Brainstem dysfunction - dwayne
- 1. Brainstem dysfunction - Dr. Dwayne
- 2. What is brain death? Determination of brain death in term newborns, infants and children is a clinical diagnosis based on the absence of neurologic function with a known irreversible cause of coma Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720
- 3. Pre-requisites Physical examination Apnoea test Ancillary tests Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720
- 4. Brainstem dysfunction PRE REQUISITES 1. Irreversible and identifiable cause – status eplepticus with anoxic brain injury 2. Correction of contributing factors that can interfere with neurological examination a. Temp >95F b. Maintainance of MAP – on inotropes c. Sedatives/ Analgesics – NA d. Metabolic intoxication – None via history e. Neuromuscular blockade - none
- 5. Brainstem dysfunction PHYSICAL EXAMINATION Flaccid tone; patient unresponsive to deep painful stimuli Pupils midpostion/fully dilated and light reflexes absent Corneal/ cough/ gag reflexes absent Oculovestibular reflex absent Spontaneous respiratory effort whilst on mechanical ventilation is absent
- 6. Brainstem dysfunction APNOEA TEST Normal temp/BP. No sedation/NMB Preoxygenate 100% O2 5-10mins ABG – record PaCO2 (Pre test) Disconnect from vent and connect to T piece (100% FiO2) Monitor closely for 15 mins PaCO2 >60/ increase >20 from baseline with no respiratory effort – consistent with brain death
- 7. Brainstem dysfunction ANCILLARY INVESTIGATIONS 1. EEG – features suggestive of Beta coma 2. Radionucleotide cerebral blood flow Indications: (i) When components of the examination or apnea testing cannot be completed safely due to the underlying medical condition of the patient (ii) If there is uncertainty about the results of the neurologic examination (iii) If a medication effect may be present or (iv) To reduce the inter-examination observation period
- 8. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720
- 9. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720
- 10. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720
- 11. Thomas A. Nakagawa et al; Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations. Pediatrics 2011;128;e720
- 12. Why is it so important?
- 13. Counselling
- 14. Organ donation
- 15. Thank you