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Discusses the present status of Brain Death Concept in Indian Context.
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Dr (Brig) YD SinghMBBS, MD, FIACM, DIT
Professor (Internal Medicine)SKN Medical College & Gen Hospital
Pune 411 041
Brain DeathBrain Death Death: An IntroductionDeath: An Introduction
Genesis of Brain Death concept ?Genesis of Brain Death concept ? DeathDeath definition under Indian Laws definition under Indian Laws What is brain death? What is brain death?
Scene in USAScene in USA Scene in IndiaScene in India
Causes of Brain DeathCauses of Brain Death Brain Death DiagnosisBrain Death Diagnosis Other Related TermsOther Related Terms
Permanent Vegetative StatePermanent Vegetative State Locked in SyndromeLocked in Syndrome ComaComa
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Normal Brain AnatomyNormal Brain Anatomy
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Cerebral CortexCerebral Cortex
Brain StemBrain Stem
Reticular Reticular Activating Activating
SystemSystem
Receives multipleReceives multiplesensory inputssensory inputs
&&MediatesMediates
ConsciousnessConsciousness(wakefulness)(wakefulness)
Two Dimensions of Two Dimensions of ConsciousnessConsciousness
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Cerebral Cortex: FunctionCerebral Cortex: Function
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
CognitionCognition Voluntary MovementVoluntary Movement SensationSensation
Brain Stem : FunctionsBrain Stem : Functions
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
MidbrainMidbrain
Cranial Nerve IIICranial Nerve III
Pupillary FunctionPupillary Function
Eye MovementEye Movement
Brain Stem : FunctionsBrain Stem : Functions
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
PonsPons
Cranial Nerve IV, V, VICranial Nerve IV, V, VI
Conjugate Eye MovementConjugate Eye Movement
Corneal ReflexCorneal Reflex
Brain Stem : FunctionsBrain Stem : Functions
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
MedullaMedulla
Cranial Nerve IX, XCranial Nerve IX, X
Pharyngeal (Gag) ReflexPharyngeal (Gag) Reflex
Tracheal (Cough) ReflexTracheal (Cough) Reflex
RespirationRespiration
Death : DefinitionDeath : Definition
Thanatology Thanatology Branch of science dealing with study of deathBranch of science dealing with study of death
Death is the complete and irreversible Death is the complete and irreversible stoppage of stoppage of CirculationCirculation RespirationRespiration Brain function (Tripod of life)Brain function (Tripod of life)
As long as oxygenated blood reaches brain stem, Life As long as oxygenated blood reaches brain stem, Life exists ….exists ….
Mechanical Ventilator use in ICUMechanical Ventilator use in ICU Brought concept of “Brain Death”Brought concept of “Brain Death”
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : USABrain Death : USA
Uniform Determination of Death Act 1981Uniform Determination of Death Act 1981 An individual who has sustained eitherAn individual who has sustained either
Irreversible cessation of circulatory & respiratory Irreversible cessation of circulatory & respiratory functions, or functions, or
Irreversible cessation of all functions of the entire Irreversible cessation of all functions of the entire brain, including the brain stem, is dead. brain, including the brain stem, is dead.
A determination of death must be made with A determination of death must be made with accepted medical standardsaccepted medical standards..
