and is

revising its guideline to conform with AANrevising its guideline to conform with AAN

• All of these guidelines are 100% specificAll of these guidelines are 100% specific Despite aggressive treatment, a patient who is found Despite aggressive treatment, a patient who is found

to be brain dead never regains any brain functionsto be brain dead never regains any brain functions

Definition of brain deathDefinition of brain death

• Brain death is the irreversible loss of all brain functionsBrain death is the irreversible loss of all brain functions

• "Functions" are clinically ascertainable"Functions" are clinically ascertainable Animation and respiration are brain functionsAnimation and respiration are brain functions Generation of electrical activity, cerebral blood Generation of electrical activity, cerebral blood

circulation, and metabolism are circulation, and metabolism are notnot brain functions brain functions

• A person who is brain dead is deadA person who is brain dead is dead according to standards of according to standards of medical practice and the law in all US jurisdictionsmedical practice and the law in all US jurisdictions This is not optionalThis is not optional However, reasonable accommodations can be made to However, reasonable accommodations can be made to

support the family in case of religious or moral objectionssupport the family in case of religious or moral objections

• The time of death is the time that this determination is made The time of death is the time that this determination is made (usually at the conclusion of an apnea test)(usually at the conclusion of an apnea test) It is not sometime later when the heart stopsIt is not sometime later when the heart stops

The diagnosis of brain death in The diagnosis of brain death in 55 easy steps easy steps

1.1. The cause of brain failure is irreversible.The cause of brain failure is irreversible.

2.2. The patient is unresponsive.The patient is unresponsive.

3.3. Brainstem reflexes are absent.Brainstem reflexes are absent.

4.4. An apnea test shows no breathing.An apnea test shows no breathing.

5.5. Laboratory tests are not required unless the clinical Laboratory tests are not required unless the clinical diagnosis is uncertain.diagnosis is uncertain.

Note: the guidelines are different for diagnosis of brain death Note: the guidelines are different for diagnosis of brain death in infants under 1 year of age. in infants under 1 year of age. 

1.1. The cause of brain failure is The cause of brain failure is irreversibleirreversible

• Most brain deaths occur fromMost brain deaths occur from

Severe brain traumaSevere brain trauma

Massive stroke (usually hemorrhage)Massive stroke (usually hemorrhage)

Prolonged cardiac arrestProlonged cardiac arrest

• Sufficient time has elapsed to insure irreversibilitySufficient time has elapsed to insure irreversibility

Post-cardiac arrest, 6 hours is a reasonable intervalPost-cardiac arrest, 6 hours is a reasonable interval

• Absence of cerebral blood flow (on a CBF test) also Absence of cerebral blood flow (on a CBF test) also documents an irreversible process.documents an irreversible process.

2.2. The patient is unresponsive The patient is unresponsive

• We're talking here about We're talking here about cerebralcerebral unresponsiveness. unresponsiveness.

Grimacing and other cranial-nerve responses are Grimacing and other cranial-nerve responses are absent (except for CN XI). absent (except for CN XI). 

Spinal reflexes, e.g. “spinal withdrawal”, can be Spinal reflexes, e.g. “spinal withdrawal”, can be present.present.

• Less common spinal movements include:Less common spinal movements include:

Fragments of decerebrate posturing (including neck Fragments of decerebrate posturing (including neck extension)extension)

The undulating toe signThe undulating toe sign

Lazarus signLazarus sign

3.3. Brainstem reflexes are Brainstem reflexes are absentabsent• Pupillary light reflexPupillary light reflex

Pupils should be mid-position or largePupils should be mid-position or large

• Vestibulo-ocular reflex (eye movements)Vestibulo-ocular reflex (eye movements)

Doll's eyes and ice-water caloricsDoll's eyes and ice-water calorics

• Corneal reflexCorneal reflex

• Gag and cough reflexGag and cough reflex

Response to suctioningResponse to suctioning

4.4. An apnea test shows no An apnea test shows no breathingbreathing• Prerequisites: absence of respiratory depressants (CNS or Prerequisites: absence of respiratory depressants (CNS or

peripheral), hypotension (SBP<100), or hypothermia peripheral), hypotension (SBP<100), or hypothermia (<36ºC). (<36ºC). 

