= Brain dead and organ

donation

Dr Ajeet singh

Altered states of consciousness-Sleep-normal state of unconsciousness with

prompt reversiblity on thershold sensory stimulus and maintin wakefulness following recovery.

Depressed consciousness-suprathreshold required and wakefulness cannot be maintained unless the stimulation continued

Stuporous-arousable only with vigorous noxious stimuli,while awake cant demonstrate normal content of consciousness

Coma- A state of unconsciousness from which the patient cannot be aroused even with stimulation such as pressure on the supraorbital nerve, temporomandibular angle of the mandible, sternum, or nailbed

Locked-in state-state of paralysis without loss of consciousness.patient completely paralysed except for muslces subserved by midbrain structure[e.g.vertical eye movemnt and blinking]

Persistent vegetative state- -also known as cerebral death. -normal sleep-wake cycles. -no response to environmental stimuli. -diffuse brain injury with preservation of

brain stem function.

Brain death-Refers to determination of physical death by

brain based,rather than cardio-pulmonary based criterias.

Its is defined as a irreversible destruction of the brain,with the resulting total absence of all cortical and brainstem functions,although spinal cord refleves may remain

It should not be confused with severe but incomplete brain damage or with vegetative state

in which some function of vital brain centers still remains,and decisions regarding on going life support clearly depend on the wishes of the patient or his/her proxy.

Brain death should be suspected in any patient rendered deeply comatose and apneic from a profound or diffuse brain insult

Pathogenesis of brain death- Direct cellular injury potentiated by a vicious cycle of failure of blood flow, hypoxia, cerebral acidosis and endothelial swelling to brain edema,aseptic necrosis and herniation of the brain.

When the lower brain herniates through the skull onto the brainstem and pons, cutting off the blood supply to the brain.

Prerequisites for testing of brain death - Clinical or neuro-imaging evidence

of acute catastrophe leading to a diagnosisdiagnosis of brain death.

-No severe electrolyte , acid base, endocrine disturbances

-no drug intoxication - core temperature>90 degree

Farenheit

Brain Death Diagnosis made by the separate examination of 2 doctors: 1. One of the doctors must be a specialist recognized

by the appropriate College as having demonstrated skill and knowledge in the performance of brain death certification. This should usually be an intensivist, critical care physician, neurologist or neurosurgeon .

2. The other medical practitioner should preferably be of the same qualification as described in 1. but should be at least 6 years after registration & possess the skill and knowledge in the performance of brain death certification .

Criteria for CNS Determination of Death (Brain Death)Irreversible comaAbsence of cortical functionAbsence of brainstem functionApnea2 examinations with interval according to

patient’s age

Irreversible ComaKnown etiology and or reversible causes ruled

outMust have an absence of

Hypothermia (>32.50C)Neuromuscular blockadeShock or significant hemodynamic instabilitySignificant levels of sedativesSevere metabolic distrubancePoisoningEndocrine abnormalities

Absence of cortical functions-No spontaneous movement, eye opening, or

movement or response after auditory, verbal, or visual commands

Cerebral motor response to painSupraorbital ridge, the nail beds,

trapeziusMotor responses may occur

spontaneously during apnea testing (spinal reflexes)

Spinal arcs are intact!

Absence of brain stem function-1)Pupillary reflex

2)Corneal reflex

3)Gag reflex

4)Cough reflex

5)Oculocephalic reflex (doll’s eye reflex)

6)Oculovestibular reflex (caloric reflex)

7)No integrated motor response to pain

8)Apnea testing

Pupils-Midsize (4-6 mm), but may be totally dilatedAbsent pupillary light reflex

Although drugs can influence pupillary size, the light reflex remains intact only in the absence of brain death

IV atropine does not markedly affect response

Paralytics do not affect pupillary sizeTopical administration of drugs and eye

trauma may influence pupillary size and reactivity

Pupils fixed and unresponsive to light

•Pre-existing ocular anatomic abnormalities may also confound pupillary assessment in brain death

Corneal reflex-Corneal reflexes are absent in brain death

Corneal reflexes - tested by using a cotton-tipped swab

.

There is no blink response to direct corneal stimulation.

Gag and Cough reflex-Both gag and cough reflexes are absent in

patients with brain deathGag reflex can be evaluated by

stimulating the posterior pharynx with a tongue blade.

Cough reflex can be tested by using ETT suctioning, past end of ETT

There is no gag or cough reflex.

Oculocephalic reflexRapidly turn the head 90° on both sides

Normal response = deviation of the eyes to the opposite side of head turning

Brain death = oculocephalic reflexes are absent (no Doll’s eyes) = no eye movement in response to head movement

Vestibularocular reflexNo eye movements within 3 mints after

irrigating each tympanic membrane (if intact) sequentially with 50 ml ice water for 30 to 45 seconds while the head of the supine patient is elevated 30 degrees

Retained vestibulocular reflex

Eyes do not deviate away cold water instilled into an auditory canal.

