Celebral Death

Transplantation

ŞERİFE GÜL ŞİMŞEK

Akdeniz üniversitesi tıp fakültesi

hastanesi

CONTENT

Death

Celebral Death

Donor Care

Transplantation

Results

WHAT IS DEATH?

Cardiopulmonary Death

It is the arrest in the cardiac functions

and adiaphoresis.

Celebral Death

Cerebral death is the death of brain cells.

DEFINITION OF DEATH FOR AES

((American Electroencephalograpic

DEATH :

Theirreversible arrest of respiration and

circulation

The irreversible arrest of brain and brain

stem reflexes

Brain blood supply exists but oedema

continues and after a while, circulation

fails and blood suppy stops.

WHAT IS CEREBRAL DEATH?

HISTORY OF CELEBRAL DEATH

1959: Dr. Mallret Le Coma Depasse

1968: Harvard University

1976: Royal Medicine Collage

1981: President’s Commission

1995: Neurology Academy

CEREBRAL DEATH PERSISTENT VEGETATIVE STATE

*connected to

respiratory tract

* loss in 24-36 hours

*Impossible to revive

*Patient continues to

aspirate

*The patients may live

for months or even

years

*The patients may have

the chance of survival in

some cases.

* The patients react to

painful stimulus

DIAGNOSIS OF CEREBRAL

DEATH

*While it seems very related among the

countries, there are some differences

with respect to the diagnosis tests.

*After diagnosed with cerebral death

clinically in Turkey, they run an apnea

test and the diagnosis is confirmed with

another supportive test.

LEGAL REGULATIONS IN

TURKEY

LEGAL REGULATIONS IN

TURKEY

LEGAL REGULATIONS IN

TURKEY

DIAGNOSIS OF CEREBRAL

DEATH-2012

(1)The preconditions required in the diagnosis of cerebral death

a)Specify of the reason of coma

b)Specify of that the brain damage is extensive and irreversible

c)Central body tempereture be ≥32 C

d)No existence of Hypotansive shock chart

e)Ostracising the medicine affects and intoxications that can provide irreversing from coma

f)No existence of metabolic , electrolit and acid-base disorders that will explain the case independently from the brain damage

DIAGNOSIS OF CEREBRAL

DEATH-2012

(2) On the condition that all the conditions are detected in the first paragraph, following points are required for the cerebral death.

A)Deep coma state ( fully responselessness state)

B)Not receiving the brain stem reflexes

1)no pupilla response to the bright light ,central lined and dilated

2) Absence of oculacephalic and vestibula-ocular reflexes

3)Absence of cornea reflexes

4) Absence of pharyngeal and tracheal reflexes

C) No existence of spontenous aspiration effort and positive apnea test.

DIAGNOSIS OF CEREBRAL

DEATH-2012

(3 ) Normothermia, normotension and normovolemia preconditions are provided for running an apnea test.It should be provided that PaCO2 be 35-45 mmHg and PaO2 be over 200 mmHg with the modality of suitable mechanic ventilation under these circumstances.After providing all these conditions, patient should be detached from mechanical aspiratory support unit and intratracheal oxigen should be applied.If there is no spontenous aspiration at the end of the test in spite of the fact that the PaCO2 ≥60 and/or PaCO2 base value rises 20 mmHg or more , apnea test is positive.

(4) In medical situations such as pneumothorax,pneumomediastinum when apnea test is not possible, a supportive test evaluating the arrest in brain circulation determined by the board of doctors is run and cerebral death detection is completed if the test result matches the cerebral death diagnosis.

