Determination of Death by Neurologic Criteria (Brain Death)



University of Colorado Hospital Policy and ProcedureDetermination of Death by Neurologic Criteria (Brain Death)Related Policies and Procedures:????Organ and Tissue DonationDonation after Cardiac DeathApproved by:??? Patient Care & Assessment Subcommittee??????????????????????????????? Effective: 10/96Revised: 8/10Description:???? This policy states the procedure for determining brain death.Accountability:???? Brain death is determined by an Attending Neurosurgeon, or Neurologist, or Neuro-Intensivist. The determination of brain death must be made in accordance with accepted medical standards and with Colorado Revised Statutes, § 12-36-136.Definitions:Brain death: The complete and irreversible cessation of all functions of the entire brain including the brainstem. Brainstem reflexes: cranial nerve function is an indicator of brainstem function; reflexes assessed are: pupillary reaction to light, corneal reflex, cough reflex, gag reflex, oculocephalic reflex, oculovestibular reflex, and respiratory reflex.Spinal Reflexes: Movements when a sensory stimulus arises from receptors in the muscle, joints, and skin, resulting in a motor response that is entirely contained within the spinal cordComa: state of unarousable, unresponsiveness. Sleep-wake cycles are absent and respiratory patterns are variable and often abnormal. Policies and Procedures: Assure that all reasonable efforts have been made to notify the patient’s healthcare decision maker and family that an examination to determine death will be completed. Arrangements should be made to include the patient’s healthcare decision maker and family in the processes used to determine neurologic death. Involvement of the patient’s healthcare decision maker and family should occur PRIOR to initiation of neurologic death examinations. Legal documentation of death is the time at which death by neurologic exam (brain death) is declared by the neurosurgeon/neurologist/neuro-intensivist. Once death by neurologic criteria has been declared, and the patient is not a potential organ donor, medical means to support the body will be withdrawn.Assure the absence of reversible causes of coma. Hypothermia (Core temperature greater than 360 Celsius). No drug intoxication, neuromuscular blockade or poisoning. Exclude metabolic or endocrine disturbances. Radiological evidence of non-survivable brain injury must be documentedCriteria for determining brain death: (See Brain Death Determination form on page 4. This form is optional for use in declaring brain death. If this form is utilized, it may be placed in the patients chart as documentation. ) Note: The examining physician is not required to perform each and every aspect of the neurological examination in either the American Medical Association or the American Academy of Neurology guidelines, and it is expected that clinical judgment will play a role in each individual case.Unresponsiveness Cerebrally modulated motor responses are absent. Motor responses should be absent after application of painful stimuli. Spinal cord reflexes may be present. Seizures or decorticate/decerebrate posturing rule out a diagnosis of brain death. Absence of the following brainstem reflexes: Pupillary reflexes are unresponsive to lightCorneal ReflexesCough reflex in response to pharyngeal and deep endotracheal suctioningOculovestibular Reflex (Caloric Ice Water Test)Respiratory reflex (see apnea testing below) Procedure for administering an Apnea TestAn apnea test is necessary to support the diagnosis of brain death. The procedure is done by the critical care RN and RT with a physician present during the actual observation period.Prior to Apnea Testing: The patient must meet the prerequisites and exam criteria for brain death. Have a systolic blood pressure greater than or equal to 100 90 mmHg. Adjust vasopressors accordingly.Obtain baseline ABGOxygen at 100% by mechanical ventilation for at least 10 minutes prior to Apnea Test. Target PaO2 to greater than or equal to 200mmHgThe ventilator settings should be adjusted for a PaCO2 of about 40 35-45 mmHGObtain baseline ABG. The Apnea Test begins when mechanical ventilation is removed. Oxygen at 100% should be delivered via t-piece.Monitor blood pressure and heart rate continuously. If the patient becomes hemodynamically unstable during the observation