Brain Death determination

[skepticdoc]

I have been unable to find concrete answers, I would like to find out the opinions and references from the JREF Forum.

Have there been any cases where the nuclear brain flow study was negative (no brain blood flow) and the patient did not meet the criteria for brain death? (There are reports of brain dead patients that had brain flow, supposedly the vessels opened up after brain death, but there was no neural activity.)

Have any cases been published of a patient that had no corneal reflexes, no response to painful stimuli that was not Brain Dead?

You may send me a PM if you wish.

 

[casebro]

Is blood flow a needless complication? If the brain don't function, it's dead, regardless of whatever is flowing through?

Avatar question: lightening strike, or angiograph?

I'm not a doctor, never even played one on TV. Never slept in a Holiday Inn either.

 

[skepticdoc]

Avatar is an electric discharge.

The point is that blood flow can happen in the presence of brain death, but absence of blood flow is considered evidence of brain death, either using radioisotopes or angiography.

 

[SteveGrenard]

Avatar is an electric discharge.

The point is that blood flow can happen in the presence of brain death, but absence of blood flow is considered evidence of brain death, either using radioisotopes or angiography.

Absence of blood flow is considered a cause of brain death. Aren't you leaving a few additional things out of the protocol to insure the brain is really dead? Like
sequential isoelectric EEGs and the apnea test to
determine if the brain stem is dead?

 

[skepticdoc]

I believe that a negative angiogram is one of the irrefutable proofs, although usually the Radiologists have reviewed the Neurologist evaluation, and the angiogram or nuclear scan is more of a confirmation.

That really is my question:

Can you have absence of brain blood flow and not be brain dead?

Can you have some spontaneous breaths, that are not capable of sustaining adequate ventilation/oxygenation, and not be brain dead? If you follow a strict definition, could you be prolonging suffering? (If the respirations are insufficient to sustain life, and this the only evidence of neural activity, is this person still alive?)

 

[SteveGrenard]

Q. Can you have absence of brain blood flow and not be brain dead?

Y. Under hypothermic controlled surgery for brain procedures in a bloodless field. Search Pam Reynolds case.

Q. Can you have some spontaneous breaths, that are not capable of sustaining adequate ventilation/oxygenation, and not be brain dead?

A: Of course, that's why people are placed on vents.


Q. If you follow a strict definition, could you be prolonging suffering? (If the respirations are insufficient to sustain life, and this the only evidence of neural activity, is this person still alive?)

A: How does it prolong suffering if patient is in a coma and irreflexive to pain stimuli? Perhaps for the family. In our center they would have to be apneic on passive 100% O2 (off vent) with a PCO2 of 60+mmHg in order to have brain stem death by definition. Plus 3 isoelectric eegs. Otherwise they are not legally brain dead.

 

[SteveGrenard]

J Card Surg. 2002 Mar-Apr;17(2):115-24.
Brain protection during surgery of the aortic arch.Bachet J, Guilmet D.
Institut Mutualiste Montsouris, Paris, France. jean.bachet@wanadoo.fr

Deep hypothermia with circulatory arrest is the usual method of cerebral protection during replacement of the aortic arch. It has the enormous advantage of allowing the surgical repair to be carried out in a complete bloodless field with no aortic cross-clamping. However, this method only gives the surgeon a limited period of time to carry out the aortic repair. It also requires that cardiopulmonary bypass be prolonged to cool and rewarm the patient which may be the cause of various complications. It has been proposed to improve the efficiency and the results of deep hypothermia, by associating it with retrograde cerebral perfusion of the brain with oxygenated blood through the superior vena cava. This technique improves the tolerance of the brain to cold ischemia and increases the time of repair allowed to the surgeon. Antegrade selective cerebral perfusion has also been in use for more than three decades. When the perfusion is derived from the main arterial line and performed at moderate hypothermia, the aorta must be cross-clamped to perform the repair. In addition, there is some uncertainty as to what constitutes adequate perfusion flow at normal or moderate hypothermic conditions. To reconcile the advantages of both approaches while avoiding their major drawbacks, in 1986 we proposed an original method of selective antegrade brain perfusion. The principle is to perfuse selectively the brain with cold blood (10 to 12 degrees C) while maintaining the central temperature in moderate hypothermia (25-28 degrees C). During the time of the distal anastomosis the cardiopulmonary bypass is stopped, maintaining only the cerebral perfusion at a flow rate of about 400 to 500 mL/mn and a pressure of about 70 mmHg. As soon as the distal anastomosis is completed the main perfusion is resumed. Two hundred and six patients with a mean age of 57 years (22 to 83) were operated on with this technique between October 1984 and March 2001. One hundred forty three patients underwent an elective procedure and 63 patients were operated on in emergency, mainly for acute type A dissection (54 of 63). The hospital mortality was 17% (34 patients). Death was directly related to neurological injury in 9 patients (4.4%). All others patients awoke within 6 to 8 hours and were conscious at 24 hours postoperatively. Thirteen nonfatal neurological complications were observed. The type of lesion, gender, age, duration of CPB, cerebral perfusion, and circulatory arrest had no influence on the neurological outcome of the patients. In our experience, antegrade selective perfusion of the brain with cold blood and moderate hypothermic central temperature constitutes the method of choice for cerebral protection during surgery of the aortic arch as it requires no prolonged CPB and does not limit the time available to perform the aortic repair.

