indian prespective deceased brain death

1. Dr. T.R.Chandrashekar
Intensivist, Liver transplantation.
Department of Surgical Gastroenterology
BMC & RI super-specialty Hospital. Bangalore.
Management of Organ Donor
Following Brain Death

2. Transplantation of Human Organs Act, (THOA) 1994, 2011, 2014

3. Potential Brain dead DONOR
DONOR Referral
Donor management
Donor consent
Actual
Donation
Brain death testing ,Twice at a interval of 6 hrs
Organ retrieval

4. Huge Gap
In India around 2.5- 3
lakh patients die of
liver failure due to
cirrhosis
More than 25,000
require transplant
every year
Only 500 liver
transplants for
Indian patients
done per year
2%

5. Potential deceased donor
 In transplantation center
 In authorised retrieval hospital
 Referral hospital- has to be shifted to transplant
centers according to ROTA of state coordination
committee (ZCCK)
 Intensivist motivates
 Relatives voluntarily agree and contact ZCCK, these
patients are in a "benign neglect” hence risk of shifting
is high

6. Clinical Triggers That Should Prompt
Notification of the Organ
Procurement Organization
 At the initial indication that a patient has
suffered a non recoverable neurologic injury
(e.g., documented loss of cranial nerve reflexes)
 As soon as a formal “brain death” examination
is contemplated
 Before initiating a discussion that may lead to
withdrawal of life-sustaining therapy
ICU caregivers should notify transplant team within 1 hour after a
patient meets specified clinical triggers.
Clinicians should consider organ donation as part of end of-life
decisions.

7. WHY TEST?
Where Brain Stem Death (BSD) is suspected, it is
highly desirable to confirm this by Brain Stem
Testing:
• To eliminate all possible doubt regarding
survivability
• To confirm diagnosis for families
• In cases subject to medico-legal scrutiny
• To provide choice regarding organ donation

8. The declaration of brain death is based on straight-
forward principles:
The presence of unresponsive coma.
The absence of brain stem reflexes.
The absence of respiratory drive after a CO
2
challenge.
(Apnea test)
Ancillary testing ( any one)
Cerebral angiogram (insufficient evidence to recommend use of
CT or MRI angiography)
Hexylmethylpropylene amineoxine single-photon emission CT
Electroencephalography
Transcranial Doppler ultrasonography
If apnea test aborted or still in doubt

9. GOALS
 Impetus shifts from optimizing cerebral
perfusion pressure to maintaining hemodynamic
stability
 Diagnosing neurologic death (should it occur)
 Preparing the family for devastating news
 Counseling them on end-of-life issues
 Preserving the option of organ donation.

10. Timing of the Request
for Deceased Organ
Donation
Primary care giver
Intensivist
Transplant coordinators
Separating requests for
donation from the family
notification of brain
death, a process known
as “decoupling” is
advised
Who Should Request Authorization ?
Superior communication
skills, increased time with
families of potential donors,
trained to handle grief
counseling and also superior
knowledge about THOA
“Family consent” is a vague term, and, unlike in some countries,
no hierarchy of relatives has been specified in the rules.

11. Consent for Organ donation
 A patient’s previously expressed preferences for
organ donation are paramount. ICU clinicians
and coordinator/ ZCCK should retrieve proof
of such authorisation.
 Another clause in from 8
 There are reasons to believe that no near relative
of the said deceased person has objection to any
of his/her organs/tissue being used for
therapeutic purposes.
For organ RetrievalFirst declaration 6 hours interval

12. Issues with Medico-Legal cases
 Police clearance
 FIR registration station is required to give
clearance and sign the permission for PM
 Post Mortem timings
Delay in PM
Grief stricken families in hospital
Relatives waiting at donors residence
Time pressure for both relatives and
doctors- leads to conflicts

13. ICU Management
of the Brain Dead Potential Donor
 Stabilize profound physiologic and
homeostatic derangements provoked by BD
 Balance competing management priorities
between different organs
 Avert somatic death and loss of all organs

