brain death2

8/9/2019 Brain Death2

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BRAIN DEATH AND ORGAN

TRANSPLANTATION

JOYDEEP GHOSH

PGT, 2ND YR

IPGMER AND SSKM HOSPITAL


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TYPES OF ORGAN DONATION:

LIVING RELATED

LIVING NONRELATED

CADAVERIC


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WHY DO WE NEED CADAVERIC ORGANS? ORGAN DONATION vs

WAITLISTED PATIENTS

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080

10,00020,00030,00040,00050,00060,00070,00080,00090,000100,000

Deceased Donors Transplants - Living and Deceased Donors Wait List


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WHY THE FIGURES ARE SO

DISSAPOINTING? PROBLEMS:

ORGAN ACQUISITION:

SOCIAL

RELIGIOUS

MOTIVATIONAL

LACK OF KNOWLEDGE

MISBELIEFS


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PROBLEMS WITH IMPLEMENTATION:

IRREGULARITIES IN PURCHASE AND SALE

MALPRACTICE

LACK OF SUFFICIENT ORGANIZATION


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THE TRANSPLANTATION OF HUMAN ORGANS

ACT WAS PASSED IN PARLIAMENT ON 8TH JULY,

1994

IT STATES THAT ORGAN MAY BE TAKEN EITHER:

BRAIN DEAD CADAVER, OR

IMMIEDIATE NON-HEART BEATING CADAVER SUCHAS FAILED CPR/DNR/ON VENTILATOR


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The Act permits transplantation of various cadaveric

organs including the kidneys.

The Act makes commercial trading in organs an offence. The Act makes it mandatory for all institutions

conducting transplants to register with the authority

appointed by the government. All persons associated in

any way with hospitals conducting transplants withoutsuch registration are liable for punishment.


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The human kidney was first successfully

transplanted in Boston in 1946. Transplantation

of the liver followed in 1963 and that of theheart in 1967. Many other organs including the

lung, pancreas and intestines are now

transplanted successfully and such operations

are recognized as established therapy by the

WHO.


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BRAIN DEATHDEFINITION:

IT IS DEFINED AS THE COMPLETEAND IRREVERSIBLE CESSATION

OF ALL BRAIN FUNCTION

INCLUDING THE BRAINSTEM


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DIAGNOSISNEW YORK STATE

DEPARTMENT OF HEALTH

GUIDELINES FOR DETERMINING

BRAIN DEATH

DECEMBER 2005


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Three essential findings in brain death are :

1. Coma

2. Absence of brainstem reflexes

3. Apnea

A patient determined to be brain dead is legally

and clinically dead.


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The diagnosis of brain death is primarily clinical.

No other tests are required if the full clinical

examination, including each of two assessments ofbrain stem reflexes and a single apnea test, areconclusively performed.

In the absence of either complete clinical findingsconsistent with brain death, or confirmatory testsdemonstrating brain death, brain death cannot bediagnosed.


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Responsibilities of Physicians

determining Brain Death

Evaluate the irreversibility and potential causes

of coma Notification

Conduct the first clinical assessment

Observe for any clinical inconsistencies with the

diagnosis Conduct the second clinical assessment


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STEP 1: EVALUATION OF COMA

The determination of brain death requires theidentification of the proximate cause andirreversibility of coma.

SEVERE HEAD INJURY

HYPERTENSIVE ICH

MASSIVE SAH

HYPOXIC ISCHAEMIC INJURY

FULMINANT LIVER FAILURE etc


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The evaluation should include: Clinical or neuro-imaging evidence of an acute CNS

catastrophe that is compatible with the clinical

diagnosis of brain death Exclusion of complicating medical conditions that may

confound clinical assessment like:

1. Severe electrolyte abnormalities

2. Severe acid base disorders

3. Endocrine disturbances like hypoglycemia, myxedema

coma etc


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Exclusion of drug intoxication or

poisoning.

Screening test for drugs may be useful but not fordrugs like fentanyl, lithium, cyanide etc..

