Brain Death Management

Following brain death, a variety of neuro-hormonal responses may occur that lead to end-organ dysfunction. In brain dead patients proceeding to organ donation, good supportive care improves organ function and donor outcomes.

This covers the management of the brain dead patient proceeding to organ donation. Epidemiology and determination of brain death is covered at Brain Death.

Pathophysiology

Brain death occurs when ICP exceeds arterial perfusion pressure and cerebral blood flow ceases. This leads to a relatively predictable pattern of autonomic responses:

  • Autonomic storm
    • Transient ↑ BP with vasoconstriction, tachyarrhythmia
    • Less commonly tachypnoea, seizures, sweating, pupillary dilation
  • Autonomic collapse
    • Loss of reflex brainstem activity
    • Loss of respiratory drive
    • Loss of temperature regulation
    • Loss of vascular tone and HR regulation
    • DI

Management

In addition to regular supportive care, particular considerations include:

  • B
    • Lung protective ventilation
    • Routine respiratory care
  • C
    • Autonomic storm
      Short acting antihypertensives and β-blockers.
    • Autonomic collapse
      • Volume resuscitation
      • Vasoactives
        Bradycardia usually resistant to anticholinergics, so adrenergic vasoactives and vasopressin are preferred.
  • E
    • External warming
    • Tri-iodothyronine
      4μg bolus, then 3μg/hr given for haemodynamic instability with impaired cardiac function.
  • F
    • Electrolyte correction
      Minimise arrhythmia.
    • IVT
      Aim to prevent DI and fluid overload, with UO 0.5-3mL/kg/hr targeted.
    • Desmopressin
      4-8μg given if DI occurs. Can be repeated if polyuric.
  • H
    • Anaemia correction
    • Coagulopathy correction

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.
  2. ANZICS. The Statement on Death and Organ Donation. Edition 4.1. 2021.