Brainstem death

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Brainstem death

• Paulus Anam Ong
• Department of Neurology

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Foreword

• The purpose of medical science is to prolong life
  and not to prolong dying process.
• Physicianhealth provider who are authorized to
  define death of the individual
• Physician should know the definition of death in
  both emergency or normal situation

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Definition of Death

• Irreversible loss of the capacity for
  consciousness, combined with the irreversible
  loss of the capacity to breath
• The irreversible cessation of brainstem function
  (brainstem death), whether induced by
  intracranial events or result of extra-cranial
  phenomena will produce the same clinical state
• Brainstem death is equivalent to death of the
  individual.

U.K. Criteria for the diagnosis of brainstem
death (Working Group convened by the Royal
Collage of Surgeons, 1995)
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Brainstem death

• Brainstem regulator of respiration and
  cardiovascular stabilization
• Brainstem death discontinuity of peripheral
  neuronal system through the brain (absolute for
  consciousness)
• Brainstem death self-fulfilling prophecy

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Diagnosis of Brainstem death

• 3 step in clinical diagnose of brainstem death
• To ascertain that essential condition be
  satisfied before considering the diagnosis of
  brainstem death
• Exclude the possibilities of reversible cause of
  coma and apnea
• To ascertain the irreversible absence of
  brainstem reflexes and the apnea

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Ad 1. Certain condition should be satisfied

• Two Condition required for brainstem death
• The patient is deeply comatose and apnea
  unresponsiveness and maintained on the ventilator
• The diagnosis should be known and the condition
  should be one that is capable of causing neuronal
  death and the brain damage is irreversible

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Ad 2. To exclude the reversible cause of comatose
and apnea

• Drug intoxication (depressant drugs)
• Primary hypothermia
• Potential metabolic and endocrine disturbances as
  a cause of comatose
• U.K Code Diagnosis of brainstem death should not
  be consider with the presence of above points

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Before test the brainstem reflexes

• There should be evidence of loss of brainstem
  function
• Patient is in deeply comatose
• There is not abnormal postures (de-cortication or
  de-cerebration)
• There is no occulocephalic reflex
• There is no epileptic seizure
• There is no spontaneous breath
• Brainstem is still functioning if one of the
  above point is present.

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5 Brainstem reflexes

• Absence of
• Pupils no response to light
• Cornea no corneal reflexes
• Oculocephalic testing (head turning) and
  Oculovestibular (caloric) testing
• Motor response to adequate somatic stimulation
  within distribution of cranial nerve
• Gag reflex (pharingeal and tracheal reflexes)

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Apnea Test

• Prerequisites
• Core temperature gt36.5 C
• Systolic BP gt 90 mmHg
• Euvolemia. Option positive fluid balance in
  previous 6 h.
• Normal Pco2 gt 40 mmHg
• Normal Po2. Option preoxigenation to obtain
  arterial P o2 gt 200mmHg
• Connect a pulse oximeter and discontect the
  ventilator

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Apnea Test

• Deliver 100 O2 6l/min into trachea.
• Look closely for respiratory movement (abdominal
  or chest excursions that produce adequate tidal
  volumes)
• Measure arterial P o2, Pco2 and pH after
  approximately 8 min and reconnect the ventilar.
• If respiratory movement are absent and arterial
  Pco2 is gt60mmHg the apnea test is () ? support
  brainstem death
• If respiratory movement are observed ? apnea test
  is (-)
• Connect the ventilator if during testing systolic
  BP lt90mmHg, or cardiac arrythmia or oxygen
  desaturation are present immidiately analyze
  arterial blood gases. If Pco2 is gt60 mmHg or Pco2
  rise gt20mmHg ? apnea test () ? support brainstem
  death if Pco2 is lt60mmHg or Pco2 is lt20mmHg over
  baseline, the result is indeterminate, additional
  confirmatory test can be considered.

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Repeat of test

• Test repeating is done to avoid fault observation
  and changes of signs
• Interval time of 2 tests range from 25 minutes to
  24 hrs depend on hospital regulation and
  recommendation accepted

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Difficulties in diagnosing brainstem death
Examination results Possible causes
1. Fixed pupils Anticholinergic drugs, muscle relaxing drug, previous disease
2. Oculo-vestibuler reflex (-) Ototoxic drug, vestibular suppressant, Previous disease
3. Apnea Post hyperventilation Muscle relaxing drug
4. No motor response Locked in state, muscle relaxing drug, Sedative drugs
5. Isoelectric EEG Sedative drug, hypoxia, hypothermia, Encephalitis, trauma
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Difficulties in diagnosing brainstem death

1. Severe facial trauma
2. Disease of pupils
3. Sedative drug used
4. Severe pulmonary disease

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After diagnosis of brainstem death

• Withdraw therapeutic and palliative treatment
  gradually according to severity of individual
  patient

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Doubt in

• Primary diagnosis
• Cause of brainstem dysfunction may be reversible
  (drug and metabolic disorders)
• Completeness of clinical test
• Do not make diagnosis of brainstem death

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Ancillary Testing

• No required
• USG doppler
• MRI
• Brainstem Evoke Potential
• Electroencephalography

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According to Indonesia Doctor Association (IDI)

• Diagnosis of brainstem death should be made by at
  least 2 doctor who are experience in this field
• In IndonesiaAnestesiologist, Critical care
  doctors, Neurologist and both of them do not
  involved in the organ transplant team

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Thank You