O PROTOCOLO de MORTE ENCEFÁLICA no Brasil é um dos mais rígidos do mundo!

Dr. Leonardo Borges, coordinator of the organ search department at HCFUMUS Dr. Marcelo de Lima Oliveira, Neurosonologist at Albert Einstein Hospital and PhD from HCFMUSP Dr. Edson Bor-Seng-Shu, Professor, HCFMUSP Brain death is the cessation of brain function, meaning there is no brain function in the supraspinal region. Even if the brain is non-functional, other organs may function, allowing organ donation. After the advent of mechanical ventilators, it became possible to continue the patient's life with artificial respiration after the death of the brain that controls respiratory movements. A brain-dead donor is a very critical patient, requiring care so that the organs that still function can be donated, as the waiting list is still very long. Organs are a scarce resource in Brazil and worldwide, as the need for transplants increases without increasing availability. In Spain, there are 50 donations per million population per year, in Brazil 16 donations per million, with the state of Santa Catarina standing out at 40 per million. Other solutions to reduce the waiting list would be animal organ transplants into humans. In modern concepts, life makes sense when the brain functions: the brain's behavior characterizes a person. The loss of neurological functions can impair consciousness, which, when severe, is called a coma, or even a complete and irreversible loss of brain function due to a brain catastrophe. Thus, complete and irreversible loss leads to a diagnosis of brain death. Furthermore, the cause of the loss of brain function must be known. The Brazilian criteria for diagnosing brain death are among the most rigorous in the world. It is important to emphasize that a coma is not synonymous with brain death; however, every patient with brain death is in an irreversible coma. A patient declared brain dead after meeting the criteria is considered dead under the law established in 1997 by the Federal Council of Medicine. The resolution was updated in 2017 to maintain safety and accuracy. The diagnosis of brain death is urgent: 1) first, so the family can determine the patient's prognosis; 2) to prevent deterioration of organs that can be donated; 3) to reduce costs for the family and the healthcare system; and 4) to free up intensive care unit beds. Brazilian protocol determines that a physician trained in specific courses or with experience in 10 clinical examinations should perform the first neurological examination. The second physician must perform a second examination to confirm the diagnosis, based on training and medical specialties related to the brain, such as neurology, neurosurgery, or pediatric neurology. Between examinations, observation time (at least 1 hour) is mandatory. Afterward, additional examinations such as transcranial Doppler (the most commonly used) and electroencephalography (EEG) should be performed. After the complete process, a diagnosis of brain death can be made. The family must be notified to choose whether to donate or have the machines turned off. The machines must remain connected under one condition: a pregnant woman with an immature fetus until the fetus is ready to be born. Some patients have contraindications for donation, in which case the machines will be disconnected. The donor patient, even when diagnosed with brain death, must be carefully monitored to preserve the organs and maintain their quality so they can be received by a recipient. A donor can help up to 10 people. Regarding the reception of donated organs, there is no waiting list; there is a single organ reception registry. Each organ has allocation criteria to determine who receives the organ. The first criterion is ABO (blood type), where the organ must be compatible with the donor. Next comes weight-and-height compatibility. The recipient must be fit to receive the organ, meaning they cannot be infected. For kidneys, there is also genetic compatibility (HLA compatibility). For liver transplants, there is no priority based on the order, only on the severity of the patient's condition. The order date will be used solely as a tiebreaker between two patients. Logistics are also a consideration due to the delay in organ transport. Furthermore, technical committees comprised of specialists can determine priority based on an analysis of the patient's clinical condition. All transplant criteria are auditable and available to the Public Prosecutor's Office. Every 24 hours, approximately 120 names are added to the single transplant registry, so donors are the biggest bottleneck. Over the past 20 years, the situation has improved in Brazil: today, 16.5 donations per million inhabitants, with the worst state being Amapá (no donors) and the best being Santa Catarina (40 donations per million inhabitants). Main bottlenecks in donation: 1) family refusal (around 40%), 2) donor identification (difficulty in diagnosing brain death), 3) lack of donor care. #donor