14. Clin Infectious Diseases
Delmonico Fl 2000; 31 : 781-786
Routine serological testing of donors
• Antibody to HIV
• Hepatitis B surface antigen
• Antibody to Hepatitis B core antigen
• Antibodyto Hepatiotis B surface antigen
• Antibody to Hepatitis C virus
• Antibody to Cytomegalo Virus
CBC/ ABG
LFT/ RFT/ SE
Coagulation profile/
TEG
Two blood cultures
Urine and sputum
culture
Antibiotics as per cultures if present same may be used for recipients also

15. Physiologic Changes with Brain Death
Neurologic
Cardiovascular
Pulmonary
Endocrine
Hypothermia
Metabolic
Pro-
inflammatory
state

16. Incidence of organ involvement
 Hypotension 81%
 Diabetes insipidus 65%
 DIC 28%
 Cardiac dysrrhythmias 25%
 Pulmonary oedema 18%
 Metabolic acidosis 11%
J Heart Lung Transplantation 2004 (suppl)

17. Competing physiologic needs
Heart: Balanced Fluids, Vasopressin
Kidney: Liberal Fluids, Dopamine
Lungs: Conservative Fluids, No Pressors
Liver: Isotonic fluids

18. Failure of hypothalamo-pituitary axis
Decline in plasma hormone concentration
ADH, TSH
Impaired TSH secretion
Impaired peripheral conversion of T4
Reduced T3- progressive loss of cardiac
contractility
Increased anaerobic metabolism
Hypoadrenalism
Impairs donors stress response
Cardiovascular collapse
Decreased insulin secretion
Hyperglycaemia
Endocrine changes

19. Compared to usual care

20. Society of Critical Care Medicine/American College of Chest
Physicians/Association of Organ Procurement Organizations
Donor Management Task Force
Crit Care Med 2015; 43:1291–1325

21. Hemodynamic changes with BD
 10-20% donors are lost to cardiovascular collapse as
patient evolves to brain death
 Volume Depletion in BD
 Causes multifactorial
 Underlying medical condition – blood loss, etc
 Prior management – osmotic therapy for ICP
 Neuro-hormonal cascade
 Capillary Leak
 Diabetes Insipidus
 50% of potential BD donors are volume responsive
Muragan, CCM, 2009

22. Target lactate, ScVO2, TTE, CVP
 General guidelines for adequate IV fluid
resuscitation are as follows:
a. Mean arterial pressure at least 60 mm Hg.
b. Urine output at least 1 mL/kg/hr.
c. Left ventricle ejection fraction at least 45%.
d. Lower vasopressor dose (e.g., dopamine ≤ 10
μg/kg/min).
 Use Isotonic crystalloids ,0.9% saline and
lactated Ringer solution

23. Vasoactive Medications – Pressors
Noradrenaline in vasodilatory shock
Dopamine
 Traditional 1st line pressor
 1-10 mcg/kg/min
 Inotrope and vasopressor
 Pro – suppresses
inflammation; mitigates
ischemia-reperfusion
injury
 Con – suppresses anterior
pituitary hormone
function
Vasopressin
 Alternative 1st line pressor
 .01-.04 IU/min
 Vasoconstrictor
 Pro – catecholamine sparing
effect; concurrent rx of
DI
 Con - Decreases splanchnic
perfusion

24. Vasoactive Medications -
Inotropes
 If EF < 45% despite volume
repletion and pressors,
add inotrope
 Dobutamine, Epinephrine
 If EF remains depressed despite inotrope,
consider starting hormonal replacement therapy
(HRT)

25. Corticosteroid administration
Methyl-prednisolone 1,000 mg IV, 15 mg/kg IV, or 250
mg IV bolus followed by infusion at 100 mg/hr.
Corticosteroid repletion reduces inflammation in
donor livers
 Lower levels pro-inflammatory cytokines – serum,
tissue
 Fewer adhesion molecules in tissue
 Less ischemia-reperfusion injury
 Lower acute rejection rates
Given after blood has been collected for tissue typing as it
has the potential to suppress HLA expression.

