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8/3/2019 Deceased Donor Transplantation
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DECEASEDDONOR
TRANSPLANTATIO
N
SANJEEV V NAIR
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TERMINOLOGY &DEFINITIONS
In order to be dead enough to bury butalive enough to be a donor, you must beirreversibly brain dead. If its reversible,
youre no longer dead; youre a patient-
David Crippen MD
Living donors: Related Unrelated-
Deceased donors: Brain dead Donor after cardiac
Explicit vs Implicit consent
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Facts and Figures
1962: Drs Murray &Hume; Boston
1967: KEM, MumbaiTHOAct 19941995: 1st successful
multi-organ Tx,Apollo Chennai
Amendment toTHOA passed in Aug2011
~1000 deceased
donor renaltrans lants in India
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What are we doing wrong?
Liver Transpl 15:1443-1447,2009.
Brain death donationassent rate: 19%
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1959 Mollaret & Goulon: le come depasseEducating caregivers about potential donorsWho?
-Pts with irremediable brain injury-Pts with apnea requiring ventilation Accepted fact but variabilities in diagnosis Brainstem death vs Brain death
Diagnosing Brainstemdeath
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Exclusion of confounding conditions: Hypothermia
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Absent brainstem reflexes: Pupillary reflex Dolls eye reflex
Corneal reflex Gag reflex Cough reflex Cold caloric test
Criteria for diagnosis
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Apnea test: Baseline ABG Pre-requisites: Core temp >35oC SBP > 90mmHg
Euvolemia
pCO2 > 40mmHg
pO2 > 200mmHg
Disconnect ventilator: O2 from trachealcannula placed at carina 10L/m
Criteria for Diagnosis
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Apnea test: Observe for resp movts ABG after 8-10mins and reconnect vent
Abort test if SBP15mmHg from
baseline
Test may be indeterminate or negative
Criteria for Diagnosis
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The above tests have to be repeated 2times 6 hours apart.
Indian law does not mandate confirmatorytests to diagnose brainstem death.
Criteria for Diagnosis
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Panel of 4 Doctors: THOA 1994Doctor in charge of hospitalTreating physician
Neurologist/Neurosurgeon*Independent specialist of unspecified
specialty
THOA Amendment*
v Time of death
Who can Certify?
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Non heart beating organ donor:Death determined by demonstrating irreversiblecessation of cardiopulmonary function
The three required elements of the criteria
are simultaneous and irreversible unresponsiveness apnea
absent circulation Observe for >2mins but
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When to start care? Ideally before brain death occurs
Atleast before withdrawal of life support Shift of focus
Why?
Brainstem damage has adverse effects on function ofother organs
Care of potential donor
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Exclusion criteria: Overwhelming sepsis with MODS
Active malignancy HIV, HTLV, Systemic viral infections
Prion disease
Herpetic meningoencephalitis
A localized infection should not preclude organdonation.
Care of potential donor
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Cardiovascular effects:Progressive rostral to caudal ischemia deactivation ofSNS, s.catecholamines, loss of cardiac stimulation cardiac dysfunction and vasodilation ischemiareperfusion injury inflammatory response
Goal:
Achieve euvolemia, maintain BP, optimize CO with theleast amount of vasoactive drug support.
Care of potential donor
Thresholds of cardiovascular stability:MAP >60mmHg
Vasoactive Dx: 10 g/kg/min (DA/DOB)UOP >1.0ML/KG/HR
LVEF 45%NEJM 2004;351:2730-9
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Pulmonary artery catheterization
Vasoactive drugs @ lowest doses to achievetargets
Care of potential donor
Targets:PCW Pressure: 8-
12mmHgCVP: 6-8mmHgCardiac index:2.4l/minUOP: 1.0ml/kg/hrMAP: 60 mmHg
NEJM 2004;351:2730-9
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Hypotension:80% initially, ~ 20%
persist
Multifactorial
Care of potential donor
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Hydration: Crystalloids vs Colloids
Avoid HES Warm to 37oC
Cautions: Unregulated NS use esp in unrecognised DI
Overzealous rehydration
Correction of hyperNa with 5D
Care of potential donor
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Diabetes insipidus: 2o to pituitary destruction
Hypovolemia, hyperosmolarity, electrolyteabnormalities
If UOP 250ml/hr: Vasopressin or Desmopressin
Strict monitoring of labs
Care of the potential donor
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Hormone therapy:Direct injury to HPA, effect of cytokines and
catecholamines
Care of potential donor
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Care of potential donor
NEJM 2004;351:2730-9
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Hypothermia Target temp >35oC
Hyperglycemia: Target 80-150mg/dl
Coagulation abnormalities: Target Hct >30%
INR: 80000/cm3
Care of potential donor
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Evaluation of potentialdonor
General screening:CBP,RFT,SE,RBS,ABG, CUEABO & HLA typingPan c/sHIV, HTLV, CMV, EBV, Hep B& CVDRL/RPR
Heart donor:ECG2DECHCK, TropTCardiac cath
Lungdonor:SerialABGsCXRBronchosc
opy
Liverdonor:LFTLiver BxPT/APTT
Pancreas
donor:Serial bloodglucoseS. Amylase &Lipase
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Request for EYES FIRST - SEE HOW FAMILYREACTS
Family Willing Family Reluctant
Ask For Solid Organs AbandonEfforts
(Heart, Liver, Kidneys ..)
Inform Transplant Co-coordinator
The RamachandraProtocol
Courtesy Dr Sunil Shroff
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Multiple organ recovery
Multidisciplinaryapproach
Incision, explorationand inspection
Mobilization ofindividual organs
In situ perfusion
Removal of organs Closure of incision &handing over ofbody
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2 phases of damage: warm & cold ischemicphases
Mechanisms of injury: Altered integrity of cell membr
Ionic composition of the cell
ATP generation Reperfusion injury
Techniques: Hypothermic preservation: 2 methods Cryopreservation
Vitrification
Organ Presevation
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Preservation solutions
UW solutionOsmolality :320 mmol/kgpH 7.4
Potassium 135 mmol/L
Sodium 35 mmol/LMagnesium 5 mmol/L
Lactobionate 100 mmol/L
Phosphate 25 mmol/L
Sulphate 5 mmol/LRaffinose 30 mmol/L
Adenosine 5 mmol/L
Allopurinol 1 mmol/L
Glutathione 3 mmol/LInsulin 100 U L
Euro-Collinssolution:
potassium 110 mMhos hate 60 mM
Andhra Pradesh Govt
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Andhra Pradesh GovtOrder:
11/11/2009CadaverTransplantationAdvisoryCommittee (CTAC):
1.The PrincipalSecretary, HM&FWDepartment
2. The Director of
Medical Education
3. TheSuperintendent,Osmania MedicalCollege
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Deceased donor transplantation is best wayto address organ shortage
Intensive awareness programmes need ofthe hour
The care of the potential donor issimultaneous care of multiple recipients
Best results with an Organ sharing model likeFORTE, ZTCC, AORTA OR MOHAN
Conclusion
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Thank
you