Brain Death2
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BRAIN DEATH AND ORGAN
TRANSPLANTATION
JOYDEEP GHOSH
PGT, 2ND YR
IPGMER AND SSKM HOSPITAL
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TYPES OF ORGAN DONATION:
LIVING RELATED
LIVING NONRELATED
CADAVERIC
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WHY DO WE NEED CADAVERIC ORGANS? ORGAN DONATION vs
WAITLISTED PATIENTS
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080
10,00020,00030,00040,00050,00060,00070,00080,00090,000100,000
Deceased Donors Transplants - Living and Deceased Donors Wait List
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WHY THE FIGURES ARE SO
DISSAPOINTING? PROBLEMS:
ORGAN ACQUISITION:
SOCIAL
RELIGIOUS
MOTIVATIONAL
LACK OF KNOWLEDGE
MISBELIEFS
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PROBLEMS WITH IMPLEMENTATION:
IRREGULARITIES IN PURCHASE AND SALE
MALPRACTICE
LACK OF SUFFICIENT ORGANIZATION
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THE TRANSPLANTATION OF HUMAN ORGANS
ACT WAS PASSED IN PARLIAMENT ON 8TH JULY,
1994
IT STATES THAT ORGAN MAY BE TAKEN EITHER:
BRAIN DEAD CADAVER, OR
IMMIEDIATE NON-HEART BEATING CADAVER SUCHAS FAILED CPR/DNR/ON VENTILATOR
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The Act permits transplantation of various cadaveric
organs including the kidneys.
The Act makes commercial trading in organs an offence. The Act makes it mandatory for all institutions
conducting transplants to register with the authority
appointed by the government. All persons associated in
any way with hospitals conducting transplants withoutsuch registration are liable for punishment.
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The human kidney was first successfully
transplanted in Boston in 1946. Transplantation
of the liver followed in 1963 and that of theheart in 1967. Many other organs including the
lung, pancreas and intestines are now
transplanted successfully and such operations
are recognized as established therapy by the
WHO.
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BRAIN DEATHDEFINITION:
IT IS DEFINED AS THE COMPLETEAND IRREVERSIBLE CESSATION
OF ALL BRAIN FUNCTION
INCLUDING THE BRAINSTEM
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DIAGNOSISNEW YORK STATE
DEPARTMENT OF HEALTH
GUIDELINES FOR DETERMINING
BRAIN DEATH
DECEMBER 2005
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Three essential findings in brain death are :
1. Coma
2. Absence of brainstem reflexes
3. Apnea
A patient determined to be brain dead is legally
and clinically dead.
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The diagnosis of brain death is primarily clinical.
No other tests are required if the full clinical
examination, including each of two assessments ofbrain stem reflexes and a single apnea test, areconclusively performed.
In the absence of either complete clinical findingsconsistent with brain death, or confirmatory testsdemonstrating brain death, brain death cannot bediagnosed.
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Responsibilities of Physicians
determining Brain Death
Evaluate the irreversibility and potential causes
of coma Notification
Conduct the first clinical assessment
Observe for any clinical inconsistencies with the
diagnosis Conduct the second clinical assessment
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STEP 1: EVALUATION OF COMA
The determination of brain death requires theidentification of the proximate cause andirreversibility of coma.
SEVERE HEAD INJURY
HYPERTENSIVE ICH
MASSIVE SAH
HYPOXIC ISCHAEMIC INJURY
FULMINANT LIVER FAILURE etc
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The evaluation should include: Clinical or neuro-imaging evidence of an acute CNS
catastrophe that is compatible with the clinical
diagnosis of brain death Exclusion of complicating medical conditions that may
confound clinical assessment like:
1. Severe electrolyte abnormalities
2. Severe acid base disorders
3. Endocrine disturbances like hypoglycemia, myxedema
coma etc
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Exclusion of drug intoxication or
poisoning.
Screening test for drugs may be useful but not fordrugs like fentanyl, lithium, cyanide etc..
