Table II. Clinical Testing for Cranial Nerves to diagnose absence of Brainstem Reflexes

S.No	Brainstem Reflexes	Sensory cranial nerve	Motor cranial nerve
1.	Absence of pupillary response to light	II	III (parasympathetic Nerve fibres)
2.	Absence of corneal reflexes	V	VII
3.	Absence of cranial nerve response to pain	V	VII (and limb motor responses)
4.	Absence of Vestibulo-ocular	VIII	III, VI
5.	Absence of gag and cough reflexes	X	IX

The PaCo2 should be 5.33 kPa (.40mmHg) prior to testing and should rise to at least 6.66kPa (50mmHg) during the test. The patient should be pre-oxygenated with 100% oxygen for 10 minutesprior to testing & baseline arterial blood gases should be taken. Disconnect patient from ventilator but oxygen should be administered at 6 litres/min via a fine bore catheter down the endo-tracheal tube Observe patient for 5 to10 minutes for any respiratory effort andensure PaCo2 has risen above 6.66kPa (50mmHg) by repeating arterialblood gases. Reconnect patient to the ventilator. Discontinue testing if any hypotension, cardiac arrhythmias or hypoxia occurs

TableIII. Aponea Test for Confirming 'Brainstem Death'



Table IV. 'Ramachandra Protocol' To Ask For Organs 



Table V. Organizing multi-organ donation in abrain death

Corneas	0  100 years	(poor eyesight not a contraindication)
Heart Valves	0 60 years	(Heart Attack not a contraindication)
Trachea	15  60 years
Skin	16  85 years
Kidneys	0  75 years	(Paediatric donors are assessed according to weight and size)
Liver	0  70 years	(size matching is usually recommended)

Table VI. Different Age criteria for organ donation

Testing for HIV, Hep B & C on all donors. Additional tests for syphilis, cytomegalovirus and toxoplasmosis may be necessary  Virology testing is performed after the completion of brain stem death tests but before the ventilator is discontinued.

Table VII - Virology Screen for Brain Dead Patient When Organ Donation is Being Considered

Common Clinical Problems Of Brain Stem Dead Patient Hypotension Hypothermia Endocrine Disturbances Electrolyte Imbalance Arrhythmias Hypoxia Uncommon Clinical Problems Coagulopathy Neurogenic Pulmonary Oedema

Table VIII. Common & Uncommon Clinical Problems in Brain dead patients

CARDIOPULMONARY
Systolic blood pressure	100-120mmHg
Mean arterial pressure	>60mmHg
Central venous pressure	8-10 mmHg
Hemoglobin	10gm/dl
Hematocrit	30?
(Arterial blood gas)pH	7.37-7.45
Pa	O2 >75mmHg
PaCO	2 40mmHg
SpO	2 95?
RENAL
Urine output	1-2ml/kg/hr
Core temperature (rectal)	>35 *C
METABOLIC
Correct glucose and electrolyte abnormalities	Na+, K+, Ca++,PO4-, Mg++

Table IX. Management goals supporting the brain stem organ donor

Fig.1. Common causes of Brain Death
	Test Pupillary Light Reflex (for optic and occulomotor nerves). Pupils are fixed and dilated in brain death.
	Test for Corneal Reflexes (for Trigeminal & Facial nerves). No corneal reflexes in brain death.
	Test for motor response to pain (Trigeminal and Facial nerves). No response in brain death.
	ColdCaloric test to look for eye movements (Occulomotor, Abducens &Vestibulo- cochlear nerves). Absence of Vestibulo-ocular nerves)reflexes in brain death.
	Check the Gag and Cough’ reflexes (for Glossopharyngeal and Vagus nerves) No reflex response in brain

Fig .2. Bedside Clinical Testing to establish Brain Death diagnosis

Recommended Reading:

1. Pallis C, ABC of Brain Death, 2nd Edition, BMJ Publishing Group,1996, Pages - 13-26

2. Shroff S, Ramachandra Protocol for Organ Donation, Antiseptic 1997:94-3, 73-74.

Acknowledgement: Dr.Mahendran for help in compiling the information about support of brain dead donor. A similar article has been contributed by the author in the 6th API Textbook of Medicine and the author wishes to thank the editors for giving me the permission touse the material in this publication