DIAGNOSIS OF CEREBRAL

DEATH-2012

(5) The following findings do not constitute an impediment for the diagnosis of cerebral death.

a) Reception of deep tendon reflexes

b)Reception of shallow reflexes

c) Presence of Babisnki sign

d)Presence of spinal reflexes and automatisms

e)Presence of perspiration , reddening , high temperature and tachycardia

f)No existence of Diabetes insipidus,

DIAGNOSIS OF CEREBRAL

DEATH-2012 (6) In cases diagnosed with cerebral death ;

a)The clinical view in the first neurologic examination when the patient is diagnosed should continue without change in the second neurologic examination performed after

48 hours for Newborns(younger than 2 months old)

24 hours for ages 2 months old – 1 year old

12 hours for children over 1 year old and adults

24 hours for anoxic cerebral death

b) In cases diagnosed with clinical celebral death , cerebral death diagnosis is confirmed with 2 supportive test in the new born (younger than 2 months old) group , with one laboratory procedure accepted by the board of doctors in the cases who are 2 months old and over.

c) There is no need to wait for the second neurological examination if a brain circulation evaluation test is run and the results of the tests are positive for those who were clinically diagnosed with cerebral death.

Diagnostic Criterias Supportive tests

Tests showing that

the brain circulation

is fully arrested

Transcranial Doppler

Cerebnal

Angiography

*Cerebnal Perfusion

Scintigraphy

Tests showing the

loss of bioelectrical

activity

*EEG

*Alerted Potentials

Beyin

ölümünü

desteklemez

Beyin

ölümünü

destekler

Beyin

ölümünü

destekler

ANJİOGRAFİ

SİNTİGRAFİ

ELEKTROENSEFALOGRAFİ

Attention !!!!

It is obliged that the group of doctors to

diagnose the cerebral death be totally

different from the team performing the

transplantation.

CEREBRAL DEATH and PATIENT

RELATIVE

*The state of patient’s heart continues

beating after the diagnosis of cerebral

death or brain stem death affects the

patient relative but ;

*If the brain stem dies, brain doesn’t

function and heart functions stops in a

short

AFFECT THE DECISION OF

ORGAN DONATION

Patient Relatives may develop such thoughts and feelings as ;

Not enough care to their patients

Monetary gain

Organ trading

Disintegration of body

Anger

As a result of this ,

*They may not trust the hospital.

KatılıyorumFikrim

YokKatılmıyorum

Türkiye’de Doktorlar Beyin Ölümü

Kararını Doğru Verecek Durumdadır

%63,2 %27,6 %9,2

Organlarımı Bağışlarsam Tedavim

Yeterince Yapılmadan veya Tam Ölüm

Gerçekleşmeden Organlarım Alınabilir

%19,8 %28,2 %52,0

Organlarımı Bağışlarsam, Onlar Uygun

Şekilde Kullanılmaz ve Başka Bir İnsana

Fayda Sağlamaz. Yani Vücudum

Boşuna Kesilmiş Olur

%8,0 %25,2 %66,8

Organlarımı Bağışlarsam, Onlar

Gerçekten İhtiyacı Olanlara Değil Çok

Parası Olanlara Takılabilir

%24,8 %32,0 %43,2

Transplantasyon Ekibine Güven

REASONS OF DONOR ORGAN

LOSS

*Prolongation of diagnosis of cerebral

death

*prolongation of documantation

*prolongation of organ extraction

*Disorder in coordination (logistic)

*Physical transportation of organ to the

recipient ( Time Period)

ROLES OF INTENSIVE CARE UNIT

*Diagnosing the cerebral death in the shortest

time possible

*Sustaining the organ protective treatment

*Providing an accurate and healthy

communication between the donor’s family

and transplantation coordination center

*Intensive care is the one who treats patients,

not the one who requires donation

WHAT IS DONOR CARE?

*Donor care is the patient’s care after the

cerebral death

*It is a simultanous care of a few

recipient

MONİTORİZASYONS

ÜR

EK

Lİ

• EKG,

• İnvaziv Arter Basıncı

• SVB

• Pulsoksimetre

• Vücut Isısı (mesane rektalozofajiyal)