Cold calorics interpretationNot comatose

Nystagmus; both eyes slow toward cold, fast to midline

Coma with intact brainstemBoth eyes tonically deviate away cold water

No eye movement Brainstem injury / death

Movement only of eye on side of stimulus Internuclear ophthalmoplegia Suggests brainstem structural lesion

Apnea test-Prerequisites:- -Core temp 36.5°C

- SBP >90 mm Hg

-No electrolyte imbalance

-Arterial pH 7.35-7.45 and pCO2 35-45 mm Hg

-Preoxygenation with 100% FiO2 for 10 to 15 mints

-Euvolemia

-

Give 100% O2 at 8-10 Lpm (through a

catheter) at the level of carina immediately

after disconnecting the ventilator.

Observe closely for respiratory movements

(abd and chest excursions)

Measure pO2, pCO2 and pH after apprx. 3-5

mints and reconnect the ventilator

If respiratory movements are absent and final

ABG shows-

-pH<7.30

-pCO2 increases from 40 up to 60 mm Hg or

20 mm Hg from pretest baseline then,

Apnea has been demonstrated, supporting

the diagnosis of brain death criteria.

If the above criteria are not met and

apnea test is negative-Confirmatory tests

are required

Pitfalls in clinical brain death testing-Hypotension, shock-Fluid resuscitation,

pressor agentsHypothermia-Warmed fluids, ventilatory

warmerIntoxication or drug overdose-Serum drug

levels and toxicology screens, or increase waiting time between brain-death examinations

Damage to the base of the pons, typically from a basilar artery embolism, can result in the development of the so-called locked-in syndrome, where the patient loses all voluntary movements with the exception of blinking and vertical eye movements.

GBS can involve all peripheral and cranial nerves and mimic brain death.

Neuromuscular and sedative drugs, which can interfere with elicitation of motor responses-Discontinue muscle relaxants and mood- or consciousness-altering medications, increase waiting time between brain-death examinations

Pupillary fixation, which may be caused by anticholinergic drugs, neuromuscular blocking agents, or preexisting disease

Oculovestibular reflexes diminished after prior use of ototoxic drugs (e.g., aminoglycosides, loop diuretics, vancomycin) or agents with suppressive side effects on the vestibular system (e.g., TCADs, anticonvulsants and barbiturates) or due to preexisting disease or any foreign body in EAC[e.g blood,wax]

Obtain careful medication history and patient history

Doll's eyes examination should not be performed if the cervical spine is unstable.

Chronic obstructive pulmonary disease or sleep apnea may result in elevated baseline CO2 retention, confounding the apnea examination

Certain spinal reflexes including spontaneous movements of the torso, arms, or toes should be ignored if the clinical brain stem examination is consistent with brain death or confirmatory examinations are positive.

Conformatory testing-Used as a supportive in those patients in

whom specific components of clinical testing cannot be reliably performed or evaluated.

Confirmatory test findings are listed in the order of the most sensitive test first –

1)Conventional angiography. No intracerebral filling at the level of the carotid bifurcation or circle of Willis .

2) Electroencephalography- Absence of any cerebral activity during at least 30 min of recording

3) Transcranial Doppler ultrasound -should show absent diastolic flow with small early systolic peaks.

4) SPECT using Technetium brain scan- No uptake of isotope in the brain parenchyma

5)Somatosensory evoked potentials-Bilateral absence of response with median nerve stimulation confirms brain death.

Blood flow is absent in the cranial vault when examined by cerebral scintigraphy (shown) or angiography.

SPECT using Technetium brain scan-

Cerebral perfusion scan

TCD and Brain death 2 examinations at an interval of 30 minutes

if shows cerebral circulatory arrestSmall systolic peaks in early systole

without diastolic flow in any of MCA,ICA and any artery of anterior and posterior circulation.

Intracranial examination should be confirmed with extracranial recording

Lack of flow in basal arteries can be false positive

TCD and Brain DeathTCD can be a confirmatory tool for

diagnosing brain death. The validity of TCD diagnosed brain death depends on the time lapse between brain death and the performance of TCD. TCD of both the basilar artery and the MCAs showed significant consistency in brain death diagnosis.

The specificity of TCD is close to 100%. The sensitivity of TCD is 91- 100% .

Kids over 1 year oldAbsence of all brain and brainstem

functionComatose: no purposeful response to any

stimulusBrainstem function is absent when:

Pupils are mid-position and do not react to light Eyes does not blink when touched (corneal reflex) Eyes do not rotate in the socket when the head is

moved from side to side (oculocephalic reflex). Eyes do not move when ice water is placed in the ear

canal (oculovestibular reflex) Child does not cough or gag when a suction tube is

placed deep into the breathing tube Child does not breathe when taken off the ventilator

Repeat in ~6 hours

Children under 1 yearNecessary to repeat the clinical examination

after an ‘appropriate’ observation period has passed

Age 7 days to 2 months Two examinations 48 hours apart and one EEG Age 2 months-1 year Two examinations 24 hours apart and one EEG

or perfusion scan

Confirmatory EEG unless it is determined that there is no blood flow to the brain

Organ donation-Organ donation has been one of the greatest

advances of modern science that has resulted in many patients getting a renewed lease of life.

