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Table of Contents    
Year : 2021  |  Volume : 69  |  Issue : 4  |  Page : 995-996

Brain Death Diagnosis for Potential Organ Donors During the Covid-19 Pandemic

1 Institute of Neurosciences, AIG Hospitals, Hyderabad, Telangana, India
2 Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Date of Submission10-Jul-2020
Date of Decision14-Aug-2020
Date of Acceptance15-May-2021
Date of Web Publication2-Sep-2021

Correspondence Address:
Dr. Girija P Rath
Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, A.I.I.M.S., New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.325307

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 » Abstract 

Formal brainstem reflex testing remains one of the most important procedures in identification and evaluation of patients who meet clinical criteria for brainstem death. Early identification of such patients is critical since willing donors may contribute to the organ donation process. During the first two waves of the coronavirus disease of 2019 (COVID-19) pandemic, organ transplantation from brainstem dead donors has declined significantly due to several reasons, including perceived increased risk of virus transmission to both physicians as well as patients as well as lack of awareness regarding donor workup in the context of the COVID-19 pandemic.

Keywords: Brain death diagnosis, Covid-19 pandemic, organ donation
Key Message: This article proposes a framework for proper evaluation and screening of potential donors in the context of COVID-19 pandemic.

How to cite this article:
Chavali S, Rath GP, Sengupta D, Dube SK. Brain Death Diagnosis for Potential Organ Donors During the Covid-19 Pandemic. Neurol India 2021;69:995-6

How to cite this URL:
Chavali S, Rath GP, Sengupta D, Dube SK. Brain Death Diagnosis for Potential Organ Donors During the Covid-19 Pandemic. Neurol India [serial online] 2021 [cited 2021 Oct 23];69:995-6. Available from:

The coronavirus disease of 2019 (COVID-19) is an ongoing pandemic of global proportions.[1] Many healthcare systems have been overwhelmed by the surge of patients with this disease, and the true extent of community penetration remains unknown. End-stage organ failure is another widely prevalent condition that is estimated to affect more than six million people across the world. Organ transplants are the mainstay of management of these patients; however, viable organs for donation are a scarce resource, leading to high mortality rates among patients awaiting transplantation. As the COVID-19 pandemic continues to spread, a major concern that has arisen is the effect of surges of this disease upon organ donation as well as transplantation. Hospitals may be short on resources such as staff and equipment to manage such patients, since organ donation and transplantation are resource-intensive procedures. Another concern is that recipients may have increased susceptibility to infection; however, the risk of developing COVID-19 from an infected organ donor remains unknown.

A strong association between a surge the COVID-19 cases and reduction in transplantation procedures has been observed in France (90.6%) and USA (51.1%).[2] Transplantation of solid organs provides meaningful improvement in survival probability; the decrease in organ procurement and transplantation may lead to a long-term increase in mortality in this sensitive patient population. We believe that the best way forward is an open discussion with potential recipients about the risk of death while awaiting transplantation, and the possibility of developing severe COVID-19 disease after the procedure. Careful tracking of patients and outcome may help identify areas, where the recipients have not recovered well and support is required.

The risk of developing COVID-19 from a SARS-CoV-2 infected organ donor is still unknown, and the transmission is affected by epidemiological risk factors, incubation period, degree of viremia, and viability of SARS-CoV-2 in blood and organ compartments.[3] Moreover, the real-time PCR which is widely used for laboratory confirmation of COVID-19 is not 100% sensitive. In this context, it is advisable to follow the guidelines issued by National Organ and Tissue Transplant Organization.[4] It has been suggested that prior to transplantation there should be an in-depth assessment of epidemiology, current trends, surge capacity, and impact of COVID-19 as well as assessment of ICU facility and team, in the respective hospitals. RT- PCR should be used for screening of both donors and recipients, and testing has to be done prior to procedure within 24–72 h. To reduce the risk of transmission, the clinical and epidemiological screening for COVID-19 in donors, recipients, health care workers, and care takers should be done, which is mentioned in a checklist as below.[4]

The guideline also suggests that living donor with positive COVID-19 test should not donate for at least 3–6 months until the long-term outcome of cured COVID-19 becomes clear. However, in case of lifesaving transplants, criteria of accepting donor with a previous diagnosis of COVID-19 with documented two negative COVID-19 tests and complete symptom resolution for 28 days and another negative test at the time of donation is to be used. After following this screening protocol, when a donor is deemed fit for organ donation, the test procedures for brain death diagnosis are to be followed; they are discussed in the subsequent section.

