Case of the Month #32 Brain Stem Death

Published 03/10/2022

What are the preconditions for Brain-stem Death testing?

  1. The patient must have a GCS of E1V1M1 and be mechanically ventilated with apnoea
  2. Proof that the patient’s condition is due to irreversible, structural brain damage
  3. 2 doctors of sufficient clinical experience to perform brain-stem testing.  One should be a consultant, the other should be qualified with full GMC registration for a minimum of 6 years              
  4. Exclusion of reversible causes of coma satisfied by each of the two doctors carrying out the brain-stem testing
    • Residual effects of sedative drugs or toxins – may require plasma level measurements
    • Residual neuromuscular blockade – can be tested for using peripheral nerve stimulation if required
    • Hypotension: Mean Arterial Pressure should be > 60 mmHg in the hours prior to testing for adults
    • Hypothermia: Core body temperature must be ³ 34°C
    • Hypo/Hypernatraemia: Serum Na+ levels must be between 115-160 mmol/L – rapid changes should also be avoided
    • Hypokalaemia: Serum K+ should be > 2 mmol/L
    • Severe Hypo/Hyperphosphataemia: Serum PO4- should be between 0.5-3.0 mmol/L
    • Severe Hypo/Hypermagnesaemia: Serum Mg2+ Should be between 0.5-3.0 mmol/L
    • Hypo/Hyperglycaemia: Blood Glucose should be between 3.0-20.0 mmol/L
    • When endocrine disturbance is suspected hormonal assays should be undertaken
  5. The patient is older than 2 months of age.  Separate guidance exists for infants from 37 weeks corrected gestational age to 2 months old.  Brain-stem testing is not suitable for infants below this age.  Out of the two doctors performing brain-stem testing in children should also ideally be a paediatrician and one should not be primarily involved in the child’s care [6].