Approach to deceased donor transplantation-Donor care

Dr Mayuri TrivediIPGME&R,Kolkata

Institute of Postgraduate Medical Education and Research,Kolkata

Donor action Identification of donor

Screening of donor

Confirmation of donor

Certification of donor

Counseling of family

Maintenance of donor

Concept of Brain stem death

Ancient concept as in hanging or guillotine.

These were anatomical decapitation.

Brain Stem Death in ICU is physiological decapitation

History of brain stem death

1959 – Lyons – France first observed the death of Nervous tissue leading to “coma depasse”.

1968 – Harvard Criteria (EEG was must)

1969 – Minnesota Criteria (No EEG)

1975 – U. K. Code

1994 – THOA 1994 – accepting U. K. Code

Brain stem death Death is scientifically defined as:1. Incapacity to breath spontaneously.2. Incapacity to remain conscious.

When brain stem is irreversibly damaged the cortex no longer has any connection with the rest of the body.

IT IS THE DEATH OF THE PHYSIOLOGICAL CORE OF THE BODY

Hence Brain stem death is death

Brain stem death

Brain death was not discovered for transplantation as the possibility was thought only after 1971

Single largest source of transplantable organs

Diagnosis by clinical bedside means only.

No sophisticated investigation.

3 steps-UK code preconditions exclusions bedside tests

Identification of donor Brain death always occurs in ICU.

Patient must be deeply comatose.

Must be on respirator.

Positive evidence of IC event.

Patients who can be potential donors

Patients with IC bleed Head injury RTA I C vascular thrombosis Depressed fracture Extradural, subdural or intra cerebral haemorrhage Sub arachnoid haemorrhage Brain tumor Brain surgery Anesthesia mishaps Massive brain edema

Where will one suspect a BSD?

The intensive care unit surgeon/physician may suspect brain stem death when the following factors are satisfied:

a. Comatose patient on ventilator in ICU

b. Positive diagnosis of cause of coma (irremediable structural brain damage).

Fulfilling the required preconditions…………

Brain stem death pre conditions

1. Coma lasting for at least 6 hours, or in case of cardiac arrest at least for 24 hrs after restoration of circulation.

2. No abnormal decorticate or decerebrate posture should be present.

3. No epileptic movements should be observed.

4. No spontaneous respiratory movements should be present.

5. All brain stem reflexes should be absent

Brain stem exclusion criterion

1. Absence of coma in the patient.

2. Children below age of 3 years

3. In deeply comatose patients were there is suspicion that coma may be due to:

Depressant drugs Primary Hypothermia(<35 degrees C) Metabolic or endocrine disorders Severe shock Respiratory arrest requiring relaxant or neuromuscular

agent.

4.When diagnosis of the disorder is not fully established.

Bedside test for brain stem reflexes

1. Fixed pupils unresponsive to light.

2. Absent corneal response.

3. Absent oculo-cephalic or doll’s eye movements

4. Absent vestibulo-ocular or caloric response.

5. No motor response within the cranial nerve distribution after adequate stimulation of any body part

6. Absent gag reflex and reflex response to bronchial stimulation by a suction catheter passed down the trachea.

7. Apnea test.

Apnea test Confirmatory test of brain stem death

Performed on the patient on ventilator.

1. Initial pure 100% oxygen given to the patient for a period of 10 mins

2. Followed by 5% CO2 in the oxygen for 5 mins3. Disconnection of the patient from the ventilator for

10mins or more.

However during this period O2 is continued to be delivered at a rate of 6lits/min

Blood collected for blood gases after 10mins when the PaCo2 should have reached >50mmhg with P02 >100mmhg.

Inspite of this if no spontaneous respiration occurs the test is considered positive.

The test has to repeated and confirmed once again after 6-24 hours after the first test.

The patient is then declared ‘Brain Stem Dead’

Practical points for identification

The interval for dose of muscle relaxants becomes longer and longer.

The gag reflex during suction – disappears.

Most of the time the urine bag shows – diluted urine.

Body temperature-poikilothermic

Practical points for identification It is customary to repeat tests to ensure that there

has been no observer error.

Integrity of spinal reflex.

No special investigation like EEG,Angiography,CT scan etc. are required.

BSD is essentially a bedside diagnosis.

Screening of donor All BSD not eligible for organ donation.

Few absolute contraindications.

Potential donor reviewed casewise.

Donor criterion1. Age 2 –70 years.