The Act did not define the The Act did not define the accepted medical accepted medical standardsstandards
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : USABrain Death : USA
The American Academy of Neurology (1995)The American Academy of Neurology (1995) Published practice parameter to delineate Published practice parameter to delineate
medical standards for the determination of medical standards for the determination of brain death (These are accepted world wide)brain death (These are accepted world wide)
3 clinical findings necessary to confirm 3 clinical findings necessary to confirm irreversible cessation of all functions of the irreversible cessation of all functions of the entire brain, including brain stementire brain, including brain stem Coma (with a known cause)Coma (with a known cause) Absence of brainstem reflexesAbsence of brainstem reflexes ApnoeaApnoea
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Death Definition : Indian LawsDeath Definition : Indian Laws
Registration of Births & Deaths Act 1969Registration of Births & Deaths Act 1969 Defines death as permanent disappearance of Defines death as permanent disappearance of
all evidence of life at any time after live-birth all evidence of life at any time after live-birth has taken place. {Section 2 (1)(b) }has taken place. {Section 2 (1)(b) }
Transplantation of Human Organs Act 1994Transplantation of Human Organs Act 1994 ““Brain-Stem death" Means the stage at which Brain-Stem death" Means the stage at which
all functions of the brain-stem have all functions of the brain-stem have permanently and irreversibly ceased and is so permanently and irreversibly ceased and is so certified under sub-section (6) of section 3certified under sub-section (6) of section 3
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : Indian LawsBrain Death : Indian Laws
Transplantation of Human Organs act, 1994Transplantation of Human Organs act, 1994 ““Deceased person" Deceased person"
Means a person in whom permanent disappearance Means a person in whom permanent disappearance of all evidence of life occurs, by reason of brain-stem of all evidence of life occurs, by reason of brain-stem death or in a cardiopulmonary sense, at any time death or in a cardiopulmonary sense, at any time after live birth has taken place { Section 2(e) }after live birth has taken place { Section 2(e) }
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : IndiaBrain Death : India
Transplantation of Human Organs act, 1994Transplantation of Human Organs act, 1994 Brain death needs to be certified by a board of Brain death needs to be certified by a board of
doctors consisting of :doctors consisting of : Registered Medical Practitioner (RMP) in charge of Registered Medical Practitioner (RMP) in charge of
hospital where brain death has occurredhospital where brain death has occurred An independent RMP – a specialistAn independent RMP – a specialist A Neurologist / Neurosurgeon nominated by panelA Neurologist / Neurosurgeon nominated by panel RMP treating the patientRMP treating the patient
The patient must be examined by team of The patient must be examined by team of doctors at least twice with a reasonable gap of doctors at least twice with a reasonable gap of time in between (at least 6 hours)time in between (at least 6 hours)
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : IndiaBrain Death : India
Transplantation of Human Organs act, 1994Transplantation of Human Organs act, 1994 Highlights:Highlights:
Statutary sanction to the Brain Death Statutary sanction to the Brain Death ConceptConcept
Regulation of Removal, Storage and Regulation of Removal, Storage and Transplantation of human organs for Transplantation of human organs for therapeutic purposestherapeutic purposes
Commercial dealings in human organs Commercial dealings in human organs preventedprevented
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Causes: Brain DeathCauses: Brain Death
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
NormalNormal Cerebral AnoxiaCerebral Anoxia
Causes: Brain DeathCauses: Brain Death
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
NormalNormalCerebral Cerebral
HaemorrhageHaemorrhage
Causes: Brain DeathCauses: Brain Death
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
NormalNormal Cerebral TraumaCerebral Trauma
Brain Death : MechanismBrain Death : Mechanism
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Neuronal Injury
Decreased Intracranial Blood Flow
Neuronal Swelling
Increased Intracranial Pressure
ICP > MAP is incompatible
with life
Brain Death: DiagnosisBrain Death: Diagnosis
04 Steps to diagnosis04 Steps to diagnosis
(1) Clinical Evaluation (Prerequisites)(1) Clinical Evaluation (Prerequisites) Establish Known Irreversible Cause of ComaEstablish Known Irreversible Cause of Coma Exclusion of Potentially Reversible ConditionsExclusion of Potentially Reversible Conditions
Drug Intoxication or PoisoningDrug Intoxication or Poisoning Electrolyte or Acid-Base ImbalanceElectrolyte or Acid-Base Imbalance Endocrine DisturbancesEndocrine Disturbances
