Neurological determination of death

Question 1

What is neurologically determined death?

Answer 1

1. Irreversible loss of capacity of consciousness
2. Irreversible loss of ALL brainstem functions
3. INCLUDES capacity to breathe

Question 2

What are the minimum clinical criteria for NDD

Answer 2

1. Establish aetiology
2. Deep unresponsive coma
3. absent reflexes
4. absent respiratory effort
5. absent confounding factors

Question 3

Which reflexes have to absent in NDD?

Answer 3

1. No gag/cough reflex
2. No motor responses, excludes spinal reflex
3. Corneal responses
4. Pupillary responses
5. Vestibulo-ocular responses (caloric reflex)

Question 4

What are some confounding factors in NDD?

Answer 4

1. Unresuscitated shock
2. Hypothermia - (<34)
3. Severe metabolic disorders (glucose, phosphate, calcium, and magnesium), inborn errors of metabolism, liver or renal dysfunction
4. peripheral nerve or muscle dysfunction or NM block
5. Drug intoxications

Question 5

Which drug intoxications would preclude NDD

Answer 5

1. Alcohol, barbs, sedatives, hypnotics

Question 6

Which drug therapeutic levels/dosing would NOT preclude NDD

Answer 6

1. Anticonvulsants
2. sedatives
3. analgesics

Question 7

What are the criteria for apnea testing?

Answer 7

1. PaCO2>=60 and >=20mmHg rise above baseline
2. pH<7.28
3. COntinuously observe for respiratory effort

Question 8

When should an ancillary test be performed?

Answer 8

when impossible to complete the minimum clinical criteria
drug unresponsive coma must be present
Established etiologic capable of causing ND

Question 9

what is an example of an ancillary test?

Answer 9

1. global absence of intracranial blood flow

Question 10

When is it a conflict of interest for physicians declaring ND?

Answer 10

ANY physician with an association with the proposed recipient might influence judgement

Question 11

List some brain death aetiology

Answer 11

1. Trauma
2. Intracerebral hemorrhage
3. Hypoxia (drug OD, drowning, cardiac arrest post resus)
4. Brain timor
5. Meningitis
6. Homicide or suicide

Question 12

Describe steps in Apnea test

Answer 12

1. Preoxygenate with 100% for 10 minutes
2. Normalize acid-base status
3. Disconnect from ventilator
4. 100% O2 via trach catheter
5. Observe for reap movement
   PaCO2>=60, >=20 pH<7.28 no spontaneous resp, no resp reflex

Question 13

What are some physiologic changes that happen during NDD

Answer 13

1. Central diabetes insipidus
2. Vasodilation
3. Apnea
4. Hypothermia
5. Hypothyroidism
6. Hypoadrenalism

Question 14

What are the key differences between NDD and PVS`

Answer 14

1. PVS: spontaneous ventilation
2. PVS: maintain CV stability
3. PVS: sleep/wake cycles
4. PVS: months to years
5. Brain death - hours

Question 15

After declaring death

Answer 15

1. Offer organ or tissue donation

2. Disconnect ventilator, complete death certificate , offer autopsy