The drug level should below the therapeutic range Should be observed at least four times the

elimination half life of the drug

If the particular drug is not known but highsuspicion persists, the patient should be observedfor 48hours to determine whether a change in brain-stem reflexes occurs; if no change is observed, aconfirmatory test should be performed.


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STEP 2: NOTIFICATION The facility must make diligent efforts to notify

the person closest to the patient that the process

for determining brain death is underway. Religious and moral objections should be taken

into account and referred to the concernedhospital staff accordingly

Where family members object to invasiveconfirmatory tests, physicians should rely on theguidance of hospital counsel and the ethicscommittee.


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STEP 3: CLINICAL ASSESSMENT COMA OR UNRESPONSIVENESS:

No cerebral motor response to pain in

all extremities (nail-bed pressure) and

supraorbital pressure


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ABSENCE OF BRAINSTEM RESPONSES: PUPILS:

NO RESPONSE TO BRIGHT LIGHT

SIZE MID POSITION(4MM) TO DILATED (9MM)


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OCULAR MOVEMENT:

No oculocephalic reflex (testing only when no

fracture or instability of the cervical spine or skullbase is apparent)

No deviation of the eyes to irrigation in each ear

with 50 ml of cold water (tympanic membranes

intact; allow 1 minute after injection and at least 5

minutes between testing on each side)


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Facial sensation and facial motor response:

No corneal reflex

No jaw reflex (optional)

No grimacing to deep pressure on nail bed,

supraorbital ridge, or temporomandibular joint


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Pharyngeal and tracheal reflexes:

No response after stimulation of the posterior

pharynx

No cough response to tracheobronchial suctioning


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CONFOUNDING FACTORS: FOLLOWING CONDITIONS:

Severe facial or cervical spine trauma

Preexisting pupillary abnormalities Toxic levels of any sedative drugs, aminoglycosides,

tricyclic antidepressants, anticholinergics,antiepileptic drugs, chemotherapeutic agents, or

neuromuscular blocking agents Sleep apnea or severe pulmonary disease resulting

in chronic retention of CO2


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STEP 4: INTERVAL OBSERVATION PERIOD After the first clinical exam, the patient should be

observed for a defined period of time for clinicalmanifestations that are inconsistent with the diagnosis

of brain death. Most experts agree that a 6 hourobservation period is sufficient and reasonable

When a confirmatory test confirms the diagnosis ofbrain death, the interval between clinical assessmentscan be shortened to 2 hours. If any part of the clinical

determination including the apnea test cannot becompleted, one of the confirmatory tests is required andthe interval may be shortened to 2 hours.


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STEP 5: APNEA TEST BEFORE TESTNG, THE PHYSICIAN SHOULD

ENSURE THE FOLLOWING:

Core temperature 36.5C or 97.7F

Euvolemia. Option: positive fluid balance in the

previous 6 hours

Normal PCO2. Option: arterial PCO2 40 mm Hg

Normal PO2. Option: pre-oxygenation to arterial

PO2 200 mm Hg


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PREOCEDURE: Connect a pulse oximeter and disconnect the

ventilator

Deliver 100% O2, 6 l/min, into the trachea.Option: place a cannula at the level of the carina

Look closely for respiratory movements

(abdominal or chest excursions that produceadequate tidal volumes)


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CONTD. Measure arterial PO2, PCO2, and pH after

approximately 8 minutes and reconnect the ventilator

If respiratory movements are absent and arterial PCO2is 60 mm Hg (option: 20 mm Hg increase in PCO2

over a baseline normal PCO2), the apnea test result is

positive (i.e. it supports the diagnosis of brain death)

If respiratory movements are observed, the apnea testresult is negative (i.e. it does not support the clinical

diagnosis of brain death)


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Connect the ventilator if, during testing, the systolic bloodpressure becomes < 90 mmHg (or below age appropriatethresholds in children less than 18 years of age) or the

pulse oximeter indicates significant oxygen de saturation,or cardiac arrhythmias develop; immediately draw anarterial blood sample and analyze arterial blood gas. IfPCO2 is 60mm Hg or PCO2 increase is 20 mm Hg overbaseline normal PCO2, the apnea test result is positive (it

supports the clinical diagnosis of brain death); if PCO2 is 2 mo to 1 yr old, 24 hr

