Brain Death Certification Cadaver Transplantation : Innovation and Challenges JMA Bruno Mascarenhas

8/9/2019 Brain Death Certification Cadaver Transplantation : Innovation and Challenges JMA Bruno Mascarenhas

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Innovations and Challenges inInnovations and Challenges inDeceased Donor Transplants inDeceased Donor Transplants in

Government General Hospital,Government General Hospital,Madras Medical College, ChennaiMadras Medical College, Chennai

Sundar.V, Deiveegan.K, Arunkumar.R, Ramesh.V.G,Sundar.V, Deiveegan.K, Arunkumar.R, Ramesh.V.G,Maheswar.K, Sekar.C,Maheswar.K, Sekar.C, BrunoBruno--Mascarenhas.JMAMascarenhas.JMA

19thAnnual Conference of Neurotrauma Society of India20th to 22ndAugust 2010. Chennai.


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20-Aug-2010 Neurotrauma 2010 2


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How much does IndiaHow much does India

lag?lag?As one can see here,Indias economicprosperity is not as

far behind othercountries (inpurchasing powerparity terms) as itsrecord is in cadaverdonation one

twentieth that ofThailand.


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Reasons for Low Number ofReasons for Low Number of

Deceased Donor TransplantsDeceased Donor Transplants Before 2008Before 2008

Even when the medical conditionEven when the medical condition

(clinical and medical criteria have(clinical and medical criteria havebeen met for) of a patient hasbeen met for) of a patient hasreached a brain death stage, brainreached a brain death stage, braindeath certification was not donedeath certification was not done

Lack proper mechanism forLack proper mechanism foridentifying the recipientsidentifying the recipients


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Brain Death not beingBrain Death not being

certifiedcertified ReasonsReasons

Brain death is not declared when it has occurred.Brain death is not declared when it has occurred. Doubts in medical circles on the authority by whichDoubts in medical circles on the authority by which

doctors may declare "Brain Death" whenever required.doctors may declare "Brain Death" whenever required.

Certain Grey areas of THOA 1994Certain Grey areas of THOA 1994 Procedural Difficulties / Lack of Protocol / Who to doProcedural Difficulties / Lack of Protocol / Who to do

whatwhat

Issues of not certifying brain deathIssues of not certifying brain death Several patients who are brain dead were kept on lifeSeveral patients who are brain dead were kept on life

support systems that could have been utilized by othersupport systems that could have been utilized by other

patients who are not in a similar state and have a betterpatients who are not in a similar state and have a betterchance of recovery.chance of recovery. Prolonged anxiety for all family members and friends ofProlonged anxiety for all family members and friends of

the brain dead patient.the brain dead patient.


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Lack of proper mechanismLack of proper mechanism

for identifying the recipientsfor identifying the recipientsAll Hospitals treating head injuryAll Hospitals treating head injury

patients were not doing Kidney, Liverpatients were not doing Kidney, Liver

or Heart Transplantsor Heart Transplants Many Hospitals doing Liver, HeartMany Hospitals doing Liver, Heart

Transplants do not admit Head InjuryTransplants do not admit Head InjuryPatients !!Patients !!

Lack of Co ordination MechanismLack of Co ordination Mechanism


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Initiatives in Tamil NaduInitiatives in Tamil Nadu

Initiatives for Certification of Brain DeathInitiatives for Certification of Brain Death

Initiatives for forming Tamil Nadu NetworkInitiatives for forming Tamil Nadu Networkfor Organ Sharingfor Organ Sharing

http://www.dmrhs.org/tnos/http://www.dmrhs.org/tnos/ andandmaintaining a common online waitlist ( atmaintaining a common online waitlist ( at

http://tnos.org/http://tnos.org/ )) for all potentialfor all potential

recipients in all hospitals who choose torecipients in all hospitals who choose tocome under this network in Tamil Naducome under this network in Tamil Naduand allotment of organs by the Networkand allotment of organs by the Network


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A series of GOs (Government Orders) by theA series of GOs (Government Orders) by theGovernment of Tamil Nadu (available atGovernment of Tamil Nadu (available athttp://www.dmrhs.org/tnos/ordershttp://www.dmrhs.org/tnos/orders--ofof--tntn--govtgovt))

E

stablishing clear guidelines for brain deathE

stablishing clear guidelines for brain deathcertification and organ sharingcertification and organ sharing

Creation of awareness among the neurosurgeonsCreation of awareness among the neurosurgeons

Appointment of Transplant co ordinators by a NGOAppointment of Transplant co ordinators by a NGOunder Public Private Partnership for counseling theunder Public Private Partnership for counseling the

relativesrelatives Early Postmortem of the deceasedEarly Postmortem of the deceased

Free / subsidized transportation of the dead bodyFree / subsidized transportation of the dead bodyto the home.to the home.

