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Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center
Melissa Stafford, BSN RN CCRN SCRN – highly experienced and currently practicing nationally certified neurocritical care nurse.
What You’ll Learn
- Organ procurement
- Brain death
- Determine brain death
- What happens next
- Supportive tests
- Prepare the family
- Problems with the term coma
- Apnea test
Nursing Considerations with Brain Death and Organ Procurement
Welcome to Season 4 of the FreshRN Podcast. We discuss the difference between coma and brain death, how brain death is determined, working with an organ procurement team, and general insights related to this sensitive topic.
What is brain death and how do you respond to it?
- Look for these triggers that will suggest when to call the organ procurement team:
- GCS Less Than 5
- On a ventilator
- Major neurological injury
- Plans to withdraw life support
- You cannot deny a patient or family member the chance to donate their organs.
- It’s not up to you as a nurse to decide if their injuries make them a candidate for donation.
- You have to go through the appropriate channels
- If you don’t allow the family this chance, there could be lawsuits and major fines to your facility.
What is brain death?
- Brain Death Definition: According to the National Institute of Health, brain death is “the irreversible loss of all functions of the brain including the brain stem.”
- The term coma is vague and not useful anymore.
- When someone dies there are 2 routes by which they can be pronounced dead:
- Death by neurological criteria
- Death by cardiac criteria
- It can be tough for family members to see the blood pressure still working and the heart still beating and understand that they are technically dead – brain dead.
- It may take a while, but if the brain is dead, eventually the heart will stop beating.
How to Determine That a Patient is Brain Dead
Now that we know what brain death is, how do we know a patient is brain dead?
- Normalize everything else before doing brain death tests
- MAP above 65
- Systolic blood pressure above 90
- Normothermic – core temperature above 97 degrees F
- Must have a normal ADG
- Neuro Exam Consists Of:
- Check their pupils
- Do a cold caloric – or oculovestibular reflex
- Ice water injected into the ear canal
- Inject about 50ccs of ice water into the ear and look for eye movement. It could take up to a minute
- Check both sides, but wait 5 minutes to do both sides
- A nurse cannot do this, it has to be done by a provider.
- Corneal – touch the cornea to see if they react at all
- Check gag reflex
- Cough reflex
- Put the suction all the way down with the ventilator and hold it and see if they cough.
- See if they respond at all to pain.
- Do appropriate painful stimuli, such as track pinch, supraorbital pressure, nail bed pressure.
- Be careful with the extremities, you can have spinal reflexes and still have brain death.
- Doll’s eyes test. You move their head (if they do not have a neck injury) and see if their eyes move.
- Fairly briskly turn their head to the side.
- You have to be able to see their eyes.
- Be careful with the breathing tube.
- Look at their eyes. Do their eyes stay forward? Like midline meaning, they don’t move. That’s a negative doll’s eyes.
- If you turn their head to the left, their eyes should fall to the right.
- You have to turn the head both ways in case there was a stroke or something preventing one side from moving.
- There is absolutely no medication or sedation that can be happening during the brain death test.
What Happens Next
After verifying there are no reflexes at all and made sure there is nothing else contributing to that, what happens next?
- Apnea Test
- Can be done with family in the room. Prepare them for what they might see.
- The patient is on a ventilator, so verify that they have good oxygen levels. Their CO2 levels should be normal as well.
- During the test, you put oxygen down the tracheal tube.
- Disconnect the ventilator and put a suction catheter down the tracheal tube that is connected to oxygen. They continue to get this oxygen throughout the exam.
- What we are looking for is the patient to breathe within 6-8 minutes.
- If they aren’t breathing, the carbon dioxide level will rise in the blood.
- Look for a chest rise – put your hand on their test so you don’t miss a subtle movement.
- If there wasn’t a breath in 8 minutes, the respiratory therapist will draw blood and check CO2 levels and they go back in the ventilator.
- What you’re looking for:
- A rise of at least 22 mg of CO2. So if my CO2 levels were 38 then my new CO2 (after the patient didn’t breath) levels should be 58.
- If there is a rise of CO2 and they didn’t take a breath, that would be considered confirmation of brain death.
- If the test is inconclusive, the physician has a few options:
- Try again later
- Start looking for other types of testing to do.
Other Supportive Tests for Brain Death
Not all facilities follow the apnea test. So what other tests are used?
- Confirmatory Tests or Supportive Tests
- These confirm blood flow to the brain.
- MRA – blood flow to the brain as seen on an MRI
- CTA – blood flow to the brain as seen in a CT Scan
- Traditional Cerebral Angiography – where they go in through the groin like a heart cath
- EEG – look for electrical activity in the brain
- Photo of a normal brain and one of a person that is brain dead. You can see the difference and the lack of blood flow.
How to Prepare the Family if You Think the Patient is Brain Dead
If you think the patient is brain dead and there will be tests to verify, the family should be prepared.
- Don’t use the term “brain dead.” Use the phrase “I think the brain is no longer functioning” a lot.
- Brain death is scary.
- Talk to them about the reflexes that aren’t happening.
- Always say, “I’m really concerned about your loved one. I’d really like to see more movement when I’m doing these things.”
The Problem With the Term Coma
The field is moving away from using the term “coma.” How do you explain to the family the difference between coma and brain death?
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- Talk about brain function. In a coma, there is brain function. In brain death, there is not.
- How much brain function there is can define the type of coma, or the placement on the spectrum.
- Coma is nondescript. We want to see brain function.
- Some doctors have said, “there is basic brain function there but the function that makes the person who they are isn’t there.”
What Happens After the Apnea Test
When the apnea test comes back as greater than 60, what happens now?
- Legally, they are dead. (In most, if not all states)