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BASICSOFORGANDONATION&

MANAGEMENTOFBRAINDEADDONOR

Dr.T.Venkatachalam.MD.,DA,

MadrasMedicalCollege&RajivGandhiGovtGeneralHospitalChennai

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Whatisbraindeath?

Braindeath-resultsfromtotal,irreversiblelossofallbrainfunconsincludingthe

brainstemduetototalnecrosisofthecerebral

neuronsfollowinglossofbloodflowandoxygenaon

Duetoasevereheadinjury,illnessordisease. Aperson'sheartwillsllbeatforaperiodofmeaertheybecome"braindead".

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ThepurposeofBraindeath

cerficaon1.Todeterminewhethertoconnuethelifesupport

systemsornot.

2. Ifsuitable,planfororganretrieval.

4. Paentscouldbesupportedforlongerperiods,ascricalcaremanagementofpotenalorgandonorsiscrucialinmaximizingthenumberandthequalityoftransplanted

organs.

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Braindeathisestablishedby

documentaonof

1.IrreversibleComa

2.Irreversiblelossofbrainstemreflexes3.LossofrespiratoryCentrefuncon

4.Demonstraonoflossofintracranialblood

flow.

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Responsibiliesofthephysician

determiningbraindeath

Thediagnosisofbraindeathisprimarilyclinical.

Noothertestsarerequiredifthefullclinicalexaminaon,includingeachoftwo

assessmentsofbrainstemreflexesandthe

singleapneatestisconclusivelyperformed.

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Clinicaltes9ngforbrainstem

func9on:

STEP-1Evaluatetheirreversibilityandpoten8alcausesofcoma

STEPII

Ini8atethehospitalpolicyforno8fyingthenextofkin.

STEPIIIConductanddocumentthefirstclinicalassessmentofbrain

stemreflexes.

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Clinicaltesngforbrainstemfuncon-

cont.

STEP-IV

Intervalobservaonperiod:

6hourobservaonperiodissufficientinadultsandchildrenovertheageof1year.

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Clinicaltesngforbrainstemfuncon-

cont.

STEP-V

Repeatclinicalassessmentofbrainstemreflexes:

STEP-VI

Apnoeatest:TheapnoeatestisperformedaertheII

examinaonofbrainstemreflexes.

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Clinicaltesngforbrainstemfuncon-

cont.

STEP:VII

Confirmatorytesngasindicated

Whenitisimpossibletocompletetheclinicalexaminaon,thenaconfirmatorytestis

required.

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Clinicaltesngforbrainstemfuncon-

cont.

STEP:VIII

ReasonableAccommodaonSTEP:IX Cerficaonofbraindeath:Medicalrecorddocumenta9on:

Allphasesofthedeterminaonofbraindeathshouldbedocumentedinthemedicalrecord

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Clinicaltesngforbrainstemfuncon-

cont.

STEP:X

Withdrawcardio-respiratorysupportinaccordancewithhospitalpoliciesincludingthose

fororgandonaon.

Whenorgandonaoniscontemplated,paentisshiedtothetheatrewithvenlatorysupport

andvenlaon/anaesthesiaconnuedlltheorgansareharvestedandthencardiorespiratory

supportiswithdrawn.

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BRAINDEATHMAINTENANCE

Organtransplantaonisconsideredtheopmaltreatmentforappropriatepaentswithend

stageorgandysfuncon.

Themismatchbetweensupplyanddemandresultsinmorepaentsdyingonthetransplant

wainglist.

thecricalcaremanagementofpotenalorgandonorsiscrucialinmaximizingthenumberand

thequalityoftransplantedorgans.

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Theduesofthecricalcarephysician

Earlyidenficaonofbraindeath

Cerficaonofbraindeath Theresponsibilitytoofferthepaentsfamily

theopportunitytodonateorgans/ssues.

Obligaontounknownrecipientstoprovidethebestpossibleorgansandssue.

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BRAINDEATHMAINTENANCE

Thestandardsofmedicalmanagementofthepotenalorgandonorshouldbethesameasthoseofanybraininjuredpaentunlthe

irreversibilityofinjuryisconfirmed Fulebrainorientedtherapyshouldthenbe

disconnuedbutotheraspectsofintensive

careshouldbeconnuedunlitiscertainthat

organdonaonwillnotoccur&thefamilyare

awarethatsupportistobewithdrawn.

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GENERALMEDICALCRITERIA

1.Age0-75yrs.

2.Hassufferedirreversiblelossofbrainfuncon.

3.Hasbeenmaintainedonvenlatorwithintactcirculaon.

4.HasnoH/Omalignancyexceptprimarybrain/skinmalignancy

5.Hasnomajoruntreatedsepsis.

6.Nomajorsignificantsystemspecificdisease(cardiac,pulmonary,liver)

7.Nosignificantinfecousdisease.8.Causeofdeathnotduetomassivepoisoningwithpotenal

fortransplantorgandysfuncon(cyanide,coetc.)