>1 yr to 2 mo to 1 yr old, 1 confirmatory test

>1 yr to


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Problems in donor management: Hypotension, hypovolemia: CVP 10-14mm hg

Low hemoglobin

Cardiac contractility: MBP > 60mm hg

DI: vasopressin Arrythmias

Sepsis

Aspiration pneumonitis

Hypothermia

Hyperglycemia Coagulopathy

Hormonal deficiencies


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ROUTINE TESTS FOR BRAIN DEAD:

Blood group, tissue matching, LFT/RFT, CBC

After consent HIV, HbsAg, Anti-HCV, CMV, VDRL

Kidney donation HLA typing (arranged by thetransplant coordinator), USG kidney

Liver - +/- USG liver

Heart 12 lead ECG, echocardiogram, if donor > 50

years old, coronary angiogram Lung CXR, ABG, bronchoscopy by lung transplant

surgeons


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CONTRAINDICATIONS FOR ORGAN

DONATION: Age criteria: Donor age is evaluated relative to organ function rather than

in absolute chronologic terms. Cadaveric donors has increased 30%, thenumber of donors older than 65 years of age has increased 535% .Inspite of this trend, however, the ideal donor age is still considered to be10 to 50 years

Infection: Donors with a recent history of infection documented by apositive blood, sputum, or urine culture must receive appropriateantibiotic coverage and have negative culture results to be considered fordonation. The common infections that should be rule out are HIV, syphilis,HBV, HCV and CMV.

Malignancy: Low-grade skin cancers, low-grade solid organ tumors with a

greater than 5-year documented tumor-free interval, and primary braintumors that have not undergone previous surgery usually do not precludeorgan donation

Severe Systemic Disease: The ideal organ donor is relatively young, andis free of and with no history of end-organ disease. Each organ system isevaluated separately. Other than carcinoma (except primary brain tumor),no disease by itself should be considered a contraindication to organ

donation.


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PROBLEMS IN IMPLEMENTATION OF THE

ACT: Misperceptions that hinder donor registration like:

People erroneously believe that a person can recover from brain death

Some people think doctors may not try very hard to save their lives if theyknow about their wish to be a donor

Superstitious belief that the dead body without the vital organs isincomplete and the dead person will not rest in peace

People assume there is a buy-sell black market for organs and tissuetransplant

Many people who wish to donate their organs and tissues are not surethat they will be acceptable as donors. Actually, age or health conditions

should not prevent people from becoming potential donors Socio cultural issues

Lack of awareness


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Is a Person Diagnosed as Brain Dead in a

Comatose State or Dead?

45% 55%

63% 37%

0% 20% 40% 60% 80% 100%

Non-Donor

Donor

Dead

Coma /

Don't Know

Franz, et.al. 1997.


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True or False: People Cannot Recover When

They are Brain Dead

34% 66%

74% 26%

0% 20% 40% 60% 80% 100%

Non-Donor

Donor

True

Not True /

Don't Know

Franz, et.al. 1997.


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Poor Understanding of brain death is associated

with significantly lower rates of consent to

donate organs of the deceased.

Journal of Transplant Coordination

Vol. 7, Number 1, March 1997


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An last but not the least: Malpractice: can involve any level.

There are four thieves:

Intensivist and team with certifying

neurologist

Organ transplant surgeons and physicians

Administrative authority

Ethical committee-to sort out the conflict

arising out of these


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THE MOST TRANSPLANTED ORGANS ARE

KIDNEYS, LIVER AND SOME LESS COMMON ONES

ARE HEART,PANCREASE,GUT ETC IPGMER IS SELECTED AS ONE OF THE ORGAN

TRANSPLANT CENTRES


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HOW TO INCREASE? Increasing organ availability

Directive on quality and safety

Organising transplant systems more efficiently

Mobilization of more centres

Involving voluntary nongovernment

organizations


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And finally.


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And finally:.

Motivating people


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Thank you

Thank you

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