Patients with irreversible neurological injury who meet the criteria are to be considered possible donors. They should be screened for the SARS CoV-2 and those who test positive should be excluded. Bronchioalveolar lavage may be preferred for testing in potential donors, since it is more sensitive than testing sputum or pharyngeal swabs for the diagnosis of COVID-19.[5] Concerns exist regarding the potential for aerosol generation and spread to healthcare workers who perform diagnostic tests for brain stem death to identify potential donors and optimize them. One of the fundamental tests performed is the apnea test, which involves disconnecting the patient from ventilatory support in order to assess response to increased arterial levels of CO2. In patients who are clinically able to undergo apnea test, i.e. those who do not have ventilatory or hemodynamic embarrassment, a modified approach using viral filters on the endotracheal tube and exhalation circuits may be considered. Alternatively, a safer option in the current scenario involves performing the apnea test with the patient on a ventilator set at a minimal respiratory rate with a low trigger in order to facilitate evaluation of respiratory effort, along with continuous end-tidal carbon dioxide (EtCO2) monitoring to evaluate respiratory effort.[6] Reflex respiratory movements can occur despite brain stem death and may trigger the ventilator if the sensitivity is set too low, giving the false impression of spontaneous breathing efforts. Such movements usually occur as a result of acidosis and/or hypoxemia and do not result in significant tidal volumes or changes in the EtCO2 waveform. Clinical tests performed to confirm brainstem death with the potential for aerosol generation include evaluation of function of the vagus nerve, via assessment of the cough reflex. This may be performed safely using a closed suction system attached to the endotracheal tube to stimulate the carina, which may minimize exposure to aerosols generated during the reflex cough, if present. Another test to evaluate lower cranial nerve function is testing for the gag reflex, which may generate aerosols if airway sealing is inadequate, and appropriate care to minimize exposure should be taken.

In cases where apnea test is considered not feasible, ancillary studies such as nuclear imaging of the brain, which may reveal the “hollow skull” phenomenon, or Transcranial Doppler studies may be utilized to establish loss of ascending cerebral blood flow.[7] These tests may require operators to be in close proximity to the intubated patients, and appropriate personal protective equipment should be donned prior to such tests. Other tests such as electroencephalography or angiography of the cerebral vasculature may also be considered as options for evaluation of brainstem death. Ancillary tests are adjuncts to the clinical evaluation, and their place in the clinical evaluation of brainstem death varies between countries. We suggest that ancillary tests for brainstem death be added to the protocol for brainstem death evaluation given the reduced risk of aerosol exposure to clinicians in the current scenario of COVID-19 pandemic, and that they may remain of use in the future, especially in patients in whom clinical evaluation of brainstem death is not feasible.

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Conflicts of interest

There are no conflicts of interest.

 » References Top

Phelan AL, Katz R, Gostin LO. The novel coronavirus originating in Wuhan, China: Challenges for global health governance. JAMA 2020;323:709-10.  Back to cited text no. 1
Loupy A, Aubert O, Reese PP, Bastien O, Bayer F, Jacquelinet C. Organ procurement and transplantation during the COVID-19 pandemic. Lancet 2020;395:e95-6.  Back to cited text no. 2
Moris D, Shaw BI, Dimitrokallis N, Barbas AS. Organ donation during the coronavirus pandemic: An evolving saga in uncharted waters. Transpl Int 2020;33:826-7.  Back to cited text no. 3
Kute V, Guleria S, Prakash J, Shroff S, Prasad N, Agarwal SK, et al. NOTTO transplant specific guidelines with reference to COVID-19. Indian J Transplant 2020;14:85-9.  Back to cited text no. 4
  [Full text]  
Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA 2020;323:1843-4.  Back to cited text no. 5
Ahlawat A, Carandang R, Heard SO, Muehlschlegel S. The modified apnea test during brain death determination: An Alternative in hypoxic patients. J Intensive Care Med 2016;31:66-9.  Back to cited text no. 6
Kramer AH. Ancillary testing in brain death. Semin Neurol 2015;35:125-38.  Back to cited text no. 7


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