PMID: 12220062 [PubMed - indexed for MEDLINE]

 

[skepticdoc]

Q. Can you have absence of brain blood flow and not be brain dead?

Y. Under hypothermic controlled surgery for brain procedures in a bloodless field. Search Pam Reynolds case.

Q. Can you have some spontaneous breaths, that are not capable of sustaining adequate ventilation/oxygenation, and not be brain dead?

A: Of course, that's why people are placed on vents.


Q. If you follow a strict definition, could you be prolonging suffering? (If the respirations are insufficient to sustain life, and this the only evidence of neural activity, is this person still alive?)

A: How does it prolong suffering if patient is in a coma and irreflexive to pain stimuli? Perhaps for the family. In our center they would have to be apneic on passive 100% O2 (off vent) with a PCO2 of 60+mmHg in order to have brain stem death by definition. Plus 3 isoelectric eegs. Otherwise they are not legally brain dead.

Thank you for clarifying the fine points, nobody would consider the induction of hypothermia and cessation of flow for a surgical procedure brain death.

Supposedly there is a movement to clarify the issues of inadequate CNS ventilation control, it probably is like touching the third rail, nobody wants to refine the definition, and everybody wants to be a 100% sure ( do you really need 3 EEGs on a normothermic, drug free victim of a SAH that has no corneal reflexes, no spontaneous breaths and no flow on nuclear scan? )

My real life case was a male found pulseles, apneic by the family, EMT intubated the esophagus, there was some electrical activity after epinephrine. The ER correctly intubated and restored blood pressure with sinus tachycardia. There was greater than 45 minutes of hypoxia, the CT showed massive SAH with uncal herniation, and the Neurologist was arguing with me that he was not brain dead because he saw him gasp through the ETT ( the ICU nurses never saw or documented any breaths ).

There is another issue, when should CPR be initiated, if at all? (probably a new thread in a Medical Forum)

Who pays for the 3 EEGs, the organ harvesters?

If the patient is not a donor do they still do this, or do they just withdraw care and agressive support?

 

[Dave1001]

wow, it must be so cool to be a medical doctor. This is a whole field of thought I'm unlikely to ever master.

 

[SteveGrenard]

Q: Supposedly there is a movement to clarify the issues of inadequate CNS ventilation control, it probably is like touching the third rail, nobody wants to refine the definition, and everybody wants to be a 100% sure ( do you really need 3 EEGs on a normothermic, drug free victim of a SAH that has no corneal reflexes, no spontaneous breaths and no flow on nuclear scan? )

A: Indeed. This will always be controversial. Whoever pays for the EEGs is irrelevant when it comes to this. They are a few hundred dollars each. So what? Sounds like your friend at least deserved the benefit of these plus an apnea determination. Insurance, the family, the hospital anyone can pick up or eat the cost in such a situation. He was your friend, you would've paid if that was an issue.

Q: My real life case was a male found pulseles, apneic by the family, EMT intubated the esophagus, there was some electrical activity after epinephrine. The ER correctly intubated and restored blood pressure with sinus tachycardia. There was greater than 45 minutes of hypoxia, the CT showed massive SAH with uncal herniation, and the Neurologist was arguing with me that he was not brain dead because he saw him gasp through the ETT ( the ICU nurses never saw or documented any breaths ).

A: That's a problem if he's not apneic. Remember the Quinlan case? They took her off the vent and she started to breathe and went on for years breathing on her own? What should we have done with her? Shoot her? Starve her like Schiavio? These are tough issues.

Q: There is another issue, when should CPR be initiated, if at all? (probably a new thread in a Medical Forum)

A: That's a problem when the first person there doesn't know how long the patient was out. The policy is to start CPR unless the patient is in rigor. As a cardiac arrest victim myself who was resuscitated, intubated, placed on a vent, then weaned off and left the hospital under my own steam I have some strong feelings about this. The EMTs were right to start CPR on your friend. Too bad they screwed up the intubation. Your friend would've been better off if they ventilated him with a bag and mask, even mouth to mouth. The esophageal intubation blocked his oxygenation completely. EMTs are supposed to use
CO2 monitors on the ends of ETT or bag exhal valve to insure they are in the trachea.If no CO2 registers they must pull the tube, resume bag/mask or mouth to mouth and then try again or give up till they reach the ER.

(In my neck of NY EMTs do not do intubations. Only doctors, RTs (like myself) and in the field paramedics are allowed to. And if qualified PAs and NPs also and of course nurse anesthetists. Maybe they had a paramedic, not an EMT on the ambulance.)

Q: Who pays for the 3 EEGs, the organ harvesters?

A: If the patient is isoelectric and apneic, and they happen to be an organ donor, they are placed back on the vent and taken into the OR for harvesting.

Otherwise they are left off the vent and come what may.

