donation after brain death
TRANSCRIPT
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
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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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