Achieve Body temperature > 36° CAchieve Body temperature > 36° C Achieve Normal Systolic BP ( > 100 mm Hg)Achieve Normal Systolic BP ( > 100 mm Hg)
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death: DiagnosisBrain Death: Diagnosis
04 Steps to diagnosis04 Steps to diagnosis (2) Clinical Evaluation (Neuro assessment)(2) Clinical Evaluation (Neuro assessment)
Establish ComaEstablish Coma Establish Absence of Brain Stem ReflexesEstablish Absence of Brain Stem Reflexes Establish ApnoeaEstablish Apnoea
Absence of Respiration driveAbsence of Respiration drive (3) Ancillary Tests(3) Ancillary Tests (4) Documentation(4) Documentation
Time of death is the time the arterial PaCO2 Time of death is the time the arterial PaCO2 reached the target value ORreached the target value OR
When ancillary test officially interpretedWhen ancillary test officially interpreted
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain DeathBrain DeathNeurologic ExaminationNeurologic Examination
COMACOMA
Establish No response to noxious stimulusEstablish No response to noxious stimulus Nail Bed pressureNail Bed pressure Sternal RubSternal Rub Supra Orbital Ridge PressureSupra Orbital Ridge Pressure
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain DeathBrain DeathNeurologic ExaminationNeurologic Examination
Absent Brain Stem ReflexesAbsent Brain Stem Reflexes Pupillary Reflex (absent)Pupillary Reflex (absent) Eye MovementsEye Movements
Occulo-Cephalic ( Dolls Eye Movements)Occulo-Cephalic ( Dolls Eye Movements) Occulo-Vestibular (Cold Caloric test)Occulo-Vestibular (Cold Caloric test)
Facial Sensation and Motor ResponseFacial Sensation and Motor Response Pharyngeal (Gag) Reflex absentPharyngeal (Gag) Reflex absent Tracheal (Cough) Reflex AbsentTracheal (Cough) Reflex Absent
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain DeathBrain DeathNeurologic ExaminationNeurologic Examination
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Pupils dilated with no constriction to bright lightPupils dilated with no constriction to bright light
Brain DeathBrain DeathNeurologic ExaminationNeurologic ExaminationOcculo Cephalic ResponseOcculo Cephalic Response
(No Dolls Eye Movements)(No Dolls Eye Movements)
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain DeathBrain DeathNeurologic ExaminationNeurologic Examination
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Occulo-Vestibular ResponseOcculo-Vestibular Response
““Cold Caloric Testing”Cold Caloric Testing”
Normal Response in ComaNormal Response in Coma
No Response in Brain Stem DeathNo Response in Brain Stem Death
Brain DeathBrain DeathNeurologic ExaminationNeurologic Examination
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Facial Sensations & Motor ResponseFacial Sensations & Motor Response
• Absent Corneal ReflexAbsent Corneal Reflex
• Absent Jaw reflexAbsent Jaw reflex
• No response toNo response to Supraorbital OrSupraorbital Or Temporo-MandibularTemporo-Mandibular PressurePressure
Brain Death : Apnoea TestBrain Death : Apnoea Test
Pre-requisitesPre-requisites Body Temperature > 36° CBody Temperature > 36° C Systolic Blood Pressure ≥ 100 mm HgSystolic Blood Pressure ≥ 100 mm Hg Normal Electrolytes profileNormal Electrolytes profile Normal PaCO2 (35-45 mm Hg)Normal PaCO2 (35-45 mm Hg)
Pre-OxygenationPre-Oxygenation 100% Oxygen via Tracheal Cannula for 10 min100% Oxygen via Tracheal Cannula for 10 min Achieve PaO2 = 200 mm HgAchieve PaO2 = 200 mm Hg
Monitor PaO2 with pulse oximetryMonitor PaO2 with pulse oximetry
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : Apnoea TestBrain Death : Apnoea Test
Reduce Ventilation frequency to 10/minReduce Ventilation frequency to 10/min Reduce PEEP to 5 Cm H2OReduce PEEP to 5 Cm H2O Take 1Take 1stst Blood sample for Blood Gas analysis Blood sample for Blood Gas analysis Disconnect VentilatorDisconnect Ventilator Deliver 100% O2 by catheter through ET tubeDeliver 100% O2 by catheter through ET tube
@ 6 L/min@ 6 L/min
Observe for Respiratory Movement Observe for Respiratory Movement Atleast for 8 – 10 minAtleast for 8 – 10 min
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : Apnoea TestBrain Death : Apnoea Test Discontinue TestingDiscontinue Testing
If BP drops to < 90 mm HgIf BP drops to < 90 mm Hg PaO2 to 85% by pulse Oxymetry for 30 SecPaO2 to 85% by pulse Oxymetry for 30 Sec
If no respiratory drive observed after 08 minIf no respiratory drive observed after 08 min Take next Blood sample for Blood gas studiesTake next Blood sample for Blood gas studies
If respiratory movements are absent & arterial PaCO2 is If respiratory movements are absent & arterial PaCO2 is 60 mm Hg OR60 mm Hg OR 20 mm Hg over a baseline normal PaCO220 mm Hg over a baseline normal PaCO2
The Apnea test result is POSITIVEThe Apnea test result is POSITIVESupports the clinical diagnosis of brain deathSupports the clinical diagnosis of brain death
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain DeathBrain DeathAncillary Confirmatory TestingAncillary Confirmatory Testing
