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I. PREAMBLE
Brain death is the irreversible
cessation of all spontaneous brain activity including the
brain stem.
Before any supportive means are discontinued, the family
members must be counseled. This should be documented in the patient's chart.
II. CRITERIA FOR ESTABLISHING BRAIN DEATH
All spaces provided should be
initialed by two consultants (A & B) certifying the
results of their assessment of the patient's condition.
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Preconditions:
- The etiological diagnosis for brain death should be
entered.
Exclusions:
- Any
signs of cerebral activity (like decerebrate or
decorticate posturing or seizure activities).
- Hypothermic patient should be warmed up to near normal
body temperature.
- Blood should be screened for the presence of
barbiturates, opiates, benzodiazepines, synthetic
narcotics, hypnotics and alcohol No need for blood test if
the patient had been hospitalized for 5 days or more.
It should first be established that the patient is
normothermic, is not under the influence of barbiturates
or other sedative drugs, and is not suffering from
remediable, toxic or metabolic brain disorders. In
addition, it should be established that the patient is not
in cardiovascular shock. Brain death will then be said to
have occurred when the following criteria are found on two
successive examinations, separated by an interval of 6
hours, * and performed by two consultant physicians,
experienced in the diagnosis of brain death.
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Clinical assessment:
- Total lack of response to any stimuli: painful,
auditory or visual.
- The absence of brain stem reflexes, Pupil to light,
Corneal, Oculocephalic, Oculovestibular, Gag and Cough.
- Maximal
vestibular stimulation should be used by injecting 50 ml
of ice-cold water (temperature near 0 C) as close to the
eardrum as possible in both ears.
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When the
above are fulfilled then:
ONE isoelectric electroencephalogram (EEG) of
thirty minutes duration or can be substituted by Cerebral
Angiography.
(The presence of spinal reflexes does not rule out
brain death).
* See special requirements for
children.
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If
1,2 and 3 are fulfilled then do:
APNEA
TEST:
Absence
of spontaneous respiration or movement.
This is tested by ventilating with pure oxygen or an
oxygen 95 % and carbon dioxide 5 % mixture for ten (10)
minutes. At the end of thistime, the Pa CO 2 should be within
the normal range. The
respirator should then be disconnected from the patient for
ten (10) minutes, while the patient is supplied by continuous
flow of 100 % Oxygen through an-intratracheal catheter
reaching the carina and delivering continuous flow at 6
liters/min (1.5-2 liters/min in children) and establishing
that the Pa CO 2 has risen above 8.1 kPa (60mm Hg) in adults
and 7.6 kPa (55 mm Hg) in children.
II. BRAIN DEATH DOCUMENTATION FORM
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To
document the above criteria, this form entitled
"Brain Death Documentation" must be
completed and signed by the two consultant
physicians conducting the tests. ft must be
countersigned by the Executive/Medical Director or
the Deputy Medical Director, or they may appoint a
Saudi senior staff physician to do so before any
supportive means are discontinued. All names must be
written clearly in Arabic and English and the
completed form placed in the patient's chart.
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This
form does not replace the usual death certificate.
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IV.
OTHER FINDINGS
Other findings supportive of brain death, such as
absence of the auditory brain stem evoked potential and the
absence of cerebral blood flow, documented by isotope studies,
should be entered in the section below.
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| Results
- Optional Tests if Done |
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Consultant
A |
Consultant
A |
Consultant
A |
- Absence
of brain stem auditory evoked potentials
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- Absence
of cerebral blood flow:
A- By Dynamic CT scan
B- By radionuclide flow
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* Special Requirements for Documenting Brain Death in
CHILDREN:
- Infants 7 days to 2 months: two flat EEGs separated by
48 hours of observation.
- Infants 2 months to one year: two flat EEGs Separated by 24
hours of observation.
- Children from 1 year to puberty: observation period of 12
hours, one flat EEG.
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