Preconditions, brainstem reflex testing, apnoea test, two sets 6 hours apart by the Board of Medical Experts, Form 10, and donor management in India.
At the bedside
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Confirm preconditions
Known, irreversible cause of brain injury consistent with brain-stem death on imaging; coma with no response; on ventilator. Exclude: sedatives/opioids/NMB (time, levels, train-of-four), alcohol, primary hypothermia (core temperature ≥ 36 °C per WBD 2020), hypovolaemic shock, metabolic/endocrine causes (Na, glucose, Ca, PO4, urea, thyroid, cortisol).
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Form the Board
Four members: (1) RMP in charge of the hospital; (2) RMP/specialist nominated from the Appropriate Authority panel; (3) neurologist or neurosurgeon (if unavailable, a surgeon, physician, anaesthetist or intensivist nominated by the hospital, not part of the transplant team); (4) RMP treating the patient.
- 3
Test brainstem reflexes
Pupils fixed and unreactive; corneal reflexes absent; no oculocephalic (doll's eye) response; no oculovestibular response (50 mL ice-cold water each ear, 1 min observation, tympanic membrane visible); no motor response in cranial nerve distribution to central pain; no gag; no cough to tracheal suction.
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Apnoea test (prepare)
Core temp ≥ 36 °C, SBP ≥ 100 mmHg, euvolaemia, PaCO2 35-45 mmHg baseline, pre-oxygenate FiO2 1.0 for 10 min (PaO2 > 200 mmHg). Baseline ABG.
- 5
Apnoea test (perform)
8-10 minDisconnect from ventilator with O2 6 L/min via catheter at the carina (or CPAP via T-piece/ventilator mode with no backup). Observe chest/abdomen for respiratory movement for 8-10 min. Repeat ABG: positive if PaCO2 ≥ 60 mmHg AND rise ≥ 20 mmHg above baseline with pH < 7.30, and no breathing. Abort (reconnect) if SBP < 90 mmHg, SpO2 < 85% or arrhythmia.
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Second set after ≥ 6 h
≥ 6 hRepeat all tests (Board members) after at least 6 hours in adults (longer for children per experts). Time of death = time of completion of the second test set.
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Document and communicate
Complete Form 10, inform family compassionately, and make the mandated request for organ donation (THOA 2011 amendment requires ICUs to ask). Inform NOTTO/ROTTO/SOTTO coordinator; medico-legal cases need police/magistrate procedures.
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Donor management (if donation)
MAP ≥ 65 (noradrenaline/vasopressin), treat DI (vasopressin, desmopressin, replace urine), Na 135-150 mmol/L, glucose 140-180 mg/dL, lung-protective ventilation, temperature > 36 °C, consider hormone therapy per protocol.
DI and vasoplegia in donor
Vasopressin
- Dose
- 0.5-2.4 units/h
- Preparation
- 20 units in 50 mL = 0.4 units/mL
- Worked example
- 1 unit/h = 2.5 mL/h
Brain-stem death checklist (Form 10 domains)
| Domain | Requirement |
|---|---|
| Cause | Known irreversible structural brain injury |
| Exclusions | Drugs, alcohol, NMB, primary hypothermia, hypovolaemic shock, metabolic/endocrine disorders |
| Coma | No response to pain |
| Brainstem reflexes | Pupils, light reflex, doll's eye, corneal, cranial motor, gag, cough, caloric - all absent |
| Apnoea | No respiratory effort with PaCO2 ≥ 60 mmHg (and ≥ 20 above baseline) |
| Timing | Two sets ≥ 6 h apart (adults) by the Board |
| Documentation | Form 10 signed by all four Board members |
Calculators for this topic
References
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Brain-stem death certification (India)
Step 1 of ~3
Decision: Preconditions met and confounders excluded?
Based on National Organ and Tissue Transplant Organisation (NOTTO); Greer DM, Shemie SD, Lewis A, et al. Educational use; follow local protocol.
Pathophysiology
Brain-stem death is irreversible loss of capacity for consciousness and of the capacity to breathe. Herniation compresses the brainstem, abolishing reflexes and respiratory drive; hypothalamic-pituitary failure follows (DI, hypothermia, haemodynamic instability), and cardiac arrest usually ensues within days without support.
Evidence
- India: THOA 1994 legally recognised brain-stem death; THOTA amendment 2011 and Rules 2014 define the Board, Form 10 and the 6-hour interval [THOTA Rules 2014].
- World Brain Death Project 2020 provides international consensus on prerequisites, examination, apnoea testing and ancillary testing [Greer 2020].
Controversies
- Hypothalamic function and 'whole brain' versus 'brainstem' concepts; apnoea testing in ECMO patients.
🇮🇳 India notes
- India's deceased donation rate remains low (< 1 per million population); many brain-stem deaths are never certified. Certification is required whether or not donation follows, and allows honest communication and withdrawal of futile support.
- ICUs registered under THOTA must have trained transplant coordinators; Board panels are notified by State Appropriate Authorities.
- The Supreme Court-directed withdrawal of life-sustaining treatment guidelines (2023) are separate from brain-stem death; see the Ethics module.
References
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Test yourself
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.