Determining Brain Death

Brain death accounts for less than one percent of all deaths in the United States, and can be quite confusing for families confronting an unexpected loss of a loved one. It is not unusual for families to question a brain death declaration: although ventilators are artificial, basic logic suggests that a beating heart, a chest rising and falling with each breath and warm skin indicate life. However, we now know that there is no resuscitative strategy that will revive a brain that has been deprived of blood and oxygen and whose cells have died. Brain death is a legal, clinical and measurable condition.

The Determination of Death Act (1980) defines brain death as the “irreversible cessation of all functions of the entire brain, including the brain stem.” In order for donation coordinators from PNTB to manage organ donation, a patient must be declared dead. While PNTB donation coordinators are available to offer guidelines to hospital staff testing for brain death, brain death is not and cannot be declared by donation coordinators. Brain death should not be declared using any arbitrary or subjective judgments and must be declared in accordance with hospital policies, medical standards, and national best practices. Below you will find general guidelines for determining brain death. These are only guidelines, and are suggested with the understanding that every clinical situation is different and may require other and/or additional methods of evaluation. If you have questions, please refer to your hospital policy and physician practice. Additionally, the Brain Death Checklist outlines the minimum diagnostic criteria necessary for diagnosing brain death.

NEUROLOGY 2010 Determining Brain Death in Adults

Critical Care Medicine; 2011 Pediatric Brain Death Guidelines

Ventilator self-cycling may falsely suggest patient effort during brain death determination

Brain death: assessment, controversy, and confounding factors

Declaration of Brain Death Checklist

  1. Presence of a severe neurological injury
  2. Absence of the following confounding factors:
    1. Temperature < 36 C
    2. Severe hypotension (SBP <100 as appropriate for patient’s age)
    3. Drug intoxication or effects (barbiturates, opiates, neuromuscular blocking agents, etc.)
    4. High cervical spinal cord injuries
    5. Severe electrolyte, acid-base and/or endocrine disturbances
  3. Clinical exam which conclusively excludes the following reflexes:
    1. Spontaneous respirations
    2. Bilateral motor responses (excluding spinal reflexes)
    3. Corneal reflex
    4. Cough and gag reflexes
    5. Negative doll’s eyes
    6. No response to ice calorics
  4. Apnea Challenge Test
    1. Normalize patient’s PaCO2 and confirm with ABG
    2. Hyperoxygenate with 100% O2 for 10 minutes
    3. Remove patient from vent and deliver 6-10 L of O2 via ET-tube
    4. Observe for respiratory effort for 6-10 minutes (if patient becomes hemodynamically unstable, draw ABG and resume ventilation)
    5. After 6-10 minutes of apnea, draw ABG BEFORE placing patient back on vent
    6. If PaCO2 is >60 mmHg and no respiratory effort is exhibited, the test is positive for apnea which indicates lack of brain steam function and is confirmatory for the diagnosis of brain death
  5. Should steps 1-4 not provide adequate criteria for diagnosis of brain death, other confirmatory tests such as cerebral perfusion scan, cerebral angiogram, and EEG can also be used to confirm brain death.

Suggested Guidelines for Caring for the Catastrophically Brain Injured Patient (CBIGs)

The following are guidelines intended to preserve the option of donation and are commonly referred to as Catastrophic Brain Injury Guidelines (CBIGs). These guidelines are to help guide the care of the potential organ donor, while preventing harm should a patient survive their injuries. They are meant as care recommendations before death has been formally declared, and before the donation coordinator takes over medical management of the donor patient. **All patient care management will be dictated by the hospital physician/care provider unless or until the patient has legally been declared brain dead AND disclosure or authorization for organ donation has occurred.**

  1. Management Goals:
    1. Normalize hemodynamic status
      1. Optimize fluid balance:
        1. Continue maintenance IV fluid infusion
        2. Consider fluid bolus (crystalloid or colloid) for hypotension
        3. Blood product replacement as indicated by hospital policy
      2. For hypotension unresponsive to fluid bolus:
        1. Consider vasopressor support to maintain either a MAP > 60 or a SBP >90mmHg (7 years-adult), >80mmHg (6 months-2 years), >60 (0-6 months)
        2. Preferred drugs for organ preservation:
          1. Dopamine 0-20mcg/kg/min
          2. Neosynephrine 0-200 mcg/min (adult), 0.1-0.5 mcg/kg/min (pediatrics)
    2. Optimize oxygenation/ventilation
      1. Maintain oxygen saturation >95%
        1. Adjust FiO2 to keep PaO2 >90
        2. Use physiologic PEEP (+5cm H2O)
      2. Normalize pH (7.35-7.45)
        1. Normalize pCO2 (~40mmHg)
        2. Administer buffers (e.g. sodium bicarbonate) as indicated
      3. Prevent pulmonary edema/pneumonia
        1. Pulmonary toilet/suction/reposition q 1-2 hrs
        2. Follow daily chest x-rays
    3. Treat coagulopathy
      1. Maintain normothermia (core temperature 36.5-37.5°C)
      2. Monitor CBC and coagulation panel daily
      3. Blood product/factor replacement as indicated by hospital policy
    4. Treat neuro-endocrine disturbances
      1. Diabetes insipidus (urine specific gravity <1.005 and sustained polyuria)
        1. Consider treatment of hypernatremia (Na>155)
        2. Preferred drugs for organ preservation:
          1. DDAVP 0.5-1 mcg IV, repeat dose Q2h as indicated
          2. Vasopressin continuous IV infusion 0.5-5 U/h (adult), 0.5-1 milli-U/kg/hr (pediatrics)
      2. Impaired glucose tolerance
        1. Utilize hospital insulin therapy protocol to treat hyperglycemia
    5. Monitor and treat electrolyte abnormalities
      1. Monitor electrolytes daily
      2. Utilize hospital electrolyte replacement protocol
    6. Treat infection
      1. Broad-spectrum antibiotic coverage for clinical indications of infection