ORGAN DONATION CRITERIA
Refer imminent deaths of ventilator patients within one hour of patient meeting either of the following criteria:
• PLAN TO DISCUSS WITHDRAWAL OF SUPPORT WITH FAMILY (potential candidate for Donation after
Circulatory Death)
• Severe brain injury, ventilator-dependent and GCS< 5
• PLAN TO DISCUSS WITHDRAWAL OF SUPPORT WITH FAMILY (potential candidate for Donation after
Circulatory Death)
• Severe brain injury, ventilator-dependent and GCS< 5
BRAIN DEATH DETERMINATION
The following are a summary of the American Academy of Neurology’s (AAN’s) Evidence-based Guidelines for Clinicians for determining Brain Death in Adults.
PLEASE reference this hospital’s policy that addresses determination of brain death as it may differ from these guidelines.
Prior to exam, all of the following must be met according to AAN guidelines:
• Coma, irreversible and cause known
• Neuroimaging explains coma
• CNS depressant drug effect absent (if indicated toxicology screen; if barbiturates given, serum level < 10μg/ml)
• No evidence of residual paralytics (electrical stimulation if paralytics used)
• Absence of severe acid-base, electrolyte, or endocrine abnormalities
• Normothermia (>36°C)
• Systolic blood pressure >100 mm Hg
• No spontaneous respirations
PLEASE reference this hospital’s policy that addresses determination of brain death as it may differ from these guidelines.
Prior to exam, all of the following must be met according to AAN guidelines:
• Coma, irreversible and cause known
• Neuroimaging explains coma
• CNS depressant drug effect absent (if indicated toxicology screen; if barbiturates given, serum level < 10μg/ml)
• No evidence of residual paralytics (electrical stimulation if paralytics used)
• Absence of severe acid-base, electrolyte, or endocrine abnormalities
• Normothermia (>36°C)
• Systolic blood pressure >100 mm Hg
• No spontaneous respirations
brain death examination
*All must be checked
• Pupils non-reactive to bright light
• Corneal reflex absent
• Oculocephalic reflex (dolls eyes) absent (tested only if C-spine integrity is ensured)
• Oculovestibular reflex absent (iced-caloric testing)
• No facial movements to noxious stimuli at supraorbital nerve, temporomandibular joint
• Gag reflex absent
• Cough reflex absent to tracheal suctioning
• Absence of motor response to noxious stimuli in all four limbs (spinally mediated reflexes are permissible)
• Pupils non-reactive to bright light
• Corneal reflex absent
• Oculocephalic reflex (dolls eyes) absent (tested only if C-spine integrity is ensured)
• Oculovestibular reflex absent (iced-caloric testing)
• No facial movements to noxious stimuli at supraorbital nerve, temporomandibular joint
• Gag reflex absent
• Cough reflex absent to tracheal suctioning
• Absence of motor response to noxious stimuli in all four limbs (spinally mediated reflexes are permissible)
APNEA TESTING** (CO2 Challenge)
When those have been evaluated and determined that reflexes are negative, then proceed with apnea test as part of the clinical exam.
• Apnea testing consistent with brain death
• If apnea is aborted or not performed because of hemodynamic instability, there must be a confirmatory test ordered such as Nuclear Cerebral Blood Flow, EEG, Transcranial Doppler Scan, or Four Vessel Cerebral Angiogram.
*Reference: AAN Guidelines
• Apnea testing consistent with brain death
• If apnea is aborted or not performed because of hemodynamic instability, there must be a confirmatory test ordered such as Nuclear Cerebral Blood Flow, EEG, Transcranial Doppler Scan, or Four Vessel Cerebral Angiogram.
*Reference: AAN Guidelines
Prerequisite
• Prerequisites: 1) normotension, 2) normothermia, 3) euvolemia, 4) eucapnia (PaCO2 35-45 mm Hg), 5) absence of hypoxia, 6) no prior evidence of CO2 retention
• Adjust vasopressors to keep SBP >100 mm Hg
• Preoxygenate for at least 10 min with 100% FiO2
• Draw base line ABG to assess CO2 level
• Disconnect ventilator and place insufflation catheter through ET tube close to the carina. Deliver 100% O2 at 6L/min
• Observe for any spontaneous respirations for 8-10 min. If observed, abort test.