2. No long standing HT, DM, IV drug abuse, malignancy.

3. No primary organ disease or trauma.

4. Avoid occult sepsis – drowning, burns, more than 7 days indwelling catheter.

5. Negative viral markers.

6. For kidneys – no acute/chronic renal failure, UTI, Creatinine <1.8mg/dl, BUN <20mg/dl, warm ischemia time not > 1hr.

Certification of donor

Brain death committee

Neuro surgeon / neuro physician/Intensivist

Referring RMP

Any specialist from the Institute (pre-selected)

Medical head of the Institution

How confirmation is done?• Confirm the Precondition Exclusion Test for brain stem reflexes Apnea test

All the tests are repeated again between 6-24hrs. Form 8 is filled & signed by all 4 members

Maintainence of potential donor

AIMS of maintainence:

To restore the stability

To maintain or improve the organ functions

To maximise potential for organ donation

To reduce loss of donors prior to organ retrieval

Thus to enhance the successful transplantation

Investigations of the donor

General investigation:1. CBC, BUN, creatinine, electrolytes, ABG, LFT, RBS2. Urine routine, culture3. Blood culture4. Blood group5. X-Ray, ECG, USG6. HBsAg, HIV, HCV, CMV7. 50 cc donor blood for HLA & lymphocyte cross match

with recipient.

Organ specific screening:

Counseling of family To present clear, unambiguous information to the

relatives.

Regular and correct communication.

Care in use of language.

It should be consistent for all multidisciplinary team members.

Councelling to be done to the key person amongst the next to kin of the deceased donor

Who can counsel? Members of the parent unit.

Sister in charge of the parent unit

Medical social workers

Assistant medical officer

Any person authorized by the Institution

Decoupling

The counselor should never make a request to the family about organ donation when the the family has been told of the death of the patient.

Some time must be given to the family to accept the death of their loved one before the topic of organ donation is approached.

Decouple the news of death from the request of organ donation

Stages of Grief Observe the stages of grief in the relatives.

1. Denial2. Anger3. Bargaining4. Depression5. Acceptance

The request for organ donation should be made during the stage of acceptance

Consent Taking the consent of the family.

Consent to be taken from the responsible adult and next to kin of the deceased donor

Consent for organ retrival from relatives is taken on form 6 and form 7.

Maintainence of the donor Standardised , systematic, critical care to increase the quantity & quality of transplantable organs.

Complicated challenge

Optimize physiology prior to retrieval

Minimizes cold ischemia time

Helps more precise co ordination with recipient institution

Maintainence of donor

General care

Organ specific care

General care Clear unambiguous information to relatives.

Change to donor organ goal.

1. Monitor temperature –warming measures if necessary

2. Initiate/ continue enteral feeds3. Tight glycemic control4. Continue antibiotics5. Lung protective ventilation - avoid excess fluid6. Invasive monitoring

CVS ECG monitoring, 12 lead ECG

X-ray chest, arterial line, CVP

Goals :1. Sinus rhythm with pulse rate of 60- 100 beats/min2. CVP <12 mm Hg3. PAP <12 mm Hg4. MAP = 60 – 80 mm Hg5. C I >2.4 l/min /m26. Mixed venous O2 saturation > 60%

Haemodynamic Stability IV fluids 3-5ml/ kg bolus,

Restore euvolume – blood components, albumin, crystalloids. Decrease catecholamine dose

Consideration of vasopressin use

Bradycardia – dobutamine

Arrhythmia – correct electrolyte imbalance, isoproteranol, electrical pacing

Presence of persistent arrythmia –expeditious organ retrieval

Respiratory care Neurogenic pulmonary oedema

X-Ray chest,Peripheral O2 saturation ,ABG

Goals:

1. Peripheral O2 saturation=92 – 95 %2. PEEP 5 cm water3. T V = 6- 8 ml / kg4. Judicious iv fluid, antibiotics5. Corticosteroids6. Diuretics7. Aggressive pulmonary toilet

Renal and electrolytes Hypernatremia, hypokalemia, hypomagnesemia,

hypophosphatemia.

Goals: 1. Urine output 1 – 2 ml / kg/hour2. If urine output > 4ml / kg---D I- vasopressin3. Hypernatraemia – 5% dextrose, plain water RT feeds4. Correct electrolyte levels5. Continue enteral feed

Endocrinology

Polyuria, hyponatraemia

Marginal donors showed adequate organs & improved graft survival with hormonal resuscitation.

GOALS:

1. Treat D I2. Tight glycaemic control-Insulin 1 unit/ hr @ titrate3. Vasopressin 0.5 – 2 ml/ kg / hr4. T 3 - 4 micro gm bolus, 4 mi gm/ hr infusion5. Methylprednisolone

Coagulopathy Thrombocytopenia, hypothermia, release of

plasminogen activator.

Goal:

1. Hb>10 gm %2. INR<23. Platelet count > 50,000/4. Treat only if bleeding

Complications in the donor Hypotension

Cardiac arrhythmias

Electrolyte disturbance

Alteration in pulmonary function

Diabetes insipidus

Hyperglycaemia

Hypothermia

Coagulopathy

Thank you