Q: If the patient is not a donor do they still do this, or do they just withdraw care and agressive support?

A: See Q. above. Aggressive support in terms of mechanical ventilation, pressors, etc etc are withheld.

In my personal experience with these cases the
heart just bradys down and stops. And it's over.

 

[SteveGrenard]

wow, it must be so cool to be a medical doctor. This is a whole field of thought I'm unlikely to ever master.

I am a respiratory therapist with 30+ years specializing in critical care, not a medical doctor.
But this was pretty cool too. You can master whatever you set your mind too.

 

[Dave1001]

I am a respiratory therapist with 30+ years specializing in critical care, not a medical doctor.
But this was pretty cool too. You can master whatever you set your mind too.

Oh, I didn't mean I thought I was incapable of mastering that field. Just that there's too big a backlog of what I need to learn. But a sincere thanks for the positve words.

 

[SteveGrenard]

Thank you for clarifying the fine points, nobody would consider the induction of hypothermia and cessation of flow for a surgical procedure brain death.

true, mostly. But hypothermic cardiac arrest occurs in the field also especially in coldwater near drowning. Such patients can survive with or without a neuro deficit.

 

[SteveGrenard]

Oh, I didn't mean I thought I was incapable of mastering that field. Just that there's too big a backlog of what I need to learn. But a sincere thanks for the positve words.

When I was working at Lenox Hill, one year we had a new intern -- a 62 year old grand mother who raised her family, went back to school and medical school. She said she figured her grand kids needed a doctor she could trust!

 

[Dave1001]

When I was working at Lenox Hill, one year we had a new intern -- a 62 year old grand mother who raised her family, went back to school and medical school. She said she figured her grand kids needed a doctor she could trust!

Amazing. I recall reading about an extremely old law student in Upstate NY - in her 70s at least- who was interested in being an SEC litigator after graduation. She had put off school for the same reasons.

 

[SteveGrenard]

Q: There is another issue, when should CPR be initiated, if at all? (probably a new thread in a Medical Forum)

In December 2005 the AHA issued new guidelines including ethical guidelines for CPR as a Supplement to their journal Circulation. While I am certain forum members will have some interesting opinions this document represents the "law of the land" for now, sorta..check out the issue at:

http://circ.ahajournals.org/content/vol112/24_suppl/

 

[skepticdoc]

Thanks Steve, you always honor the threads by illumination!

My question remains unanswered still!

 

[SteveGrenard]

Sorry I can't tell you that the sole criteria regarding the brain perfusion in
conjunction with the other factords you mention is not definitive proof of brain death without the EEGs and the apnea test, at least where I work.

Just to go back over your friend's hx for a sec, I have a few ?s of my own:

You reported:
Q: My real life case was a male found pulseles, apneic by the family, EMT intubated the esophagus, there was some electrical activity after epinephrine. The ER correctly intubated and restored blood pressure with sinus tachycardia. There was greater than 45 minutes of hypoxia, the CT showed massive SAH with uncal herniation, and the Neurologist was arguing with me that he was not brain dead because he saw him gasp through the ETT ( the ICU nurses never saw or documented any breaths ).

Are you saying he was hypoxic for 45 minutes due to the fact his esophagus was intubated all that time?

1. If so didn't anyone use a stethescope on him to check for, er, breath sounds?

2. If they didn't hear them they could've slid it down and heard air in the stomach. I find it hard to believe paramedics, even EMTS in the field don't know how to do this.

3. Didn't anyone notice the stomach getting larger?
It has no elastic recoil so the air remains trapped until it backs up out.

If not due to the esophageal intubation , how do you know he was hypoxic/anoxic this length of time?

 

[skepticdoc]

Sorry, don't have those details. The ER diagnosed the esophageal intubation.

He was found slumped over, unresponsive, the length of anoxia/hypoxia can only be estimated, best guess- 30-45 minutes. (Family left him to get dinner, called paramedics when they arrived at the house)

 

[Camillus]

I have been unable to find concrete answers, I would like to find out the opinions and references from the JREF Forum.

Have there been any cases where the nuclear brain flow study was negative (no brain blood flow) and the patient did not meet the criteria for brain death? (There are reports of brain dead patients that had brain flow, supposedly the vessels opened up after brain death, but there was no neural activity.)

Have any cases been published of a patient that had no corneal reflexes, no response to painful stimuli that was not Brain Dead?

You may send me a PM if you wish.

I am not aware of anyone being correctly diagnosed as brain dead and then showing any degree of recovery. I have seen a couple of Lazarus syndrome events but those have always been in patients who would not be expected to suffer brain death but I have never seen anyone diagnosed as brain dead survive termination of ventilation.

It is worth pointing out that in the UK there is no need to perform either EEG or blood flow studies to diagnose brain death. The current code of practice governing brain stem death testing says:

The safety of the clinical criteria for the diagnosis of brain stem death during the past 17 years provides justification for not including the results of neurophysiological or imaging investigations as part of those criteria. At present there is no evidence that imaging, electroencephalography or evoked potentials assist in the determination of brain stem death and, though such techniques will be kept under review, they should not presently form part of the diagnostic requirements.