period, tThe test should be terminated if:More than 50% increase of current vasopressor dose is required to maintain systolic blood pressor greater than or equal to 90 mmHgSymptomatic cardiac arrhythmias developOxygen saturation measured by pulse oximetry drops below 85% for greater than 30 seconds, mMechanical ventilation resumed, and an ABG obtained. AIf desired results are not achieved, alternative confirmatory test recommended. test must be utilized.Observe and/or feel for any respiratory effort for 8-10 minutes. If respiratory effort is noted, stop the test and resume mechanical ventilation. The patient does not meet brain death criteria.During the test, the PaCO2 will rise about 3 mmHg/minute during apneic oxygenation. The amount of time off the ventilator will depend on the starting PaCO2 level. The desired PaCO2 endpoint is 60 mmHg or greater OR 20mmHg above a known baseline.For verification/documentation purposes, an ABG should be drawn at the end of the observation period to assure the PaCO2 has reached the desired level. RESUME VENTILATION.If there is no evidence of respiratory effort AND the PaCO2 is 60mmHg or greater OR 20 mmHg above a known baseline, THEN the apnea test, supports the diagnosis of brain death. If the test is inconclusive but the patient is hemodynamically stable during and after the procedure, it amy be repeated for a longer period of time (10-15 minutes) after patient is adequately again preoxygenated.Procedure for administering Cold Caloric testThe oculovestibular reflex (cold caloric) is to determine brain stem function of an unconscious patient. The procedure is done by a physician.Each ear canal is irrigated with a minimum of 50 mL of cold water (allow 1 minute after injection and at least 5 minutes between testing on each side.) No eye movement indicates brain stem damage.Confirmatory testsThese tests are not required. These are optional and may be used in conjunction with a clinical exam to support the diagnosis of brain death. They are recommended in any case where the etiology of coma is unclear or the patient is too hemodynamically unstable to perform apnea test.Cerebral Arteriography 2.Radionuclide Scanning 3.Electroencephalogram (EEG)4.Transcranial Doppler Ultrasonography (TCD)Additional Supportive InformationIntracranial Pressure Monitoring: A diagnosis of brain death is supported when patient’s intracranial pressure (ICP) is equal to or greater than the patient’s mean arterial pressure (MAP). Documentation by the Physician Etiology and irreversibility of condition Clinical observations including prerequisite criteria and apnea testing Date and time of death Confirmatory testing methodology and results (if done) Special considerations: Pediatric patients are required toshould be evaluated by a pediatric neurologist or neurosurgeon.University of Colorado HospitalBRAIN DEATH DETERMINATION DOCUMENTATIONHave all reasonable efforts been made to notify patients’ family or decision maker that a determination of death based on cessation of brain function will be completed?Checklist for determination of brain deathPrerequisites (all must be checked)Coma, irreversible, and cause knownNeuroimaging explains comaCNS depressant drug effect absent (if indicated toxicology screen; if barbituartes given-sereum level must be <10 ug/mLNo evidence of residual paralytics (train of four 4:4)Absence of severe acid-base, electrolye, endocrine abnormalityNormothermia (>36 degrees C)Systolic BP > or equal to 100 mmHgNo spontaneous respirationsExamination (all must be checked)Pupils nonreactive to bright lightAbsent corneal reflexOculocephalic reflex absent (if no C-spine injury suspected)No facial movements to noxious stiuli at supraorbital nerve/temporalmandibular jointAbsent gag reflexAbsent cough reflexAbsence of motor response to noxious stimuli in all 4 limbs (spinally mediated reflexes permissible)Apnea testing (all must be checked)Patient is hemodynamically stablePreoxygenate with 100% Fio2 for >10 minutes Draw baseline ABGVentilator adjusted to PaCo2 35-45 mmHgDisconnect ventilatorProvide oxygen via T-piece at 100%Spontaneous respirations absentABG drawn at 8-10 minutes, patient reconnected to ventilatorPCO2 > or equal to 60 mmHg or 20 mmHg rise from normal baseline value ORApnea test abortedAncillary Tests (recommended if clinical exam cannot be fully performed or if apnea test aborted)Cerebral