Brain Death (DDNC)

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Deter­mi­na­tion of Death by Neu­ro­log­i­cal Criteria

In 2010, the Amer­i­can Acad­e­my of Neu­rol­o­gy updat­ed guide­lines for deter­min­ing brain death in adults. Pri­or to the neu­ro­log­i­cal exam­i­na­tion, the patient must meet clin­i­cal pre­req­ui­sites. Once the neu­ro­log­i­cal exam­i­na­tion is com­plet­ed, an apnea test should be con­duct­ed. It only needs to be con­duct­ed once. If clin­i­cal pre­req­ui­sites can­not be met or any por­tion of the neu­ro­log­i­cal exam­i­na­tion or apnea test can­not be con­duct­ed, an ancil­lary test is recommended. 

Clin­i­cal Eval­u­a­tion Prerequisites

• Coma, irre­versible and cause known
• Neu­roimag­ing explains coma (or is con­sis­tent with the cause of a coma)
• CNS depres­sant drug effect absent
• No evi­dence of resid­ual paralytics
• Absence of severe acid-base, elec­trolyte, or endocrine abnormality 
• Nor­moth­er­mia or mild hypother­mia (core temp 36 C — 38 C)
• Sys­tolic blood pres­sure ≥ 100 mm Hg
• No spon­ta­neous respirations

Neu­ro­log­i­cal examination

• Pupils non­re­ac­tive to bright light
• Corneal reflex absent
• Ocu­lo­cephal­ic reflex absent (test only if C‑spine integri­ty ensured)
• Oculovestibu­lar reflex absent
• No facial move­ment to nox­ious stim­uli at supra­or­bital nerve, tem­poro­mandibu­lar joint
• Gag reflex absent
• Cough reflex absent to tra­cheal suctioning
• Absence of motor response to nox­ious stim­uli in all 4 limbs (spinal­ly medi­at­ed reflex­es are permissible)

Apnea Test

• Ensure patient is hemo­dy­nam­i­cal­ly stable
• Adjust ven­ti­la­tor to pro­vide nor­mo­car­bia (PaCO2 34 – 45 mmHg)
• Pre­oxy­genate patient with 100% FiO2 for 10 min­utes to PaO2 200 mmHg
• Patient well-oxy­genat­ed with a PEEP of 5 cm of water
• Pro­vide O2 via suc­tion catheter to the lev­el of the cari­na at 6 L/​min or attach T piece with CPAP at 10 cm H20
• Dis­con­nect ven­ti­la­tor and mon­i­tor for spon­ta­neous respirations
• Draw arte­r­i­al blood gas at 8 – 10 min­utes and recon­nect patient to the ventilator

An apnea test is con­sid­ered pos­i­tive if the PCO2 is 60 mmHg or ris­es ≥ 20 mmHg nor­mal base­line value. 

Ancil­lary Test

In instances in which a com­po­nent of the neu­ro­log­i­cal exam­i­na­tion or apnea test can­not be com­plet­ed, ancil­lary test­ing can be used to con­firm brain death.

• Cere­bral angiogram
• Nuclear med flow study
• HMPAO SPECT
• EEG (option­al)
• TCD (option­al)

Ref­er­ence:

Wijdicks F.M., Vare­las P.N., Gron­seth G.S., Greer D.M. Evi­dence-based guide­line update: deter­min­ing brain death in adults: report of the Qual­i­ty Stan­dards Sub­com­mit­tee of the Amer­i­can Acad­e­my of Neu­rol­o­gy. Neu­rol­o­gy. 2010; 74:1911 – 1918.

Pedi­atric Considerations

In pedi­atrics, it is rec­om­mend­ed that two physi­cians must per­form inde­pen­dent exam­i­na­tions sep­a­rat­ed by spec­i­fied time intervals.

Term new­borns 37 weeks ges­ta­tion­al age up to 30 days old:

• First exam may be per­formed 24 hours after birth or fol­low­ing car­diopul­monary resus­ci­ta­tion or oth­er severe brain injury
• Time inter­vals between tests should be at least 24 hours unless an ancil­lary study is per­formed and is con­sis­tent with brain death

In 31 days to 18 year olds:

• First exam may be per­formed 24 hours fol­low­ing car­diopul­monary resus­ci­ta­tion or oth­er severe brain injury
• Time inter­vals between tests should be at least 12 hours unless an ancil­lary study is per­formed and is con­sis­tent with brain death

Ref­er­ence:

Nak­a­gawa T. et al. Guide­lines for the deter­mi­na­tion of brain death in infants and chil­dren: an updat­ed of the 1987 task force rec­om­men­da­tions. Crit Care Med. 2011; 39:2139 – 2155. 

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