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Brain Death in The ICUBrain Death in The ICU
Dr. Jonathan GoodallDr. Jonathan Goodall
M62 Coloproctology CourseM62 Coloproctology Course
March 22March 22ndnd 2007 2007
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
ScopeScope
Development of ConceptsDevelopment of Concepts
Diagnosis of Brain Stem Death (BSD)Diagnosis of Brain Stem Death (BSD) PreconditionsPreconditions Testing brain stem functionTesting brain stem function
ImplicationsImplications Organ donationOrgan donation
Recent developmentsRecent developments Non-heart beating donationNon-heart beating donation
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Development of Concepts of BSDDevelopment of Concepts of BSD
Mollaret and Goulon – ‘Le coma dMollaret and Goulon – ‘Le coma déépasspassé’ é’ Rev Neurol 1959; Rev Neurol 1959; 101101: 3-15: 3-15
Ad Hoc Committee of Harvard Medical Ad Hoc Committee of Harvard Medical School 1968 School 1968 JAMA 1968; JAMA 1968; 205205: 85-8: 85-8
Minnesota Criteria ~ 1971Minnesota Criteria ~ 1971 Notion of aetiological preconditionsNotion of aetiological preconditions
Conferences of Medical Royal Colleges Conferences of Medical Royal Colleges and their Faculties and their Faculties Br Med J 1976;Br Med J 1976;iiii: 1187-8; Br Med J : 1187-8; Br Med J 1979; 1979; ii: 3320: 3320
From Brain Death to Brain Stem Death
Pallis C, Br. Med J 1982; 285: 1487-1490
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Development of Concepts of BSDDevelopment of Concepts of BSD
Cadaveric organs for transplantation: A Cadaveric organs for transplantation: A code of practice including the diagnosis of code of practice including the diagnosis of brain death. London 1983 HMSO brain death. London 1983 HMSO
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Diagnosis of BSD: PreconditionsDiagnosis of BSD: Preconditions
The patient is deeply unconscious. The patient is deeply unconscious.
There should be no doubt that the patient's There should be no doubt that the patient's condition is due to irremediable brain condition is due to irremediable brain damage of known aetiology. damage of known aetiology.
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Diagnosis of BSD: PreconditionsDiagnosis of BSD: Preconditions
There is no evidence that this state is due There is no evidence that this state is due to depressant drugs.to depressant drugs.Primary hypothermia as the cause of Primary hypothermia as the cause of unconsciousness must have been unconsciousness must have been excluded. excluded. Potentially reversible circulatory, metabolic Potentially reversible circulatory, metabolic and endocrine disturbances excluded.and endocrine disturbances excluded.
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Diagnosis of BSD: PreconditionsDiagnosis of BSD: Preconditions
The patient is being The patient is being maintained on a maintained on a ventilator because ventilator because spontaneous spontaneous ventilation has been ventilation has been insufficient or has insufficient or has ceased altogether. ceased altogether.
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Brain Stem TestingBrain Stem Testing
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
BST – Response to PainBST – Response to Pain
No motor responses within the cranial No motor responses within the cranial nerve distribution can be elicited by nerve distribution can be elicited by adequate stimulation of any somatic area. adequate stimulation of any somatic area. There is no limb response to supra-orbital There is no limb response to supra-orbital pressure.pressure.
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
BST- Apnoea TestBST- Apnoea Test
No respiratory No respiratory movements occur movements occur when the patient is when the patient is disconnected from the disconnected from the mechanical ventilator. mechanical ventilator.
PaCO2 should reach PaCO2 should reach 6.65kPa. 6.65kPa.
Hypoxia prevented by Hypoxia prevented by apnoeic oxygenationapnoeic oxygenation
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
BST – Who?BST – Who?
Must be made by at least two medical Must be made by at least two medical practitionerspractitioners Registered for at least 5 yearsRegistered for at least 5 years Are competent in this fieldAre competent in this field Are not members of the transplant teamAre not members of the transplant team At least one must be a consultantAt least one must be a consultant
Repetition of testing and time of deathRepetition of testing and time of death
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Organ DonationOrgan Donation
Involvement of familyInvolvement of family
Legal situationLegal situation Donor cardsDonor cards Authorisation of removal of organsAuthorisation of removal of organs
Designated personDesignated person
In absence of relativesIn absence of relatives
Involvement of HM CoronerInvolvement of HM Coroner
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Retrieval of Organs & TissuesRetrieval of Organs & Tissues
Transplant co-ordinatorTransplant co-ordinator Practical details Practical details
Screening TestsScreening Tests Tissue compatibiltyTissue compatibilty Viral screeningViral screening
Organ retrieval and transplantOrgan retrieval and transplant
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Care of the Potential DonorCare of the Potential Donor
Good medical careGood medical care
Maintenance of organ perfusionMaintenance of organ perfusion Appropriate monitoringAppropriate monitoring Inotropes and vasopressorsInotropes and vasopressors
Hormone replacementHormone replacement DDAVPDDAVP Thyroid HormonesThyroid Hormones SteroidsSteroids
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Non-Heart Beating DonorNon-Heart Beating Donor
Response to organ shortagesResponse to organ shortages
Organs removed from donors in death Organs removed from donors in death ascertained by cardiac criteriaascertained by cardiac criteria ‘‘stand off period after declaration of death’stand off period after declaration of death’ Variable time of ‘warm ischaemia’Variable time of ‘warm ischaemia’
Reasonable outcomes – delay in recovery Reasonable outcomes – delay in recovery of functionof function
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
UK Donation ‘05/’06UK Donation ‘05/’06
Organs from 764 people were used in Organs from 764 people were used in 2,195 transplants 2,195 transplants
125 non-heartbeating donors, 44% more 125 non-heartbeating donors, 44% more than the previous year. than the previous year.
At the end of March 2006, At the end of March 2006, 6,6986,698 patients patients were listed as actively waiting for a were listed as actively waiting for a transplant, a 9% increase compared to the transplant, a 9% increase compared to the previous year. previous year.
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
SummarySummary
Concept of Brain death established and Concept of Brain death established and acceptedaccepted
Strict guidelines for establishing brain Strict guidelines for establishing brain death – BSTdeath – BST
Organ transplantation process well Organ transplantation process well organisedorganised
JRG M62 Meeting 3/2007JRG M62 Meeting 3/2007
Almost a million more people pledged to Almost a million more people pledged to help others after their death by registering help others after their death by registering their wishes on the NHS Organ Donor their wishes on the NHS Organ Donor Register, bringing the total at 31 March Register, bringing the total at 31 March 2006 to 2006 to 13,122,05613,122,056. .