Question 15

College Answer

a)

Conditions precluding clinical testing brain death                         

• Absence of diagnosis consistent with brain death
• Hypothermia (< 35 degrees)
• Hypotension (< 90 mmHg systolic or < 60 mmHg MAP in adult)
• Recent administration of sedative drugs
• Abnormalities of electrolyte, metabolic or endocrine function
• Recent administration of neuromuscular blocking agents or spinal cord injury
• Inability to adequately examine the brain stem reflexes (surgery to pupils/perforated ear drum)
• Inability to perform apnoea testing (acute lung injury)

b)

Examination components:

Observation

• Minimum of 4 hour period of observation and mechanical ventilation during which patient has unresponsive coma

Clinical test                                                         Cranial Nerve

i. Coma

ii. Pupillary reflex                                                   II, III

iii. Corneal reflex                                                   V, VII

iv. Pain reflex in trigeminal nerve distribution  V, VII

v. Vestibular ocular reflex                                     III, IV, VI, VIII

vi. Gag reflex                                                         IX, X

vii. Cough reflex                                                   X

viii. Breathing effort with apnoea

Imaging techniques                                                                                              

• Four vessel intra-arterial angiography with digital substraction
• Radionucleotide imaging with Tc 99m HMPAO
• CT angiography – may be acceptable

Imaging techniques need to be done in association with exclusion of preconditions and assessment of those cranial nerves that can be assessed and results need to be reviewed by 2 appropriate clinicians excluding the clinician performing the test.

Discussion

a)

The below preconditions are taken directly from the ANZICS Statement.

• "Brain death cannot be determined without evidence of sufficient intracranial pathology". There must be an explanation for the coma which is consistent with the diagnosis of brain death.
• Minimum period of 4 hours in which the patient is observed to have unresponsive coma, unreactive pupils, absent cough/tracheal reflex and no spontaneous respiratory effort
• Normothermia
• Normotension
• Exclusion of the effects of sedating drugs
• Absence of severe electrolyte, metabolic or endocrine disturbance
• Intact neuromuscular function
• Ability to adequately examine brainstem reflexes
• Ability to perform apnoea testing

Four hours of observation during which the patient remains in unresponsive coma

• GCS of 3
• Unresponsive pupils
• Absent cough reflex
• No spontaneous breathing efforts

Preconditions for apnoea testing

• Absence of concomitant high cervical cord injury
• Normoxia; satisfactory gas exchange
• Haemodynamic stability
• Absent brain stem reflexes

b)

Testing for unresponsive coma

• Painful stimulus in cranial nerve distribution, eg. supraorbital nerve pressure
• Painful stimulus in all 4 limbs, eg. nailbed pressure
• There should be no response

Brain Stem  Reflex Testing (these are tested in sequence; all reflexes must be absent)

• Pupil Light Reflex: CN II,  III
• Corneal  Reflex: CN V,  VII
• Trigeminal Pain: CN V, VII
• Vestibulo-ocular reflex: CN II, IV, VI, VIII
• Gag reflex: CN IX, X
• Cough reflex: CN X

Apnoea testing

• Preoxygenate with 100% FiO2 for 5 minutes, and then turn off the ventilator.
• Continue supplying oxygen via T-piece or something similar. Watch for absent breaths.
• After 10 minutes, take an ABG to demonstrate that the CO₂ is rising.
• To qualify for  brain death, apnoea must persist despite adequate respiratory stimulus (PaCO₂ 60mmHg, or a rise by 20mmHg)

c)

Investigations used to demonstrate a lack of intracranial blood flow are slightly different to those which might be used to demonstrate brain death, as the lattercategory may include such things as EEG (isoelectric EEG).

The imaging modalities are discussed in greater detail in the chapter on radiological testing for brain death.

In brief, the ANZICS-recommended modalities are:

• Tc-99 HMPAO SPECT scan
• DSA (Four-vessel Intra-Arterial Angiography)

Modalities which are not recommended as strongly include:

• MRI
• CT angiography
• Transcranial doppler

The ANZICS statement now says CT angio "is acceptable", whereas at the time of this exam paper being written they merely weazeled that it "may be acceptable". The argument againt CT angiography is the gated timing of the scan. Whereas DSA watches contrast wash in over time in a series of still images, the CT offers a momentary snapshot of that contrast in the vessels. One might argue that the CT was mis-timed, and the contrast did not yet have time to move into the brain (in this way, perfectly healthy people could be made to appear brain-dead by adjusting the timing of the scan). Obviously, when one is going to declare brain death, there needs to be no argument about the validity of the confirmatory test. The 2014 Cochrane review (Taylor et al) could not support the use of CTA, but subsequent improvements in technology have improved the level of confidence with this modality. ANZICS now recommends the use of a four-point scale to radiologically confirm absent brain perfusion by CTA, which consists of "absent enhancement of both middle cerebral artery (MCA) cortical branches (i.e. beyond the Sylvian branches); andabsent enhancement of both internal cerebral veins"

ANZICS Statement on Death and Organ Donation

Taylor, Tim, et al. "Computed tomography (CT) angiography for confirmation of the clinical diagnosis of brain death." The Cochrane Library (2014).