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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