brain death in the icu dr. jonathan goodall m62 coloproctology course march 22 nd 2007

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


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


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


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.



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.



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.


Brain Stem TestingBrain Stem Testing


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.


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


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


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


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


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


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


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.


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


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. .

brain death in the icu dr. jonathan goodall m62 coloproctology course march 22 nd 2007

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