• If ODN or family has not yet been notified, please do so If ODN or family has not yet been notified, please do so now!now!

• Remove ventilator for at least 10 minutes while giving ORemove ventilator for at least 10 minutes while giving O22 by tracheal cannula. Observe closely for breathing. Monitor by tracheal cannula. Observe closely for breathing. Monitor BP and OBP and O22 saturation continuously. saturation continuously.

• The apnea test confirms brain death if the end-of-test The apnea test confirms brain death if the end-of-test PaCOPaCO22 is ≥60 mmHg (or, ≥20 mmHg above pre-test PaCO is ≥60 mmHg (or, ≥20 mmHg above pre-test PaCO22).).

• If the apnea test cannot be completed, repeat it with better If the apnea test cannot be completed, repeat it with better patient preparation, or do a cerebral blood flow test.patient preparation, or do a cerebral blood flow test.

5.5. Laboratory tests Laboratory tests

• Are not required unless the clinical diagnosis of brain death Are not required unless the clinical diagnosis of brain death is uncertain.is uncertain.

• The most commonly performed tests are serum chemistry The most commonly performed tests are serum chemistry and toxicology and CT scan of the brain.and toxicology and CT scan of the brain.

• Please put laboratory findings in clinical context! Please put laboratory findings in clinical context! 

Abnormal chemistry or toxicology does not invalidate a Abnormal chemistry or toxicology does not invalidate a diagnosis of brain death unless the clinical diagnosis is diagnosis of brain death unless the clinical diagnosis is uncertain.uncertain.

Presence of an intoxicant is relevant only if the quantity Presence of an intoxicant is relevant only if the quantity present would cause intoxicationpresent would cause intoxication

• EEG is of very limited value for diagnosis of brain death, EEG is of very limited value for diagnosis of brain death, however it is mentioned in some pediatric brain death however it is mentioned in some pediatric brain death protocols.protocols.

5.5. Laboratory tests (continued) Laboratory tests (continued)

Perform a Perform a cerebral blood flow studycerebral blood flow study (catheter angiogram, (catheter angiogram, CTA, MRA, radionuclide study, transcranial doppler) whenCTA, MRA, radionuclide study, transcranial doppler) when

cranial nerve examination is inhibited by peripheral lesionscranial nerve examination is inhibited by peripheral lesions

the apnea test is invalidated by central or peripheral the apnea test is invalidated by central or peripheral respiratory depressant drugs (you still do the apnea test)respiratory depressant drugs (you still do the apnea test)

the apnea test cannot be completed due to hypotension or the apnea test cannot be completed due to hypotension or hypoxia (do as much of the apnea test as can be done hypoxia (do as much of the apnea test as can be done safely)safely)

the brain failure is not clearly due to an irreversible processthe brain failure is not clearly due to an irreversible process

in infants under the age of 1 yearin infants under the age of 1 year

>95% of brain death evaluations do not require a CBF >95% of brain death evaluations do not require a CBF studystudy

One exam or two?One exam or two?

• Prior to 2010, brain death guidelines specified that the Prior to 2010, brain death guidelines specified that the brain death exam had to be performed twicebrain death exam had to be performed twice

AAN (1995): suggested 6 hour interval between examsAAN (1995): suggested 6 hour interval between exams

• There was never any evidence supporting this!There was never any evidence supporting this!