It means that a person pledges during his lifetime that after death, organs from his/her body can be used for transplantation to help terminally ill patients and giving them a new lease of life.

Types of organ donation-1)living related- donor remains alive and

donates a renewable tissue, cell, or fluid (e.g. blood, skin), or donates an organ or part of an organ ((primarily single kidney donation, partial donation of liver, small bowel)

2)living non related(brain death and cadeveric donor)-In brain- dead organs are kept viable by ventilators or other mechanical mechanisms until they can be excised for transplantation.

Commonly donated organs from brain death are –kidney ,cornea ,heart, lung, liver, pancreas, skin.

Cadeveric donar-Tissues may be recovered from donors up to 24 hours past the cessation of heartbeat.

Cadeveric donar are major source of organs and tissues.

Almost everywhere organ donation is voluntary- tTwo voluntary systems include –

1.Opt In - Where the donor gives consent

2.Opt Out - Where anyone who has not refused is considered as a donor

In India we have the Opt in system, while many western countries practice the opt out system

Worldwide, the demand for organs is growing, as the supply of organs and tissues for transplantation has not kept pace with demand.

In the UK only approximately 900 individuals become organ donors each year, while over 6000 people are waiting for suitable organs.

The reasons for the shortage of organ donation are-

1) Misperceptions2) Superstitious belief 3) Fear, ignorance and misunderstanding

4) Legal aspects

5) Media reports on scandals involving organ rackets

To attempt to overcome the uncontrollable trade in organs the Indian parliament implement transplantation of human organ act in 1994.

The essence of this legislation was threefold:1. To accept brain death as also a definition of

death. 2. To stop commercial dealing in organs 3. To define the first relative (father, mother, brother, sister, son, daughter and wife) who could donate organs without permission from the government

Organ transplant law does not allow exchange of money between the donor and the recipient.

Unrelated donor has to file an affidavit in the court of a magistrate stating that the organ is being donated out of affection.

If it is found that the money has been exchanged in the process then both the recipient as well as the donor are considered as prime offenders under the law.

Current status of organ donation act-It is proposed to amend the THO Act by

changing its name from ‘Transplantation of Human Organs Act’ to ‘Transplantation of Human Organs & Tissues Act’

Law will broaden the definition of ‘near relative’ to include grandparents, grandchildren, uncles and aunts. Also, not-so-close relatives who have stayed with the patient can donate organs, provided there is no commercial dealing.

Also recommended that every hospital should make it mandatory for the ICU/ Treating Medical Staff to request relatives of brain dead patients for organ donation.

To ask each patient on or before admission to a hospital as soon as thereafter as to whether the person has pledged a donation of organ or tissue.

To prohibit grant of permission by the authorization committee for organ transplantation where the recipient is a foreign national and the donor is an Indian national.

“No cells, tissues or organs should be removed from the body of a living minor for the purpose of transplantation other than narrow exceptions allowed under national law.(eg.kidney transplantation betw identical twins)

To have a post of ‘transplant coordinator’ in ICU’s of hospitals and centers with transplant activity.

Enhancement of Penalties-the term “five years” years shall be substituted by the term “ten years” and the term “ten thousand rupees” shall be substituted by term“five lakh rupees”

Organ donation algorithm-Hospital Organ Donation Registry

(HODR)coordinates the process of cadaver organ donation

During lifetime, a person can pledge for organ donation by filling up a donor form in the presence of two witnesses, one of who shall be a near relative and send the same to HODR

The organ donor form could be obtained from HODR either personally or through mail

After receiving the filled in form, HODR provides the donor with an organ donor card bearing registration number on it.

It is suggested to keep the donor card in your pocket and share your decision with your near and dear ones.  

If a person expires without registration, the family members can donate his/her organs.  For this they need to sign a consent form, which is provided at that time.  

Once, the relatives give a written consent, organs are harvested within a few hours.  

The family of the donor does not face any difficulty or extra burden upon them.

The transplant coordination team carries out the entire process till the relatives receive the body of the deceased.

Contraindications to donationHepatitis B or Hepatitis C may be

acceptable for HBV/C recipients

IV drug abuse or practicing homosexual

Untreated bacterial, fungal or viral

infection (treated infection may be

considered)

Malignancies other than primary brain

tumours and nonmelanoma skin cancers

ORGAN RETRIEVAL BANKING ORGANISATION (ORBO)

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

ORGAN DONOR FORM Date Regd. No. I, ……………………………………………………………………son / daughter / wife of ………………………………………………………………………...in the hope that I may help other hereby make this anatomical gift, if medically acceptable, to take effect upon my brain death. I hereby with to donate the following organs. Hearts, Lungs, Kidneys, Liver, Corneas & ……………………………………………….……………….………………………………… ………………………………………………………………………………………………….. My blood group is ………………………………… Special wishes, if any ……………………………………………………………………………………….………… ………………………………………………………………………………………………… Signed by the donor in the presence of two witnesses: Signature of donor with date Date of birth of donor Address of the donor ……………………………………………………………………………………….. …………………………………………………………………… Telephone No.………………………..

Witness Witness