donation after brain death

DONATION AFTER BRAIN DEATH

Dr.Babita ghai

Dr.shiv soni

Dr.vinoth natarajan

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GCS Assessment

Pupils size and Character

Proper history

Resuscitative line of management.

ICU call.

Transplant co ordinatar’s role.

Inform transplant team.

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DEFINITION Irreversible loss of all functions of the brain,

including the brainstem, with a beating heart.

BRAIN DEATH

Apnoea

Coma

No brainste

m reflexes

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ETHICAL ISSUES

Following the transplantation of human organ act,1994.

Notify the next of kin. All the forms duly signed. Order the requisite blood tests. Recipient’s list. Required Radiological investigations.

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PHYSIOLOGICAL CHANGES

Cardiovascular system

Respiration

Endocrine

Immunological

hematological

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CVS

Increased icp

Cushing reflex

Followed by ischemia of distal medulla

Autonomic storm

Completion of herniation

Hypotension and cvs collapse

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RS

Increased icp

Neurogenic pulmonary edema

Pulmonary dysfunction

Ventilator induced injury

aspiration pneumonia

contusion

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ENDOCRINAL

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Pituitary failure

Deceased thyroid hormone

Decreased cortisol

Increased insulin resistance

Decreased ADH

Cardiac unstable

No active inflammmatory response

Hyperglycemia

Diabetes insipidus

24Hypothalmic failure

No body temperature regulation

hypothermia

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IMMUNOLOGICAL AND HEMATOLOGICAL

Damaged Brain

DIC

Organ damage

Release of cytokines and acute

phase reactants

Release of tissue thromboplastin

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MANAGEMENT

General care

Respiratory care

Cardiovascular care

Hormone therapy

Fliud and nutrition

Blood and coagulation

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GOALS

SBP >100 HR < 100 UO > 100 ml/hr Pa02 > 100 mm hg Hb > 100 g/l

CVP >10 mm hg. Temp > 35 . C

No dyselectrolytemi

aFio2 < 40%(if

lung transplant)

RULE OF ‘100’

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GENERAL CARE

PROPER NURSING CARE.

SUPPORT FOR RELATIVES.

MINIMUM INVASIVE MONITORING.

DVT PROPHYLAXIS(MECHANICAL).

ACTIVE WARMING.

IDENTIFYING AND TREATING IF ANY INFECTION.

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HEMODYNAMIC CARE Pulse pressure variation guided > CVP guided

fluid therapy if co monitoring not available.

Albumin>starch based >crystalloids

NS/2 > NS (risk of hypernatremia)

Minimum positive balance.

Ionotropes (vasopressin>NA>dopa)

Dextran 40 – to improve microcirculation.

T3 protocol.

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RESPIRATORY CARE Lung protective ventilation.

TV 6-8ml/kg.

Minimum PEEP and minimum Fio2.

Recriutment maneuvers and chest pt.

BAL and culture guided antibiotics.

Re recuitment after apnea testing and suctioning.

Head end elevation.

Consider diuretics if fluid overload.

Methyl predinsone therapy.

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HORMONE REPLACEMENT THERAPY

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METHYL PREDISONONE 15MG/KG BOLUS AS SOON AS POSSIBLE.

-Improved oxygenation. -Role in NPE. -increases lung yield -reduces inflammation in organs -increased organ retrival. -improves donor organ function and graft

survival. - improves cardiac function following

transplantation.

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VASOPRESSIN bolus 1 u sc and followed by infusion of .5 to 2 u/hr.

-take care of DI and SHOCK. -hypernatremia correction too.

INSULIN infusion or according to sliding scale.

-increases survival benefits.

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T3 bolus 4mcg followed by infusion 3mcg/hr or t4 bolus 20mcg followed by 10mcg/hr infusion.

-improves tissue and organ perfusion.

-activates mitochondria to conduct aerobic metabolism

-increases bp,left ventricular SWI and CO.

-needs more study.

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FLUID AND NUTRITION

Maintainence fluid (enteral route). Avoid fluid overload and hypernatremia. Maintain feeding or glucose source. If pancreas transplant planned-gut decontamination.

BLOOD AND COAGULATION Correct coagulation if active bleeding. Coagulation support during retrieval. Maintain hmt >30%.

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Planning for organ retrivel.

Informing OT table and proper arrangement.

Careful shifting.

How many organs retrieved.

Planning according to cold ischemic time.

Checking the all ethical papers and consent.

Relax and repair.

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ANAESTHESIA AFTER DEATH

Wide exposure of field.

Standard monitoring.

Ibp and cvp monitoring.

Iontrope support.

Vasodilators to control HTN due to noxious stimuli and even distribution of preservative solution.

Full neuromuscular blockade to control spinal reflexes.

Sedation and analgesia ??

Prevention of hypothermia.

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ANAESTHESIA AFTER DEATH Inhaled anaesthestics (vasodilation and ischemic

preconditioning).

Heparination.

Isolation of organs to be removed.

Proximal aortic cross clamping and cardioplegia.

Removal according to their cold ischemic time.

Surgical technique “no touch” en bloc procedure.

Immediate cooling and initial flushing.

Stored at 4.c without continuous perfusion.

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COLD ISCHEMIC TIMES

HEART 3-4 HRS

LUNGS 3-4 HRS

PANCREAS 6 HRS

SMALL INTESTINE 4-6 HRS

LIVER 8 HRS

KIDNEYS 36 HRS

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ORGAN PRESERVATION

Collins

Euro collins

HTK solution

Celsior(heart)

Perfadex(lungs)

University of wisconsin solution(high k+)

With additives also.

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CONTRAINDICATIONS Positive HIV, Hepatitis B or C, HTLV, syphilis or malaria tests

Evidence of Creutzfeldt-Jakob disease

Progressive neurological disease of unknown cause (e.g. Alzheimer’s, Parkinson’s, motor neurone disease)

Untreated systemic sepsis

Uncontrolled hypertension or end-organ damage from hypertension or diabetes mellitus

Malignancy

A previous transplant recipient who has received immunosuppressive treatment.

Sickle crisis

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HOW TO REGISTER

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Please log in once,if time permits :-

www.lampoflife.in

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CARRY HOME MESSAGE

Understanding about brain death and its ethical aspects.

ICU management and proper care.

All parameters should be in normal range.

Full neuromuscular blockage.

Cold preservation and transport.

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