1. Brainstem death Paulus Anam Ong Department of Neurology

2. Foreword The purpose of medical science is to prolong life and not to prolong dying process. The purpose of medical science is to prolong life and not to prolong dying process. Physician:health provider who are authorized to define death of the individual Physician:health provider who are authorized to define death of the individual Physician should know the definition of death in both emergency or normal situation Physician should know the definition of death in both emergency or normal situation

3. Definition of Death Irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breath” Irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breath” The irreversible cessation of brainstem function (brainstem death), whether induced by intracranial events or result of extra-cranial phenomena will produce the same clinical state The irreversible cessation of brainstem function (brainstem death), whether induced by intracranial events or result of extra-cranial phenomena will produce the same clinical state Brainstem death is equivalent to death of the individual. Brainstem death is equivalent to death of the individual. U.K. Criteria for the diagnosis of brainstem death (Working Group convened by the Royal Collage of Surgeons, 1995)

4. Brainstem death Brainstem: regulator of respiration and cardiovascular stabilization Brainstem: regulator of respiration and cardiovascular stabilization Brainstem death: discontinuity of peripheral neuronal system through the brain (absolute for consciousness) Brainstem death: self-fulfilling prophecy

5. Diagnosis of Brainstem death 3 step in clinical diagnose of brainstem death: 1. To ascertain that essential condition be satisfied before considering the diagnosis of brainstem death 2. Exclude the possibilities of reversible cause of coma and apnea 3. To ascertain the irreversible absence of brainstem reflexes and the apnea

6. Ad 1. Certain condition should be satisfied Two Condition required for brainstem death: 1. The patient is deeply comatose and apnea; unresponsiveness and maintained on the ventilator 2. The diagnosis should be known and the condition should be one that is capable of causing neuronal death and the brain damage is irreversible

7. Ad 2. To exclude the reversible cause of comatose and apnea Drug intoxication (depressant drugs) Drug intoxication (depressant drugs) Primary hypothermia Primary hypothermia Potential metabolic and endocrine disturbances as a cause of comatose Potential metabolic and endocrine disturbances as a cause of comatose U.K Code: Diagnosis of brainstem death should not be consider with the presence of above points U.K Code: Diagnosis of brainstem death should not be consider with the presence of above points

8. Before test the brainstem reflexes There should be evidence of loss of brainstem function Patient is in deeply comatose Patient is in deeply comatose There is not abnormal postures (de- cortication or de-cerebration) There is not abnormal postures (de- cortication or de-cerebration) There is no occulocephalic reflex There is no occulocephalic reflex There is no epileptic seizure There is no epileptic seizure There is no spontaneous breath There is no spontaneous breath Brainstem is still functioning if one of the above point is present.

9. 5 Brainstem reflexes Absence of : 1. Pupils: no response to light 2. Cornea: no corneal reflexes 3. Oculocephalic testing (head turning) and Oculovestibular (caloric) testing 4. Motor response to adequate somatic stimulation within distribution of cranial nerve 5. Gag reflex (pharingeal and tracheal reflexes)

10. Apnea Test Prerequisites: Prerequisites: Core temperature >36.5 ‘C Core temperature >36.5 ‘C Systolic BP > 90 mmHg Systolic BP > 90 mmHg Euvolemia. Option: positive fluid balance in previous 6 h. Euvolemia. Option: positive fluid balance in previous 6 h. Normal Pco2 > 40 mmHg Normal Pco2 > 40 mmHg Normal Po2. Option: preoxigenation to obtain arterial P o2 > 200mmHg Normal Po2. Option: preoxigenation to obtain arterial P o2 > 200mmHg Connect a pulse oximeter and discontect the ventilator Connect a pulse oximeter and discontect the ventilator

11. Apnea Test Deliver 100% O2 6l/min into trachea. Deliver 100% O2 6l/min into trachea. Look closely for respiratory movement (abdominal or chest excursions that produce adequate tidal volumes) Look closely for respiratory movement (abdominal or chest excursions that produce adequate tidal volumes) Measure arterial P o2, Pco2 and pH after approximately 8 min and reconnect the ventilar. Measure arterial P o2, Pco2 and pH after approximately 8 min and reconnect the ventilar. If respiratory movement are absent and arterial Pco2 is >60mmHg; the apnea test is (+)  support brainstem death If respiratory movement are absent and arterial Pco2 is >60mmHg; the apnea test is (+)  support brainstem death If respiratory movement are observed  apnea test is (-) If respiratory movement are observed  apnea test is (-) Connect the ventilator if during testing systolic BP 60 mmHg or Pco2 rise >20mmHg  apnea test (+)  support brainstem death; if Pco2 is 60 mmHg or Pco2 rise >20mmHg  apnea test (+)  support brainstem death; if Pco2 is <60mmHg or Pco2 is <20mmHg over baseline, the result is indeterminate, additional confirmatory test can be considered.

12. Repeat of test Test repeating is done to avoid fault observation and changes of signs Test repeating is done to avoid fault observation and changes of signs Interval time of 2 tests range from 25 minutes to 24 hrs depend on hospital regulation and recommendation accepted Interval time of 2 tests range from 25 minutes to 24 hrs depend on hospital regulation and recommendation accepted

13. Difficulties in diagnosing brainstem death Examination results Possible causes 1. Fixed pupils Anticholinergic drugs, muscle relaxing drug, previous disease 2. Oculo-vestibuler reflex (-) Ototoxic drug, vestibular suppressant, Previous disease 3. Apnea Post hyperventilation Muscle relaxing drug 4. No motor response “Locked in state”, muscle relaxing drug, Sedative drugs 5. Isoelectric EEG Sedative drug, hypoxia, hypothermia, Encephalitis, trauma

14. 1. Severe facial trauma 2. Disease of pupils 3. Sedative drug used 4. Severe pulmonary disease Difficulties in diagnosing brainstem death

15. After diagnosis of brainstem death Withdraw therapeutic and palliative treatment gradually according to severity of individual patient Withdraw therapeutic and palliative treatment gradually according to severity of individual patient

16. Doubt in: Primary diagnosis Primary diagnosis Cause of brainstem dysfunction may be reversible (drug and metabolic disorders) Cause of brainstem dysfunction may be reversible (drug and metabolic disorders) Completeness of clinical test Completeness of clinical test Do not make diagnosis of brainstem death Do not make diagnosis of brainstem death

17. Ancillary Testing No required USG doppler USG doppler MRI MRI Brainstem Evoke Potential Brainstem Evoke Potential Electroencephalography Electroencephalography

18. According to Indonesia Doctor Association (IDI) Diagnosis of brainstem death should be made by at least 2 doctor who are experience in this field Diagnosis of brainstem death should be made by at least 2 doctor who are experience in this field In Indonesia Anestesiologist, Critical care doctors, Neurologist and both of them do not involved in the organ transplant team In Indonesia Anestesiologist, Critical care doctors, Neurologist and both of them do not involved in the organ transplant team