There are no reports of recovery after a properly There are no reports of recovery after a properly performed brain death exam shows no brain functionsperformed brain death exam shows no brain functions

Lustbader et al. (2011): 2nd exam unnecessary on 1300 Lustbader et al. (2011): 2nd exam unnecessary on 1300 brain death evaluations, also 24-hour delay in diagnosisbrain death evaluations, also 24-hour delay in diagnosis

• AAN 2010: single exam is sufficient if performed by AAN 2010: single exam is sufficient if performed by qualified examiner "several hours" after incident eventqualified examiner "several hours" after incident event

NYSDOH: does not disagree and will be updating state NYSDOH: does not disagree and will be updating state guidelinesguidelines

Guidelines for infants <1 year of Guidelines for infants <1 year of ageage• Below age 1 year, the observation period should be 24 Below age 1 year, the observation period should be 24

hours, and a confirmatory test should be performed.hours, and a confirmatory test should be performed.

• Below age 2 months, the observation period should be 48 Below age 2 months, the observation period should be 48 hours.hours.

• Below age 1 week (and in premature infants), the diagnosis Below age 1 week (and in premature infants), the diagnosis of brain death may be unreliable.of brain death may be unreliable.

• Everyone agrees these guidelines for infants are Everyone agrees these guidelines for infants are excessively conservative.excessively conservative.

"Clinical triggers" for brain "Clinical triggers" for brain deathdeath• Suspect brain death when a patient with severe brain Suspect brain death when a patient with severe brain

injury (e.g., from trauma, stroke, or anoxia)injury (e.g., from trauma, stroke, or anoxia)

Is unresponsiveIs unresponsive

Has pupils that do not react to lightHas pupils that do not react to light

Requires a ventilator for breathingRequires a ventilator for breathing

Do not assume that "triggered" breaths are Do not assume that "triggered" breaths are initiated by patient respiratory activityinitiated by patient respiratory activity

When you suspect brain deathWhen you suspect brain death

1. Document your findings.1. Document your findings.

You don't have to be a brain death expert to document that You don't have to be a brain death expert to document that the pupils and corneals are nonreactive, the eyes don't move, the pupils and corneals are nonreactive, the eyes don't move, there is no response to suctioning, and there are no there is no response to suctioning, and there are no spontaneous breaths.spontaneous breaths.

2. Obtain consultation from a designated brain death expert.2. Obtain consultation from a designated brain death expert.

Requirements for privileging vary by institution. Experts do Requirements for privileging vary by institution. Experts do not necessarily have to be neurologists or neurosurgeons.not necessarily have to be neurologists or neurosurgeons.

3. Contact the patient's family or significant other (if known).3. Contact the patient's family or significant other (if known).

Or, contact hospital administration to help find the patient's Or, contact hospital administration to help find the patient's family. family. 

4. Contact the NY Organ Donor Network: 1-800-GIFT-4-NY4. Contact the NY Organ Donor Network: 1-800-GIFT-4-NY

You must do this even if the patient will not be an organ You must do this even if the patient will not be an organ donor.donor.

ReferencesReferences

Wijdicks E.F.M, et al. Evidence-based guideline update: Determining brain death in Wijdicks E.F.M, et al. Evidence-based guideline update: Determining brain death in adults: Report of the quality standards subcommittee of the American Academy of adults: Report of the quality standards subcommittee of the American Academy of Neurology. Neurology 2010; 74:1911-1918.Neurology. Neurology 2010; 74:1911-1918.

Lustbader D, et al. Second brain death examination may negatively affect organ Lustbader D, et al. Second brain death examination may negatively affect organ donation. Neurology 2011; 76:1-6.donation. Neurology 2011; 76:1-6.

New York State Department of Health: Guidelines for determining brain death, New York State Department of Health: Guidelines for determining brain death, December 2005. December 2005. http://www.health.state.ny.us/professionals/doctors/guidelines/determination_of_braihttp://www.health.state.ny.us/professionals/doctors/guidelines/determination_of_brain_death/docs/determination_of_brain_death.pdfn_death/docs/determination_of_brain_death.pdf