Initiatives for CertifyingInitiatives for Certifying

Brain DeathBrain Death


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Procedure for declaration ofProcedure for declaration of

brain deathbrain death G.O. (Ms) No. 75 Dated : 03.03.2008G.O. (Ms) No. 75 Dated : 03.03.2008

Health and Family Welfare (Z1)Health and Family Welfare (Z1)DepartmentDepartment

Form 8 of the THO Act and Rules as foundForm 8 of the THO Act and Rules as foundin the Annexurein the Annexure--I to this order areI to this order areprescribed as the brain death certificationprescribed as the brain death certificationformat to be utilised for any given situationformat to be utilised for any given situationrequiring certification that a person is deadrequiring certification that a person is dead

on account of permanent and irreversibleon account of permanent and irreversiblecessation of all functions of the brain stem.cessation of all functions of the brain stem. The tests prescribed therein and theThe tests prescribed therein and the

findings required shall remain the same.findings required shall remain the same.


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Who, When, What, WhyWho, When, What, Why

According to Form 8 of the said ActAccording to Form 8 of the said Actand Rules, when such certification isand Rules, when such certification is

required, there shall berequired, there shall be two medicaltwo medicalexaminationsexaminations conducted by aconducted by a teamteamof doctorsof doctors after aafter a minimumminimuminterval of six hoursinterval of six hours and theand the

findings made based on the testsfindings made based on the testsprescribed therein.prescribed therein.


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How ??How ??

One aspect of the above formOne aspect of the above formrequires further clarification and thisrequires further clarification and this

is provided inis provided inAnnexureAnnexure--II of thisII of thisorder as Guidelines for Apnoeaorder as Guidelines for ApnoeaTestsTests


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Transplant co ordinatorsTransplant co ordinators

Appointment of Transplant co ordinators by a NGOAppointment of Transplant co ordinators by a NGOunder Public Private Partnershipunder Public Private Partnership

Counseling the relativesCounseling the relatives Informing Transplant Co Ordinators of OtherInforming Transplant Co Ordinators of Other

Hospitals Involved and keeping in touchHospitals Involved and keeping in touch Arranging a Room in the Hospital for the bereavedArranging a Room in the Hospital for the bereaved

familyfamily Co Ordinating with the RMO Office, Matron Office,Co Ordinating with the RMO Office, Matron Office,

Theatre, Labs etc for arranging surgeries at shortTheatre, Labs etc for arranging surgeries at short

notice even at odd hoursnotice even at odd hours Arranging Early PostmortemArranging Early Postmortem Free / subsidized transportation of the dead bodyFree / subsidized transportation of the dead body

to the home.to the home.


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20-Aug-2010Neurotrauma 2010

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First CertificationFirst Certification

2626thth Oct 2009Oct 2009

First Brain Death CertificationFirst Brain Death Certification

following the GOs issuedfollowing the GOs issued Kidneys were transplantedKidneys were transplanted

One at GGHOne at GGH

One at Stanley Medical College HospitalOne at Stanley Medical College Hospital


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Nov 2009 : 2 DonorsNov 2009 : 2 Donors

Dec 2009 : 4 DonorsDec 2009 : 4 Donors

Feb 2010 : 3 DonorsFeb 2010 : 3 Donors Of these 2 Donors happened on theOf these 2 Donors happened on the

same day and 3 kidneys were used insame day and 3 kidneys were used inGGH and 1 for Stanley.GGH and 1 for Stanley.

3 Kidney Transplants were done on3 Kidney Transplants were done onthe same day in GGHthe same day in GGH (when the 175(when the 175thth

Year Celebrations were going on)Year Celebrations were going on)


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Mar 2010 : 3 DonorsMar 2010 : 3 Donors This includes a tragic, yet heartwarmingThis includes a tragic, yet heartwarming

story of a 10 year old girl who Sustainedstory of a 10 year old girl who Sustained

head injury following RTAhead injury following RTA Childs father was undergoing Dialysis atChilds father was undergoing Dialysis at

GGHGGH

As the father was not the number 1 inAs the father was not the number 1 inwaiting list, permission of Governmentwaiting list, permission of Governmentwas obtained As a special case and thewas obtained As a special case and thechilds kidneys were transplanted to thechilds kidneys were transplanted to thefatherfather


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April 2010 : 4 Donors in GGH and 2 inApril 2010 : 4 Donors in GGH and 2 inStanleyStanley

June 2010 : 1 in GGH and 2 inJune 2010 : 1 in GGH and 2 inStanleyStanley

July 2010 : 4 in GGHJuly 2010 : 4 in GGH

GGH did 2 heart transplantsGGH did 2 heart transplants


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Transplant Done in GovernmentTransplant Done in Government

Setup (Oct 2008 to Jul 2010)Setup (Oct 2008 to Jul 2010) Kidneys (72)Kidneys (72)