ArteriographyEEGRadionucliotide CBFTCD or ICP equal to MAPPATIENT IDENTIFICATION LABELUniversity of Colorado HospitalBRAIN DEATH DETERMINATION DOCUMENTATIONNOTE: The patient must be examined in this hospital during treatment of potentially correctable abnormalities. The examining physician will initiate each component of the exam and where appropriate, document supporting laboratory or examination data. If a component of the exam is not or cannot be done, please document.THE EXAMINING PHYSICIAN MUST DOCUMENT THE DATE AND TIME OF THE EXAMINATION. RESULTS OF EXAM MUST BE DOCUMENTED FOR ALL OF SECTIONS A, B, AND C AND ACCORDING TO GUIDELINES FOR SECTION D.EXAM Date : EXAM Time:Have reasonable efforts been made to notify patients’ family or decision maker that a determination of death based on cessation of brain function will be completed? Yes A. No Evidence of/Cause of Reversible CNS Depression 1. Core temperature must be greater than 360 Celsius. Record temperatureTemp ______ 2. Record no evidence of severe metabolic perturbations that could potentiate central nervous system depression. Consider glucose, Na, creatinine, PaCO2, SaO2.No evidence 3. No CNS depressant drugs or paralytic agents given a minimum of 2-hours prior to exam. Record no evidence of pharmacological perturbations within 2-hours.No evidence 4. Absence of hypotension (SBP greater than 90 mm Hg or MAP greater than 60 mm Hg). Record blood pressure.B/P ______B. Absence of Cortical Function 1. No motor response to any stimuli (excluding spinal reflex)No response 2. No eye opening to any stimuli.No response 3. No verbal response to any stimuli.No responseC. Absence of Brain Stem Reflexes and Responses **Physician must perform all 4 of the tests listed below. ** 1. Pupils non-reactive to strong light. Reflex absent 2. Absent corneal reflexesReflex absent 3. Absent response to upper and lower airway stimulation, such as pharyngeal and endotracheal suctioning.Reflex absent 4. Absent ocular response to irrigation of the ears with 50 mL of ice water (no ocular cephalic reflexes)Reflex absentD. Document Confirmatory Test Utilized (minimum of 1) 1. Apnea Test: (with physician present)PaCO2 at start of test PaCO2 at end of testpH at end of testOther confirmatory tests are not required if a clinical exam including an apnea test is done. If an apnea test is not done as part of the clinical exam, one of the following confirmatory tests is required: 2. Other Test(s):□ Cerebral arteriography□ Radionuclide CBF □ EEG□ Transcranial Doppler or ICP is equal to MAP Having considered the above findings, I hereby certify brain death pronounced by:Attending Physician Signature ______________________________ Date_______________Time _______________Name Printed ____________________________ UPI#__________MED 90304 E/-(05/07) References: Greer, David M., Varelas, Panayiotis N., Wijdicks, Eelco F.M., Wijdicks, Shamael Haque. (2010). Variability of brain death guidelines in leading US neurologic institutions. Neurology, 70, 283-289. ( Level IV).Colorado Revised Statutes, Volume 4, Title 12 (May 21, 1997). § 12-36-136 Determination of death. Ducrocq, X., Braun, M., Debouverie, M., Junges, C., Hummer, M. and Vespignani, H. (1998). Brain death and transcranial doppler: experience in 130 cases of brain dead patients. Journal of the Neurological Sciences, 160, 41-46. (Level III)Peiffer, K.M.Z. (2007). Brain death and organ procurement. AJN, 107, 3, 58-67. (Level VI)Manno, E.M., & Wijdicks, E.F.M. (2006). The declaration of death and withdrawal of care in the neurologic patient. Neurologic Clinics, 24, 159-169 (Level V). Wijdicks, Eelco F.M., Varelelas, Panayiotis N., Groneseth, Gary S., Greer, David M. (2010). Evidence-based guideline update: Determining brain death in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 74, 1910-1918. (Level IV).Yee, Alan H., Mandrekar, Jay, Rabinstein, Alejandro A., Wijdicks, Eelco F.M. (2010). Predictors of apnea test failure during brain death determination. Neurocritical Care Society, online publication: 09 March 2010. (Level V).Llompart-Pou, J.A., Abadal, J.M., Velasco, J., Homar, J., Blanco, C., Ayestaran, J.I., Perez-Barcena, J. (2009). Contrast-enhances transcranial color sonography in the diagnosis of cerebral circulatory arrest. Transplantation Proceedings, 41, 1466-1468. (Level IV).c150910 ................
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