The drug level should below the therapeutic range Should be observed at least four times the
elimination half life of the drug
If the particular drug is not known but highsuspicion persists, the patient should be observedfor 48hours to determine whether a change in brain-stem reflexes occurs; if no change is observed, aconfirmatory test should be performed.
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STEP 2: NOTIFICATION The facility must make diligent efforts to notify
the person closest to the patient that the process
for determining brain death is underway. Religious and moral objections should be taken
into account and referred to the concernedhospital staff accordingly
Where family members object to invasiveconfirmatory tests, physicians should rely on theguidance of hospital counsel and the ethicscommittee.
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STEP 3: CLINICAL ASSESSMENT COMA OR UNRESPONSIVENESS:
No cerebral motor response to pain in
all extremities (nail-bed pressure) and
supraorbital pressure
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ABSENCE OF BRAINSTEM RESPONSES: PUPILS:
NO RESPONSE TO BRIGHT LIGHT
SIZE MID POSITION(4MM) TO DILATED (9MM)
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OCULAR MOVEMENT:
No oculocephalic reflex (testing only when no
fracture or instability of the cervical spine or skullbase is apparent)
No deviation of the eyes to irrigation in each ear
with 50 ml of cold water (tympanic membranes
intact; allow 1 minute after injection and at least 5
minutes between testing on each side)
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Facial sensation and facial motor response:
No corneal reflex
No jaw reflex (optional)
No grimacing to deep pressure on nail bed,
supraorbital ridge, or temporomandibular joint
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Pharyngeal and tracheal reflexes:
No response after stimulation of the posterior
pharynx
No cough response to tracheobronchial suctioning
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CONFOUNDING FACTORS: FOLLOWING CONDITIONS:
Severe facial or cervical spine trauma
Preexisting pupillary abnormalities Toxic levels of any sedative drugs, aminoglycosides,
tricyclic antidepressants, anticholinergics,antiepileptic drugs, chemotherapeutic agents, or
neuromuscular blocking agents Sleep apnea or severe pulmonary disease resulting
in chronic retention of CO2
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STEP 4: INTERVAL OBSERVATION PERIOD After the first clinical exam, the patient should be
observed for a defined period of time for clinicalmanifestations that are inconsistent with the diagnosis
of brain death. Most experts agree that a 6 hourobservation period is sufficient and reasonable
When a confirmatory test confirms the diagnosis ofbrain death, the interval between clinical assessmentscan be shortened to 2 hours. If any part of the clinical
determination including the apnea test cannot becompleted, one of the confirmatory tests is required andthe interval may be shortened to 2 hours.
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STEP 5: APNEA TEST BEFORE TESTNG, THE PHYSICIAN SHOULD
ENSURE THE FOLLOWING:
Core temperature 36.5C or 97.7F
Euvolemia. Option: positive fluid balance in the
previous 6 hours
Normal PCO2. Option: arterial PCO2 40 mm Hg
Normal PO2. Option: pre-oxygenation to arterial
PO2 200 mm Hg
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PREOCEDURE: Connect a pulse oximeter and disconnect the
ventilator
Deliver 100% O2, 6 l/min, into the trachea.Option: place a cannula at the level of the carina
Look closely for respiratory movements
(abdominal or chest excursions that produceadequate tidal volumes)
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CONTD. Measure arterial PO2, PCO2, and pH after
approximately 8 minutes and reconnect the ventilator
If respiratory movements are absent and arterial PCO2is 60 mm Hg (option: 20 mm Hg increase in PCO2
over a baseline normal PCO2), the apnea test result is
positive (i.e. it supports the diagnosis of brain death)
If respiratory movements are observed, the apnea testresult is negative (i.e. it does not support the clinical
diagnosis of brain death)
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Connect the ventilator if, during testing, the systolic bloodpressure becomes < 90 mmHg (or below age appropriatethresholds in children less than 18 years of age) or the
pulse oximeter indicates significant oxygen de saturation,or cardiac arrhythmias develop; immediately draw anarterial blood sample and analyze arterial blood gas. IfPCO2 is 60mm Hg or PCO2 increase is 20 mm Hg overbaseline normal PCO2, the apnea test result is positive (it