26. AVP ↓-DI
 Polyuria (> 200ml/hr for 3hrs).
 Normal or increased serum osmolality.
 Inappropriately dilute urine (specific gravity < 1.005,
 Urine osmolality < 200 mOsm/kg H2O).
 Hypernatremia (Na+ > 145 mmol/L).
Hypotension -Vasopressin : 1 unit bolus; Infusion at 1-4 units/hr
IF sodium, > 145–150 mmol/L without hypotension, treatment with
Desmopressin should be initiated. ( Nasal Spray)
Bolus IV dose of 1–4 μg, additional 1 or 2 μg every 6 hours
AVP + Desmopressin can be used concurrently in unstable patients

27. Our protocol -Hormonal
replacement
• Vasopressin : 1 unit bolus; Infusion at 1-4 units/hr
• Triiodothyronine - 4mcg bolus, infusion at 3 mcg/hr (
levothyroxine 100 mcg NG )
• Methlyprednisolone – 1 gram bolus every 12th hrly
• Insulin - 1 unit/hr minimum and titrate
Na < 155 and Glu < 160,
Aim for temperature >36o C

28. Donor Management Goals
 Develop protocols to optimize donor organ
function and maximize organs per donor
 Borrow concept of “bundles” from other
disease management models
 Represent consensus of physiologic targets
based on expert opinion
 Modest clinical studies to support use

29. Thank You

30. Potential organs for retrieval
• Heart
• Lung
• Liver
• Kidney
• Cornea
• Pancreas
• Small bowel
• Vessels, Tissues

31. Organ Preservation Time
 Heart: 4-6 hours
 Lungs: 4-6 hours
 Liver: 12 hours
 Pancreas: 12-18 hours
 Kidneys: 72 hours
 Small Intestines: 4-6
hours

33. ‘Collateral damage’
 Hormonal
• Diabetes insipidus
 Hypovolaemia
 Hypernatraemia
• T3 / T4 reduces
• ↓ACTH/ cortisol levels
• Blood glucose
 Hypothermia
Organ Donation Past, Present and Future

37.  Hemodynamic assessments for brain-dead
donors include
 serial determination and interpretation of
 a. Mixed venous oxygen saturation.
 b. Lactate.
 c. Base deficit and acid-base status.
 d. CVP, PAOP, or noninvasive hemodynamic
parameters. TTE TEE ECHO

38. Our protocol -Hormonal
replacement
• Vasopressin : 1 unit bolus; Infusion at 1-4 units/hr
• Triiodothyronine - 4mcg bolus, infusion at 3 mcg/hr (
levothyroxine 100 mcg NG )
• Methlyprednisolone – 1 gram bolus every 12th hrly
• Insulin - 1 unit/hr minimum and titrate

39. Temperature
 Temperature regulation lost
 Hypothermia
 Physiological changes
associated with hypothermia
 Sepsis
 Coagulation abnormality
Fluid warmers
Forced air warming blankets
Inspired gas humidification
Minimise exposure to
environmental
temperature
Aim for temperature >36o C

40. It is imperative that the same rigor that is applied to
the care of living patients be employed in the care
of organ donors.

41. Metabolic changes with BD
 Hypernatremia
 Caused by volume depletion, Diabetes insipidus
 Na > 170 associated primary non-function (PNF)
of graft liver
 Hyperglycemia
 Caused by insulin resistance and gluconeogenesis
 Glu > 200 associated with PNF of graft pancreas
 Glu > 160 associated with PNF of graft kidney

42. Pulmonary Changes in BD
 Pulmonary edema
 Neurogenic
 Cardiogenic
 Non-cardiogenic – capillary endothelial leak
 Delayed alveolar fluid clearance
 LPV should be used in all BD