Brain Death Criteria

delta32 · Mar 2, 2005

I work in a general ICU in a rural Community hospital. We recently had a patient who had a massive stroke, she had 2 consecutive EEGs with no activity, was non responsive and was not making any respiratory effort on the vent. The family followed the patients wishes and asked for the patient to be extubated. The MD wanted to confirm brain death and so did the apnea test, which the patient failed, the tracheal O2 was turned off and she died peacefully. Following this the MD asked for changes to our Brain death policy stating that the apnea test kills people (Apparently he had a patient go into arrest during an apnea test). Our policy states that should hypotension or arrythmias occur during the test we should put the patient back on the ventilator. He feels that we should include what to do in the case of arrest (which is an arrythmia) and wether CPR should be initiated. Please let me know what your policies include. Thanks

just out of curious how long is he doing the apnea test ? this test is preformed to meet on of the multiple brain death requirements in NYS. As for a patient going hypoxic enough to cause death in his previous patient I would be concerned if he is truly qualified or competent to be doing these tests. As for the recessation it would be futile the patient failed the test to the point where it died. the test is being preformed to see/ prove brain death it would be futile to resuscitate. this is my opinion but I understand legally that if the patient is not a DNR or has not completed at that point all the brain death criteria that yes you may have to resuscitate unless you are lucky enough to have immedate family contact with permission to stop efforts.

delta32 · Mar 2, 2005

I found this on the NY dept of health website:

Has an apnea test of a minimum five minutes duration showed no respiratory movements with a documented PCO2 greater than 55 mm Hg with a pH of less than 7.40?

NOTE: Extreme caution should be exercised in the performance of the apnea test. The apnea test should be conducted only after all other evaluations are completed. An apnea test should be performed in such a manner as to minimize the risk of hypoxia or hypotension. Delivering a high concentration of oxygen to the airway (4L/min) before and during the apnea test reduces the risk of hypoxic complications. If mean arterial blood pressure falls significantly during the performance of an apnea test, it should be discontinued with an arterial blood sample drawn to determine whether PaCO 2 has either risen above 55 mm Hg or increased by more than 20 mm Hg from the level immediately prior to the test. If so, this validates the clinical diagnosis of brain death.

I know that your looking for hospital policies but i thought that this may help you a little. :)

nurse lucky · Apr 7, 2005

I found this on the NY dept of health website:
Has an apnea test of a minimum five minutes duration showed no respiratory movements with a documented PCO2 greater than 55 mm Hg with a pH of less than 7.40?
NOTE: Extreme caution should be exercised in the performance of the apnea test. The apnea test should be conducted only after all other evaluations are completed. An apnea test should be performed in such a manner as to minimize the risk of hypoxia or hypotension. Delivering a high concentration of oxygen to the airway (4L/min) before and during the apnea test reduces the risk of hypoxic complications. If mean arterial blood pressure falls significantly during the performance of an apnea test, it should be discontinued with an arterial blood sample drawn to determine whether PaCO 2 has either risen above 55 mm Hg or increased by more than 20 mm Hg from the level immediately prior to the test. If so, this validates the clinical diagnosis of brain death.
I know that your looking for hospital policies but i thought that this may help you a little. :)

I hate the apnea test. I had patients who were donors go into cardiac arrest after about 3 minutes and had to quietly resusitate them to preserve the other organs but the MI we caused ruined the heart for transplantation. It is always a hard area because we are testing for brain death to qualify for transplant status, but they are not accepted yet and were DNRs at that moment. When you call a code blue and "save" them, often the family gets a little confused that they are not really brain dead as they were saved.

I prefer a nuc med study to check for perfusion. That's safer in my book and you avoid the grey area.