• If blood pressure or sats become unstable, abort test
• If no respiratory drive is observed, repeat ABG draw to assess CO2 level
• If CO2 increases by 20 mm Hg from an elevated baseline of >40mm Hg or is greater than or equal to 60 mm Hg if baseline pCO2 is normal, the apnea exam supports clinical diagnosis of brain death
Time of brain death should be determined when the arterial CO2 reached the target value. For patients that do not complete apnea testing, the time of death is when the ancillary test is clinically interpreted.
Testing
• One exam (clinical and apnea) is sufficient to pronounce brain death if done “several hours” from onset of insult in adult populations only. Two exams are expected for pediatric populations.
• Any physician can pronounce a patient brain dead in Oklahoma
o AAN suggests that physicians be familiar with and demonstrate competence in brain death pronouncement
• NOT mandatory but hospital policy may require confirmatory testing:
o Nuclear Brain Scan ( or Cerebral Blood Flow)
o Cerebral angiogram
o Transcranial Doppler Ultrasound
o EEG
• A physician’s death note should include date and time of death (DD/MM/YY) and the physician’s signature
o This is the time of death that gets reported to the Medical Examiner
Confirmatory Tests are Recommended when:
• Toxic levels of sedatives
• One or more brain stem reflexes cannot be tested:
o Severe facial trauma exists
o C-spine injury C4 or higher
o Pre-existing pupillary abnormalities
o Severe pulmonary disease resulting in CO2 retention
• Apnea test cannot be completed
** Adopted from American Academy of Neurology Practice Parameters for Determining Brain Death in Adults.
• Prerequisites: 1) normotension, 2) normothermia, 3) euvolemia, 4) eucapnia (PaCO2 35-45 mm Hg), 5) absence of hypoxia, 6) no prior evidence of CO2 retention
• Adjust vasopressors to keep SBP >100 mm Hg
• Preoxygenate for at least 10 min with 100% FiO2
• Draw base line ABG to assess CO2 level
• Disconnect ventilator and place insufflation catheter through ET tube close to the carina. Deliver 100% O2 at 6L/min
• Observe for any spontaneous respirations for 8-10 min. If observed, abort test.
• If blood pressure or sats become unstable, abort test
• If no respiratory drive is observed, repeat ABG draw to assess CO2 level
• If CO2 increases by 20 mm Hg from an elevated baseline of >40mm Hg or is greater than or equal to 60 mm Hg if baseline pCO2 is normal, the apnea exam supports clinical diagnosis of brain death
Time of brain death should be determined when the arterial CO2 reached the target value. For patients that do not complete apnea testing, the time of death is when the ancillary test is clinically interpreted.
Testing
• One exam (clinical and apnea) is sufficient to pronounce brain death if done “several hours” from onset of insult in adult populations only. Two exams are expected for pediatric populations.
• Any physician can pronounce a patient brain dead in Oklahoma
o AAN suggests that physicians be familiar with and demonstrate competence in brain death pronouncement
• NOT mandatory but hospital policy may require confirmatory testing:
o Nuclear Brain Scan ( or Cerebral Blood Flow)
o Cerebral angiogram
o Transcranial Doppler Ultrasound
o EEG
• A physician’s death note should include date and time of death (DD/MM/YY) and the physician’s signature
o This is the time of death that gets reported to the Medical Examiner
Confirmatory Tests are Recommended when:
• Toxic levels of sedatives
• One or more brain stem reflexes cannot be tested:
o Severe facial trauma exists
o C-spine injury C4 or higher
o Pre-existing pupillary abnormalities
o Severe pulmonary disease resulting in CO2 retention
• Apnea test cannot be completed
** Adopted from American Academy of Neurology Practice Parameters for Determining Brain Death in Adults.
GLASGOW COMA SCALE
PUPIL GAUGE (mm)