supports the clinical diagnosis of brain death); if PCO2 is 2 mo to 1 yr old, 24 hr
>1 yr to 2 mo to 1 yr old, 1 confirmatory test
>1 yr to
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Problems in donor management: Hypotension, hypovolemia: CVP 10-14mm hg
Low hemoglobin
Cardiac contractility: MBP > 60mm hg
DI: vasopressin Arrythmias
Sepsis
Aspiration pneumonitis
Hypothermia
Hyperglycemia Coagulopathy
Hormonal deficiencies
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ROUTINE TESTS FOR BRAIN DEAD:
Blood group, tissue matching, LFT/RFT, CBC
After consent HIV, HbsAg, Anti-HCV, CMV, VDRL
Kidney donation HLA typing (arranged by thetransplant coordinator), USG kidney
Liver - +/- USG liver
Heart 12 lead ECG, echocardiogram, if donor > 50
years old, coronary angiogram Lung CXR, ABG, bronchoscopy by lung transplant
surgeons
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CONTRAINDICATIONS FOR ORGAN
DONATION: Age criteria: Donor age is evaluated relative to organ function rather than
in absolute chronologic terms. Cadaveric donors has increased 30%, thenumber of donors older than 65 years of age has increased 535% .Inspite of this trend, however, the ideal donor age is still considered to be10 to 50 years
Infection: Donors with a recent history of infection documented by apositive blood, sputum, or urine culture must receive appropriateantibiotic coverage and have negative culture results to be considered fordonation. The common infections that should be rule out are HIV, syphilis,HBV, HCV and CMV.
Malignancy: Low-grade skin cancers, low-grade solid organ tumors with a
greater than 5-year documented tumor-free interval, and primary braintumors that have not undergone previous surgery usually do not precludeorgan donation
Severe Systemic Disease: The ideal organ donor is relatively young, andis free of and with no history of end-organ disease. Each organ system isevaluated separately. Other than carcinoma (except primary brain tumor),no disease by itself should be considered a contraindication to organ
donation.
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PROBLEMS IN IMPLEMENTATION OF THE
ACT: Misperceptions that hinder donor registration like:
People erroneously believe that a person can recover from brain death
Some people think doctors may not try very hard to save their lives if theyknow about their wish to be a donor
Superstitious belief that the dead body without the vital organs isincomplete and the dead person will not rest in peace
People assume there is a buy-sell black market for organs and tissuetransplant
Many people who wish to donate their organs and tissues are not surethat they will be acceptable as donors. Actually, age or health conditions
should not prevent people from becoming potential donors Socio cultural issues
Lack of awareness
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Is a Person Diagnosed as Brain Dead in a
Comatose State or Dead?
45% 55%
63% 37%
0% 20% 40% 60% 80% 100%
Non-Donor
Donor
Dead
Coma /
Don't Know
Franz, et.al. 1997.
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True or False: People Cannot Recover When
They are Brain Dead
34% 66%
74% 26%
0% 20% 40% 60% 80% 100%
Non-Donor
Donor
True
Not True /
Don't Know
Franz, et.al. 1997.
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Poor Understanding of brain death is associated
with significantly lower rates of consent to
donate organs of the deceased.
Journal of Transplant Coordination
Vol. 7, Number 1, March 1997
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An last but not the least: Malpractice: can involve any level.
There are four thieves:
Intensivist and team with certifying
neurologist
Organ transplant surgeons and physicians
Administrative authority
Ethical committee-to sort out the conflict
arising out of these
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THE MOST TRANSPLANTED ORGANS ARE
KIDNEYS, LIVER AND SOME LESS COMMON ONES
ARE HEART,PANCREASE,GUT ETC IPGMER IS SELECTED AS ONE OF THE ORGAN
TRANSPLANT CENTRES
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HOW TO INCREASE? Increasing organ availability
Directive on quality and safety
Organising transplant systems more efficiently
Mobilization of more centres
Involving voluntary nongovernment
organizations
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And finally.
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And finally:.
Motivating people
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Thank you
Thank you