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Recommended when Recommended when Proximate cause of coma is not known or Proximate cause of coma is not known or When confounding clinical conditions limit When confounding clinical conditions limit
clinical examinationclinical examination
EEGEEG Cerebral AngiographyCerebral Angiography PET : Glucose Metabolic StudiesPET : Glucose Metabolic Studies Dynamic Nuclear ScanDynamic Nuclear Scan Somato-Sensory Evoked PotentialSomato-Sensory Evoked Potential
Brain DeathBrain DeathConfirmatory TestingConfirmatory Testing
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Electro-Cerebral SilenceElectro-Cerebral SilenceNormalNormal
EEGEEG
Brain DeathBrain DeathConfirmatory TestingConfirmatory Testing
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
No Intra- Cranial FlowNo Intra- Cranial FlowNormalNormal
Cerebral AngiographyCerebral Angiography
PETPETGlucose Metabolism StudiesGlucose Metabolism Studies
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
““Hollow-skull sign” Hollow-skull sign” of brain deathof brain death
Cerebral metabolism Cerebral metabolism globally reduced ~50% globally reduced ~50%
NormalNormal
Nature Rev Neurosci 2005;6:899-909
Dynamic Nuclear Brain Scan Dynamic Nuclear Brain Scan
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
““Hollow-skull sign” of brain deathHollow-skull sign” of brain death
NEJM 2001;344:1215-1221
Conditions Distinct fromConditions Distinct fromBrain DeathBrain Death
ComaComa
Persistent Vegetative StatePersistent Vegetative State
Locked in SyndromeLocked in Syndrome
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
ComaComa
It is a sleeplike state from which patient It is a sleeplike state from which patient cannot be arousedcannot be aroused It is sleep like becauseIt is sleep like because
Eyes remain closedEyes remain closed Patient is NOT aroused even by painful stimuliPatient is NOT aroused even by painful stimuli
We can simplify Coma by saying:We can simplify Coma by saying: A state lacking Wakefulness and AwarenessA state lacking Wakefulness and Awareness
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Persistent Vegetative statePersistent Vegetative state
Patient out of Coma and appears awakePatient out of Coma and appears awake Follows Normal Sleep-Wake CyclesFollows Normal Sleep-Wake Cycles
No Response to Environmental StimuliNo Response to Environmental Stimuli Not Aware of surroundingsNot Aware of surroundings
Preservation of Brain Stem FunctionPreservation of Brain Stem Function Cause :Cause :
Diffuse Brain InjuryDiffuse Brain Injury
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Persistent Vegetative statePersistent Vegetative state
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Aruna Ramachandra ShanbagAruna Ramachandra ShanbagMumbaiMumbai
Locked in SyndromeLocked in Syndrome
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Ventral Pontine Infarct
Complete ParalysisComplete Paralysis
Consciousness isConsciousness is Preserved Preserved
Preserved EyePreserved Eye MovementMovement
Brain DeathBrain DeathConclusionsConclusions
In the U.S., Brain death is considered In the U.S., Brain death is considered death for all purposesdeath for all purposes
In India Brain death is defined in Organ In India Brain death is defined in Organ transplantation act onlytransplantation act only It is Debatable if Brain Death applicable for It is Debatable if Brain Death applicable for
non organ donation?non organ donation?
We need to have Uniform Declaration of We need to have Uniform Declaration of Death legislation like US to settle the Death legislation like US to settle the issueissue
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain DeathBrain DeathConclusionsConclusions
PVS Patient is not deadPVS Patient is not dead In a state of wakefulness In a state of wakefulness
without awarenesswithout awareness
Ancillary tests (EEG, Ancillary tests (EEG, PET) can help PET) can help distinguish Coma, PVS distinguish Coma, PVS & Locked-in state from & Locked-in state from Brain DeathBrain Death
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Brain Death : Present StatusBrain Death : Present Status
Hippocrates said this long agoHippocrates said this long ago
(The Hippocratic Corpus)(The Hippocratic Corpus)
““First I will define what I conceive medicine to First I will define what I conceive medicine to be. In general terms, it is to do away with be. In general terms, it is to do away with the sufferings of the sick, to lessen the the sufferings of the sick, to lessen the
violence of their diseases, and to refuse to violence of their diseases, and to refuse to treat those who are overmastered by their treat those who are overmastered by their
disease, realizing that in such cases disease, realizing that in such cases medicine is powerless”. medicine is powerless”.
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh
Thanks !!Thanks !!
9 April 20239 April 2023 Dr (Brig) YD SinghDr (Brig) YD Singh