Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR

1. Key Points in Brain Death Diagnosis Clinical aspects and Confirmation Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR Francesco Procaccio ISS – CNT - Rome Neuro Intensive Care Unit University City Hospital, Verona - Italy

2. Whatis Brain Death? Total Brain Infarct

3. BD Definition Brain Death is theirreversiblelossof capacity forconsciousnesscombined with the irreversibleloss of allbrainstemfunctionsincluding thecapacity to breathe.The Canadian Neurocritical Care Group, 1999

4. Certainty of death:Irreversibility Brain Death or Brain Dying? Death is a process Neurologicalfunctions must haveceased irreversibly Karnice-Karnicki, 1896 F Procaccio 2012

5. (Brain) Death “Irreversibleloss of allcerebralfunctions”

6. Brainstem death

7. WhyBrain deathis the onlydeath ? Pathophysiologicalreasons

8. When a personis dead? Definitive, irreversibletotaldamageof the brain Cerebralfunctions are totallylost Due to twodifferentmechanisms: • Respiratory and circulatoryarrestcausingsecondaryirreversibledamage of brain (non HeartBeatingcadaver) • Devastatingcerebrallesionswhich cause totalirreversibledamage of the brain(Brain Death – HeartBeatingcadaver)

9. Definition of death(Universal death) Simple uniformreliable concepts & definitions may increase public confidence and trust Capron , May 2012 Montreal Forum

10. WhyonlyBrain deathisdeath ? Heart, Lung, Liver, Kidneys etc. are vitalorgans but can be supported by technology orreplaced by transplantation. except The Brain

11. Whomaybecomebrain dead ? Onlypatients with acute cerebrallesion under mechanicalventilation in ICU Brain injury – CerebralHemorrhage IschemicStroke – Brain Tumour Anoxia – CerebralInfection etc.

12. Determination of deathby neurologicalcriteria

13. Determination of Death by Neurologicalcriteria EEG CBF Clinical REFLEXES “All the cerebralfunctions are irreversiblylost”

15. Total Brain Infarct Absence of cerebralblood flow Death

16. Harvard Criteria - 1968 The Neurological Standard

17. Wijdicks E. N Engl J Med 2001

18. Brain Death DiagnosisMilestones • The etiology of the brain lesionisknown • Excludeallpotentialconfoundingfactors • The neurologicalexaminationis complete and allclinicalcriteria are fulfilled

19. Etiology

20. NMR

21. Clinical examination

22. Prerequisites • Etiology must be known • Imaging of irreversible cerebral damage • Temp. >32 °C (“Normal” BP – SO2 – Na+) • Exclusion of medical confounding factors • Exclusion of drug effects on CNS • Exclusion of drug effects on clinical exam (muscle relaxant agents, atropine etc.)

23. The Brainstem

24. Brainstemreflexes: pathways Oculocephalic Oculovestibular Corneal Light response VI VII V VIII III X II XI Painful stimuli Tracheal

26. Pupillary response to light Methodology & clinical experience

27. APNEA TEST 130 78 23 130 98 Absence of respiratory drive PaCO2 > 60mmHg 100% Oxygen

28. Why brain dead patientsmaymove ?

29. Spinal reflexes in Brain Death Brain infarct 1 Spinal Shock Spine without superior control 2 Spinal function recovery 3 Hyperexcitability

30. Are therefactorsthatmay cause unreliable brain deathdiagnosis?

31. CONFOUNDING FACTORS Severe derangement in temperature, blood pressure, oxygenation, electrolytes, glusose, cortisol, T4) Drugs (sedative/anesthetic - barbiturates ! – muscle relaxants ) Facial trauma – Cranial nerves lesions

32. Facial Trauma

33. Ifpotentiallyconfoundingfactorsmay be presentconfirmatorytestsmust be used

34. The absence of cerebralperfusionis a simple, clear, acceptablecriteria, easily to be understood and demonstrated.

35. Cerebral angiogram. Arch injection Wijdicks, 2001

37. Trans Cranial Doppler TCD Brain Death patterns

38. Angio-CT scan Girlanda R BD standard – no confoundingfactors F Procaccio 2012

39. Persistence of cerebralblood “flow”after brain deathFlowers WM et al. Southern Medical Journal 93:364,2000 Decompressingfractures Ventricularshunts Reperfusion(post-anoxic !) DecompressiveHemicraniectomy

40. PossiblePitfalls in BD diagnosis F Procaccio 2012 the BD declaredpatientisnot Deadzero mistake must be ensured the BD personisnot BD declaredsilent BD – Death isnotequal - missingPODs

41. MimickingDisorders • Hypothermia • Barbiturates • Acute poisoning • Endocrine crisis (glucose – cortisol – T4) • neurological diseases

42. “Neurological”conditionsthatmay be confused with Brain Death • Locked-in syndrome • Guillain-Barrésyndrome • Demyelinatingconditions • Post-anoxic coma • Brainstemencephalitis • “Medulla man”

43. The Medulla Man Wijdicks E. J Neurol Neurosurg Psych 2001

44. F Procaccio 2012

45. Post-anoxic BD swelling 6 hours “flow” Neuro ICU, Verona - 2005

47. PossiblePitfalls in BD diagnosis F Procaccio 2012 the BD declaredpatientisnot Deadzero mistake must be ensured the BD personisnot BD declared

49. Brain Death Declaration Certaindiagnosis plus Legal procedures

50. ClinicalDiagnosis simple and reliable Must be complete methodical rigorous