Brain death, death by neurological criteria and organ donation: Case

This boy has a catastrophic and irreversible brain injury from the severe traumatic brain injury, and the team is right to consider the determination of brain death. The cause is known and irreversible, the imaging shows the large intracranial haemorrhage and the cerebral oedema, and the intracranial pressure could not be controlled, so the prerequisite of a devastating structural cause is met. The confounders must now be formally excluded before any neurological testing, the examination and the apnoea test performed by two clinicians, and the determination made across the two evaluations separated by the observation period. [3]

The prerequisite checks

The prerequisites are the checks that guarantee the examination will be interpretable, and each must be met before any reflex is tested. The cause is the severe traumatic brain injury, which is known, structural and irreversible, confirmed on the imaging and the course. The core temperature is 36.8 degrees Celsius, which is at least 36 degrees Celsius, so the hypothermia confounder is excluded. The systolic blood pressure is 95 mmHg on low-dose adrenaline, which is normal for a 5-year-old, so the hypotension confounder is excluded. The sedation has been off for over 24 hours, the drug screen is sent, the barbiturate level is confirmed therapeutic-zero, the electrolytes and the blood gas are corrected to the normal range, and a train of four confirms the full neuromuscular recovery. [1]

The bedside examination

The brainstem reflex examination is performed and documented by two independent senior clinicians, neither of whom is part of the transplant team. The boy is in a deep coma with a Glasgow Coma Scale of 3, with no eye opening, no verbal response, and no motor response to any stimulus. The pupils are 6 millimetres and fixed bilaterally, with no reaction to a bright light. The corneal reflex is absent to a touch of the cornea. The oculocephalic reflex is omitted because the cervical spine is not yet cleared in this trauma case. The oculovestibular reflex is absent to the cold caloric stimulus, and the gag and the cough reflexes are absent to the pharyngeal and the tracheal suction. Each finding is recorded with the time and the names of the two clinicians. [4]

The apnoea test

The apnoea test is the step that tests the last surviving brainstem function, the drive to breathe. The boy is preoxygenated with pure oxygen for at least ten minutes to denitrogenate the lungs, and the PaCO2 is normalised to the baseline. The ventilator is then disconnected, and the oxygen is delivered to the trachea while the PaCO2 is allowed to rise, and the chest and the abdomen are watched for any respiratory effort. An arterial blood gas is taken at the end, and the test is positive when there is no respiratory effort and the PaCO2 reaches at least 60 mmHg or rises by at least 20 mmHg from the baseline. In this boy the test is positive, with no effort and a PaCO2 that rose to 64 mmHg, which is at least 60 mmHg and a rise of at least 20 mmHg from the baseline. [1][3]

The observation period and the declaration

The determination requires two clinical evaluations, each including the apnoea test, performed by two independent senior clinicians and separated by an observation period. For a 5-year-old, who is a child older than 30 days, the observation period is 24 hours, as set by the pediatric guideline of Nakagawa and colleagues, and the ANZICS framework retains the two-examination standard for the child. The second examination, after the 24-hour interval, repeats the full brainstem reflex testing and the apnoea test, and when the two evaluations are concordant the death is declared and recorded with the time, the date, the findings and the names of the two clinicians. The boy is now legally dead, even though the ventilator keeps the heart beating. [2]

The organ donation pathway

After the death is declared, the donation after brain death pathway is offered to the family in partnership with the donation specialist. The boy is the ideal donor for the heart, lungs, liver, kidneys and pancreas, because the brain-dead ventilated child has perfused organs. The donor resuscitation continues to protect the organs, with the vasomotor collapse managed with the fluids and the vasopressors, the diabetes insipidus with the vasopressin and the fluid matching, and the hypothalamic hypothermia with the rewarming. The treating intensive care team remains separate from the transplant team throughout, to protect the dead donor rule and the trust of the family, and the consent is sought and recorded according to the local registry and the law. [9]

The family conversation

I would explain to the family that their son has died, because the determination is the declaration of a death that has already occurred and not the withdrawal of treatment. I would name the ventilator as the machine that keeps the heart beating and the blood flowing even though the brain has stopped working, the examination as the careful tests that proved there was no function left in the brain or the brainstem, and the second examination as the safeguard that confirmed the finding beyond doubt. I would be honest that the death is irreversible and that there is no hope of recovery. I would then, with the donation specialist, explain that his organs may be given to save the lives of other children, that this is a choice for the family, and that the team will support them whatever they decide. I would give the family the time and the dignity to grieve, and return regularly to explain the findings and the next steps. [10]