solid organ transplantation · brainstem reflex 1. pupillary light reflex 2. corneal reflex (blink...
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Deceased donor
Solid organ transplantation
Deceased donor donation process
1. Potential donor detection
2. Brain death diagnosis
3. Donor management
4. Organ allocation
5. Organ retrieval
Brain death
Irreversible coma
from
Irreversible brain damage
Cerebral and Brain stem
Potential donor
1. Complete irrecoverable brain stem damage from
– Head injury
– Subarachnoid hemorrhage
– Rupture aneurysm
– Cerebrovascular accidents (CVA)
– Hypoxic brain damage
– Primary brain tumor
Glasgow Coma Scale < 5
Eye Open
Spontaneously 4
To verbal stimuli 3
To pain 2
No response 1
Best motor response
To verbal command Obeys 6
To painful stimuli
Localizes pain 5
Semi-purposeful 4
Decorticates 3
Decerebrates 2
No response 1
Best verbal response
Oriented and converses 5
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Brain death
Potential donor
2. No Contraindication
– HIV +
– Severe infection
– Malignancy :
Except
• Primary brain tumor
• Early non metastatic skin cancer
• Early cervical cancer
Brain death diagnosis
1. Presence of condition that leads to brain death
2. Exclude other causes mimics brain death
3. Procedure to confirm brain death
1. Conditions that leads to brain death
• Severe head injury
• Intracranial bleeding from other cause
– Rupture cerebral aneurysm
– Rupture AVM
• Brain tumor
• Complication after brain injury
Unconscious AND no spontaneous respiration > 6 hours
2. No conditions that mimics brain death
• Hypothermia : T < 32 C
• Brain hypoxia
• Drug intoxication
• Shock ; except neurogenic shock
• Recent major neurosurgery/head injury
If the above condition is present ………….
Duration of observation?
Make correction and observe conscious neurological sign
ระยะเวลาทเหมาะสมทจะทดสอบ ภาวะ apnoeic coma
ภายหลงจากภาวะดงน
Condition Duration (Hours)
Major neurosurgery 4
Second subarachnoid bleeding 6Head injury
Spontaneous hemorrhage
Brain hypoxia 24
Suspicious drug intoxication 50
Drug intoxication
• Sedative – Diazepam, Midazolam, Lorazepam
• Narcotic– Fentanyl– Pethidine– Morphine– Heroine
• Muscle relaxant– Succinylcholine– Atracurium, Pancuronium, Rocuronium, Vecuronium
Guillian–Barre syndrome
NEUROLOGIC STATES THAT CAN MIMICBRAIN DEATH
3. Procedure to confirm brain dead
1. No movement, except spinal reflex
2. Absence of brainstem reflex
3. 1+2 are
– Persist >= 6 hours AND
– Diagnosis by 3 MD : exclude transplant team
4. Apnea test + twice, 6 hours apart
Brainstem reflex1. Pupillary light reflex
2. Corneal reflex (blink reflex)
3. Motor response within the cranial nerve distribution (face & ocular muscle)
4. Vestibulo-ocular reflex (Caloric test)
5. Oculocephalic reflex (doll’s eyes sign)
6. Cough reflex (suction)
7. Gag reflex
3. Procedure to confirm brain dead
1. No movement, except spinal reflex
2. Absence of brainstem reflex
3. 1+2 are
– Persist >= 6 hours AND
– Diagnosis by 3 MD : exclude transplant team
4. Apnea test + twice, 6 hours apart
Apnea test
1. Maintain
– Body temperature > 36 C
– SBP > 80 mmHg
2. Preoxygenation :
– FiO2 100%, RR 10/min, TV 10 ml/Kg > 30 min
– ABG: PaO2 > 200 and PaCO2 = 40 mmHg
Apnea test
3. Remove respirator
– Insert NG tube no 10-12 to carina, O2 100% rate 6 L/min
– Monitor EKG, O2 saturation,
– If no movement of chest or abdominal wall for 10 mins
– ABG : PCO2 > 60 or increase > 20 mmHg from baseline
+ Apnea test
Perform apnea test x 2
Donor ageDuration between
apnea test (hrs)
2 months-1 year 24
>1-18 years 12
>18 years 6
Deceased donor donation process
1. Potential donor detection
2. Brain death diagnosis
3. Donor management
4. Organ allocation
5. Organ retrieval
Donor management
Goal
To maintain organ perfusion and function
Brain stem
Connect motor and sensory systems from the brain to the rest of the body
Regulate cardiac and respiratory system Control Heart rate and Breathing
Maintain consciousness
HypothalamusAnti-Diuretic Hormone(ADH)
Brain stem death
No spontaneous movement & sensation
Arrhythmia & Apnea
Unconsciousness
ADH deficiency (DI)
Hypotension Etiology Management Goal
Volume depletion CVP 8-10 cm H2O< 8 for lung donor
Previous/on going bleeding PRC
Central diabetes insipidus(DI)
dDAVP 8ng/kg (1/2 Amp)
(Desmopressin, Minirin)
NG free H2OD5W <300 ml/min
Urine 0.5-3 ml/kg/hr(25-150 ml/hr)
BS < 150 mg/dL
Cerebral salt wasting NSS /RLS Na 135-155 mEq/L
Lack of sympathetic tone Dopaminemax 10 mcg/kg/hr(Only if euvolumia + hypotension) ± NE
SBP > 100 mmHgHR 60-100 /min
Adrenal insufficiency Methylprednisolone 15 mg/Kg
U/A SpGr. < 1.010
Respiratory setting : Lung donor
• TV 6-8 ml/Kg
• PEEP 5-10 cm H2O
• PIP <25 cm H2O
• ABG : pH 7.35-7.45
: SpO2 > 95% (FiO2< 0.4)
Temp > 36 C
History taking …
• Previous surgery
• TB
• HT
• DM
• Cardiac condition
• Kidney disease
• Cancer
• Animal bite
• Fever
• Admission
• Medication
• Drug abuse
• Alcohol
• Smoke
• Behavior
• Criminal
• Transfusion
• Travelling
Physical examination
• Surgical scar
• Tattoo
• Foreign body
• BW (estimate)
• Height (บตรประชาชน)
• Chest & Abdominal circumference
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Process of brain death
diagnosis
Donor Management
Consent form
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