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EXCLUSIONCRITERIAFORORGAN

DONATION

1.HIV/HepasB/Cposivedonors.(Pleaserefertotransplantco-coordinatorforindividualassessment)

2.Anymalignancyotherthanprimaryskin/CNSlesion.3.H/Otreatmentwithhumanpituitarygrowthhormone

andotherhormonesofpituitaryorigin.

4.Untreatedbacterial,viral,fungalinfecon.

5.FamilyH/Odemena.

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INVESTIGATIONS

BeforeIbraindeathtestBloodGP,CBC,LFT,RFT

AergengconsentHIV,HbsAg,AnHCV,CMV,VDRL

Kidneydonor-HLAtyping,USGkidney LiverUSGLiver Heart-12leadECG,ECHO,ifdonoris>50yrscoronaryangiogram LungCXR,ABG,bronchoscopy.

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CLINICALMANAGEMENTOFTHEORGAN

DONOR

Severebraininjuryandbraindeathcreateavarietyofextracerebralorganmanifesta2onsincluding:

1.Autonomicstorm

2.Neuroendocrinehormonedeficiencies3.Systemicinflammatoryresponsesyndrome(SIRS)

4.Neurogenicpulmonaryedema(NPE)

5.Myocardialstunning6.Electrolyteand

7.Immunologicderangements.

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CLINICALMANAGEMENTOFTHEORGAN

DONOR

ThechallengeforICUphysicianismaintainingadequateorganperfusionandmetabolism.

MaximalICUmanagementstrategiesshouldbeemployedtobringoutimproved

outcomes:

largernumberoforganstransplanted Longerrecipientsurvivalmes Improvedorganfunconfollowing

transplantaon.

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ALTERATIONOFCEREBRALPHYSIOLOGYANDITSEFFECTSONCVS:Rapidlyexpandingsupratentoriallesion

Swilyprogressingbrainedema

Upperbrainloosesfuncon(levelofconsciousness)

IncreaseICT

Transtentorialherniaon

Distoronofpostfosse/Infratentorialcompartment

PressureonthePONS

Cushingsresponse

(HT,bradycardia,widepulsepressure)

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ALTERATIONOFCEREBRALPHYSIOLOGYANDITSEFFECTSONCVS-2

Cushingsresponse

(HT,bradycardia,widepulsepressure)

ICTcaudalspread

Ischemiaofmedulla/Brainstem

(vagal/cardiomotornuclei)

Centralautonomicdysfuncons

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ALTERATIONOFCEREBRALPHYSIOLOGYANDITSEFFECTSONCVS-3

Autonomicstorm:HR,BP,SVR

CatecholaminesurgeCardiacworkload Myocard.02Consumpon,

vasoconstricon

(endorg.perfusion)CatecholaminesfalltolevelsbelowNormalwithin20mtsofbraindeath

Autonomiccollapsesympathecoulow

SVR

CatecholaminesCO

Endorganperfusion

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MANAGEMENT

IPhaseduraonofhaemodynamicsurgeunpredictable

-closemonitoringwithoutaggressiveRx

(a)Thresholds: sysBp>160mmHg

MAP>90mmHg

(b)Preferredtherapy

SNP0.55mcg/kg/min

Esmolol-100-500mcg/kgbolus

followedby100-300mcg/kg/min.

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MANAGEMENT

IIPhase

Hypotensionmayoccurdueto Catecholaminedepleon/sympathecdrive Volumedepleonduetodiurecs-Mannitol,

FrusemideusedintheRxofcerebraledema

Connuousbloodlossfrominjuries Insensiblefluidloss. DiabetesInsipidus

Metabolic/Endocrineabnormalies Hypothermia Myocardialdysfuncon

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MANAGEMENTOFHYPOTENSION RapidreplacementofcirculangBloodVolume- colloids/crystalloids.Titratedtoa

CVP(8-10mmHg)Goal Bp-Syst.(100mmHg)

MAP-60-70mmHg HR

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MONITORING

ExpertconsensusrecommendsCVPmonitoringineverypotenal

organdonor.

Apulmonarycathetershouldnotbeplacedaerbraindeathforextracerebralorganperfusionconsideraons.

Indica8onsforPAcatheterInd:(1)2DEchoEF40%

(2)Paentsrequiring-:Dopamine>10mcg/kg/min

Vasopressorsupport

Escalaonofsupports Targets: PCWP12-14mmHg

CI ->2.4l/min/m2

SVR-8001200dynes/sec/cm-5

Bradyarrhythmias:Inthebraindeadpaents, heartisdenervatedandresistanttoatropine.

Rx-TitraonofDopamine

Smalldoesofi.v.Adrenaline(0.050.1mg)

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RESPIRATORYSYSTEM

TheConsequencesofbraindeathongasexchangeandlungfunconmaybeprofound.

Braindeathisassociatedwithsystemicinflammaon.Inaddion:

Lungfunc9oncandeterioratedueto:

Lunginjury(Releaseofproinflammatorycytokines) Aspiraons Pulmonarycontusions/pneumonia Volutrauma/Barotrauma Pul.microemboli V/Qmismatch Neurogenicpul.edema.