SA

AT

LİK

• İdrarÇıkışı

HE

R 4

-6 S

AA

TT

E B

İR

• Kan Şekeri

• Na,CI,K

• Üre,Kreatin

• Hemogram

• KoagulasyonTestleri

• ArterialKangazı

MONİTÖRİZASYON

GÖZLEM HEDEFLERİ

100’ LER KURALI

Kan basıncı~100mmHg

Diürez ~ 100 ml.st-1

PaO2 ~ 100 mmHg

Hb ~ 100 gr.lt-1

Vücut ısısı ~ 36 °C

Glukoz 140-200 mg/dl

pH ~ 7.40

PaCO2 35-45 mmHg

SVB ~ 10 mmHg

OAB >65mmHg

Na+ <160 mEq /lt

CEREBRAL DEATH

PHYSIOLOGICAL CHANGES

* Immunity system disorder

*Aqueous electrolyte balance disorder

*Hypotension

*Arrhythmia

*Endocrine Changes

*Diabetus insipitus

*Hypothermia

COMMUNICATION WITH PATIENT

RELATIVES-1

*The patient family shoud be satisfied with the care and attention to their patients

*We should gain trust of patient relatives through our body language and facial expressions

*We should choose the most ideal family relative to speak to

*We shouldn’t use medical terms.

COMMUNICATION WITH PATIENT

RELATIVES-2

We should give the patient’s relatives

adequate information about the care and

treatment

We should have a clear language about

the death time.

We should allow family to talk and

discharge

We should make them feel like a friend

COMMUNICATION WITH PATIENT

RELATIVES-3

We should provide the entrence of

relatives for the adoptation of family

We should let them take leave for the

last time in intensive care unit

We should listen to the family’s wishes

and requirements and answer their

questions

U-TURN

Aggressive

treatment

Deteriorising

state

Preparing the family

for the negative end

Legal diagnosis

Announcing the death and support to the

family

Life saving

transplantation

Discussing the donation

Supporting the donor

management

TRANSPLANTATION

*It is the changing procedure of

disfunctioning organ with an intact organ

(extracted from live or dead donor)

*Transplantation is the best option for the

treatment of End Term Organ Failure

patients

* It is applied in order to increase the life

quality and duration of patients

HISTORIC ASPECT

Cosmas and Damian

transplating a black

donor’s leg to a white

female

HISTORIC ASPECT

1962 J.Murray Kidney

1963 T.Starzl Liver Cadaver

1963 JD.Hardy Lung (donor)

TURKISH HISTORY

1979 Law of Transplantation

1993 Regulation for Transplantation

Centers

2000 Regulation for Organ and Tissue

Tranplantation

AKDENİZ ÜNİVERCİTY

AKDENİZ ÜNİVERCİTY

PROF. DR ÖMER ÖZKAN

Year Cerebral Death

Medical

Contraindicati

on

Donation Bağış oranı

2000 25 4 6 %24

2001 47 10 16 %43

2002 46 3 22 %49

2003 37 6 18 %61

2004 46 11 11 %34

2005 60 4 21 %34

OUR CEREBRAL DEATH AND DONATION RATES

Year Cerebral Death

Medical

Contraindicati

on

Donation Bağış oranı

2006 35 7 10 %28

2007 17 1 5 %29

2008

2009

2010

2011

4

16

21

23

0

2

0

1

2

4

11

4

%50

%28

%49

%14

OUR CEREBRAL DEATH AND DONATION RATES

Year Cerebral Death Aile kabul Aile red

aile

görüşmeye

gelmedi

2011

2012

2013

2014

28

25

22

35

5

9

11

6

22

15

10

24

1

1

_

2

OUR CEREBRAL DEATH AND DONATION RATES

ORGAN DONATION AND NURSING

*Nurses should support the family from the moment of informing the family of the cerebral death to the moment of decision

*Intensive care nurses should be educated and motivated in cerebral death and donor care

*Positive effect has been stated in the results with the rising information in organ donation

*Nurses shouldn’t forget that they maintain many cares simultanously

CONCLUSION

It is important that we benefit from the limited number of donations effectively with respect to minimise the patient loss

Reports in the press affects the patient relatives, thus the best press communication method should be set up

It is extremely important that we know the process of cerebral death and monitoring

CONCLUSION

It is essential that we have experienced

personnel, high technology and

mechanical support for the nursing care

and treatments

Application of scheduled nursing

initiatives affects the prognosis of donor

positively and increases the quality of

organ

CONCLUSION

*When the patient dies in spite of all the

interventions, organ donation is a

positive result of a tragic situation.

Any word you say may make a

difference between a Yes or No.