Brain death

During your time in the NSICU, you may witness a brain death exam. This is a legal process and an official definition of death. 

Notes:

• After two such conclusive exams, time of death is declared. Family meetings and spiritual care should occur prior to this.

• It is never appropriate to facilitate organ donation discussions. 

BRAIN DEATH ASSESSMENT CHECKLIST

Prerequisites (all must be met)

• Irreversible and proximate cause of coma is established

• Neuroimaging explains coma

• Exclude the CNS depressant drug effects (when possible: perform toxicology screen, serum drug level below therapeutic range, alcohol level)

• No evidence of residual paralytics

• Absence of severe acid-base, electrolyte, endocrine abnormality

• Normothermia or mild hypothermia (core temperature >36º C)

• Systolic BP >100 mmHg

• No spontaneous respirations

Assessment (all must be met)

• Brainstem reflexes

  • • • Pupillary reflex absent (both eyes)

      • Corneal reflex absent (both eyes)

      • Oculocephalic (doll's eyes) reflex absent

        • • • Only test if C-spine integrity ensured

      • Oculovestibular (cold water caloric) reflex absent

        • • • Only test if tympanic membranes intact

      • No facial movement to noxious stimuli at supraorbital nerve, temporomandibular joint

      • Gag reflex absent

      • Cough reflex absent to tracheal suctioning

• Lack of responsiveness

  • • • Absence of motor response to noxious stimuli in all four limbs

        • • • Deep tendon reflexes are permissible

• Apnea testing

  • • • Patient is hemodynamically stable

      • Ventilator adjusted to provide normocarbia (PaCO2 35-45 mmHg)

      • Patient preoxygenated with 100% FiO2 for >10 minutes

        • • • Recommended PaO2 >200 mmHG, but not required

      • PEEP of 5 cm H2O

      • Obtain baseline (pre-test) ABG

      • Preserve oxygenation via a suction catheter to the level of the carina at 6 L/min

      • Disconnect ventilator

      • Spontaneous respirations absent

      • Draw post-test ABG at 10 minutes 

        • • • pCO2 ≥60 mmHg, or 20 mmHg rise from normal baseline value

If not all assessment points met, there are two options:

• Repeat assessment at a later time OR

• Perform an ancillary study:

  • • • Cerebral angiogram

      • Cerebral blood flow testing

      • EEG

      • Transcranial doppler

Declaration

• Time of death is when second ABG results or when ancillary study is officially read by expert