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NeurogenicPulmonaryedema

CatecholaminesurgeIntensevasoconstriconsSVR

Shiingoffluidfromperipherytocentralcirculaon

AcuteinLApressure

Pulcapillarypressure

IntenseadrenergicAltera9onofPulmonary

s9mula9onpul.Capillaryedema

Permeability

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INTERVENTIONSFORPULMONARYSTABILITY

1.AggressivepulmonarycareReposioning(Q2hrly) Chestphysiotherapy,suconing&Oralhygiene.

2.Carefulfluidmanagement -CVPguidedfluidtherapytoavoidpul.Edema.

3.Venlaonstrategies:

--Fi02tratedtokeep02sat95%

--Pao280mmHg,PH7.35-7.45,Paco 235-45mmHg

--PEEP5cmH 20,TV6-8ml/kg,PIP

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EFFECTSONENDOCRINE&METABOLICACTIVITY

DYSFUNCTIONOFHYPOTHALAMOPITUITARYAXIS

Duetohypothalamopituitaryaxisdisrupon,neuroendocrinedeficienciesoccur.1.Posteriorhypothalamicpituitarydeficiency

DiabetesInsipidus(DI)

Upto90%ofdonorshaveloworundetectablevasopressin(ADH)levels.

DiabetesInsipidus:

Urineoutput>500ml/hr,Sr.Na>155meq/lU.SP.Gravity305mosm/l

Treatment

Volumereplacement(withhypotonicsalineor5%Dextroseinwater DIinisolaoncanbetreatedwithaconnuousinfusionofvasopressinor

intermi~enti.v

vasopressininfusionshouldbethefirstchoice,when*Haemodynamicsupportwithvasopressinrequired

*Combinaonhormonaltherapyindicated.

( )

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Desmopressin(DDAVP)

Highlyselecvev2receptoracvity Longerhalflife Potentandiurecacon MinimalVasopressoracvity Dosage-Loading8ng/kgInfusion4ng/kg/hrArgininevasopressin

Havebothvasoconstrictor/ADHeffect.(treatDIaswellasloweringtheVasopressorrequirementforthedonor)

Bolus1unit Infusion0.010.04unit/min. DosetratedtoaSVRof8001200dyns/cm5

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ANTERIORHYPOTHALAMICPITUITARY

DEFICIENCYadrenalandthyroid

2.Thyroid&3.Adrenalinsufficiency:

Thissteroiddeficiencyisimplicatedin

Deficiencyofnormalstressresponseandhypotension. Theinflammatoryprocessresultsinupregulaonof

cytokinesproduconintheorganstobetransplanted,increasingtheimmunogenicityposttransplant.

Management:

MethylPrednisolone-15mg/kg/24hrly Improveslungfuncon Improvedoxygenaon Improvedsurvivalinorganrecipients.

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TRIPLEHORMONALTHERAPY Thyroidhormone,vasopressin,

Methylprednisolone Combinedtherapyisusedindonorwith

EchocardiographicassessmentofEF40%

orhaemodynamicinstability.

Consideraonshouldbegiventoitsuseinalldonors.

1.T34mcgbolus/Infusion3mcg/hr

2.MethylPrednisolone15mg/Kg/Q24hrly3.Vasopressin1unitbolus

i.vinfusion0.010.04units/min

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ANTERIORHYPOTHALAMICPITUITARYDEFICIENCY

INSULIN4)Insulindeficiency

Glycemiccontrolwithinsulininfusiontratedtoabloodglucosetargetof6-8mmol/Lt(100to140mg%)

(5)Hypothermia

ConsequencesofHypothermia:

Arrhythmias,Myocardialdepression(CO),(L)shiofODC(impaired02delivery)

Colddiuresis(abilityofkidneystoconcentrateurine),Coagulopathies.Management:

Therapeucintervenonstomaintainacoretemperatureof350C

Externalwarmingdevices Warmingblankets Warmedi.vfluids Heatedhumidifiedgases Considerthyroidreplacement.

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TRANSFUSIONTHRESHOLDSAcceptabletargetsforHb,Platelets,andCoagula8on

Parameters.

AHbtargetof910g%ismostappropriatetoopmizecardiopulmonaryfunconinthefaceofhaemodynamicinstability.

Hb7g%isthelowestacceptablelimitforICUmanagementofstabledonors.

Coagulopathy Cause:Releaseofthromboplasnfrominjuredbrainissue

Diluonalcoagulopathy Hypothermia

Therearenodefinedtargetsforplatelets/INR/PTT.

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RENALSYSTEM

Maintainsystolicbloodpressureconsistentlyabove8090mmHg

HEPATICSYSTEM

Depleonofliverglycogenoccursin12hrsfollowingbraindeath.

ProvisionofbothglucoseandinsulinmayimproveglycogenstorageaswellasimproveGlycemiccontrol.

Hypernatremia(Sr.Na>155mmol/l)causesaccumulaon

ofidiogenicosmoleswithintheliverandleadstogra

dysfuncon.

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THANK YOU

Dr.T.Venkatachalam. MD.,DA.Professor of Anaesthesia,

Madras Medical College &Govt General Hospital, Chennai