GGH :GGH :

22 : From GGH Donors22 : From GGH Donors 19 : From Donors from other hospitals19 : From Donors from other hospitals

Stanley Medical College HospitalStanley Medical College Hospital

05 : From Stanley Medical College Donors05 : From Stanley Medical College Donors

26 : From Donors from other hospitals26 : From Donors from other hospitals


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Transplant Done in GovernmentTransplant Done in Government

Setup (Oct 2008 to Jul 2010)Setup (Oct 2008 to Jul 2010) Livers (11)Livers (11)

Stanley Medical College HospitalStanley Medical College Hospital

3 : From Stanley Medical College Donors3 : From Stanley Medical College Donors 8 : From Donors from other hospitals8 : From Donors from other hospitals

Heart (4)Heart (4)

Government General HospitalGovernment General Hospital

2 : From Government Hospital Donors2 : From Government Hospital Donors

2 : From Donors from other hospitals2 : From Donors from other hospitals


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In a Nut ShellIn a Nut Shell

KidneysKidneys LiversLivers Heart HeartGGH ContributionGGH Contribution 4242 1818 0505Used within GGHUsed within GGH

2222 0000 0202Given to StanleyGiven to Stanley 1515 0606 0000Given to Govt HospitalsGiven to Govt Hospitals 3737 0606 0202Government Hospitals toGovernment Hospitals to

Private Hospitals in NetworkPrivate Hospitals in Network

0505 1212 0303

Private Hospitals toPrivate Hospitals toGovernment Hospitals inGovernment Hospitals inNetworkNetwork

2121 0202 0202

Got 16Got 16 Given 10Given 10 Given 01Given 01


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Tamil NaduTamil Nadu (Oct 2008 to Jul 2010)(Oct 2008 to Jul 2010)

Donors From TN 111

Heart 25

Lung 02

Liver 98Kidney 213

Total Major organs 338

Heart Valve 122Cornea 174

Skin 1

Total Organs 635


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Increasing trend in TNIncreasing trend in TN


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Because of the Proactive action byBecause of the Proactive action bythe Government of Tamil Nadu,the Government of Tamil Nadu,

Cadaver Transplant Programme hasCadaver Transplant Programme hastaken a big leap forward in Chennaitaken a big leap forward in Chennaiand also in the rest of Tamil Naduand also in the rest of Tamil Nadu

This is aThis is a prototype model whichprototype model whichmay be followed by other statesmay be followed by other states

/ institutes./ institutes.


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Relevant Government Orders areRelevant Government Orders areavailable atavailable at

http://www.dmrhs.org/tnoshttp://www.dmrhs.org/tnos whichwhichcan be used as reference to startcan be used as reference to startsimilar programmesimilar programme

The Data Base is built with openThe Data Base is built with opensource productssource products


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Take Home MessageTake Home Message

Remember thatRemember thatthere is Life eventhere is Life evenafter Brain Deathafter Brain Death

For the patient who can be given thatFor the patient who can be given thatlife support withdrawn from brain deathlife support withdrawn from brain deathpatientpatient

For the RecipientsFor the Recipients


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Declare Brain Death, Save fiveDeclare Brain Death, Save five

ByBy ProperProper andand TimelyTimely CertificationCertificationof Brain death, we are giving life toof Brain death, we are giving life to

(1) PatientWho is going to use this(1) PatientWho is going to use thislife support systemlife support system

(2), (3) Two Patients with End Stage(2), (3) Two Patients with End StageRenal DiseasesRenal Diseases

(4) One Patient with(4) One Patient with Liver FailureLiver Failure (5) One Patient in need of(5) One Patient in need ofHeartHeart

transplantationtransplantation


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AcknowledgementsAcknowledgements

We gratefully acknowledgeWe gratefully acknowledge

The contributions made by all theThe contributions made by all the

patientspatients The relatives who took the noble,The relatives who took the noble,

valiant, gallant decision of donatingvaliant, gallant decision of donating

the organs of the deceasedthe organs of the deceased


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AcknowledgementsAcknowledgements

We gratefully acknowledgeWe gratefully acknowledge

Government of Tamil NaduGovernment of Tamil Nadu

Thiru.V.K.Subburaj IAS,Thiru.V.K.Subburaj IAS, PrincipalPrincipalSecretary, Health and Family Welfare, GovernmentSecretary, Health and Family Welfare, Governmentof Tamil Naduof Tamil Nadu

Thiru.P.W.C.Davidar IAS,Thiru.P.W.C.Davidar IAS, PrincipalPrincipalSecretary, Information Technology and PrincipalSecretary, Information Technology and PrincipalSecretary i/c Energy, Government of Tamil NaduSecretary i/c Energy, Government of Tamil Nadu


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Brain Death Certification Cadaver Transplantation : Innovation and Challenges JMA Bruno Mascarenhas