Brain Death-Organ Doner Care Q

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Outline the principles involved in the care of the organ donor.

Study Group Answer

Early identification of potential organ donor heart beating, whole brain/ brainstem dead donor or non-heart beating donors

Recognition and confirmation of clinical brain death exclude reversible medical conditions (metabolic, drugs, endocrine, hypothermia ) clinical (coma, absent BS reflex, +apnoea test) other investigations ( Technetium scan, Cerebral angiography, TCD, EEG, SEP )

Obtaining consent from the family involve active participation of intensivist,donor coordinator and donor family

establishing early rapport with family and providing medical information donor family management, emotional management and family support

Maintenance of extra-cerebral physiologic stability aim to maintain organ perfusion and prevention and treatment of physiological derangement

caused by brain death. either Supportive and Specific measures

1. SUPPORTIVE measures to maintain normal physiologic parametersCirculatory management -adequate organ perfusion pressure eg. MAP >70, HR35-36.5C

2.SPECIFIC measures to treat the complications of brain death

Cardiovascular complications :Autonomic storm -consider BBlockerHypotension -volume loading, inotropes if unresponsive consider steroids

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Arrythmias - correct underlying cause eg. electrolytes abn, hypotensionDiabetes Insipidus (high plasma osmol, low urine Na/osmol, high UO) - IV D5W, IV

DesmopressinHypothermia - blankets, warm IV fluids, humidified inspired airHypothyroidism - either real hypothyroidism or sick euthyroid syndromeHyperglycemia sec to osmotic diuresis - fluids and electrolytes correction, insulin IV

Donor screening and Organ Retrieval in theatre with proper consent activation of harvest team and/or transplant team

Aftercare of donor family follow up, feedback and continued family support

Outline the principles involved in the care of the organ donor.Principles include:

Early identification

Discuss with transplant coordinatorEstablish family rapport early Diagnose brain death correctlyEstablish presence of condition causing brain death. Exclude confounders

(sedation, paralysis, endocrine, metabolic, temperature) - use vascular

imaging if necessary. Satisfy legal criteria for organ donors relevant to

the jurisdiction

Non-coercive sensitive family discussion re opportunity for donation

High availability. Answer questions

Initiate tissue typing, viral screen, further organ function tests

Maintain extra-cerebral physiological stability Ventilatory -

oxygenation, normocapnia, lung protective strategies. Circulatory -

monitoring, filling, noradrenaline, vasopressin. Normothermia. Diagnose

and treat diabetes insipidus (DDAVP/vasopressin, free water). Steroid

and T3 replacement

Facilitate family time at bedside Ensure aftercare of donor familyTransplant co-ordinator. Limited anonymous information available.

Further family meeting offered Few candidates considered that the donor

could be either living related, or a non-beating heart donor.

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Hypotension and hemodynamic instability

Neurogenic shock

- Result of defective vasomotor control and subsequent loss

progressive loss of SVR

Hypovolemic shock

- Therapeutic dehydration for cerebral edema

- Hemorrhage

- Diabetes insipidus with massive diuresis

- Osmotic diuresis due to hyperglycemia

Cardiogenic shock

- Hypothermic depression of myocardial contractility

- Left ventricular dysfunction

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Brain Death.

Irreversible cessation of all functions of the brain.

Definition applies in all states and territories except WA and NZ, which have no

legal definition of death.

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Brain death can be diagnosed by any medical practitioner but for the purposes of

organ donation this must be done by 2 medical practitioners each of more than 5

years post graduation, one of whom must be a designated specialist in that

hospital. They should not be caring for the potential recipient, be the designated

officer who will authorise transplant or be the doctor who will remove tissue to

be transplanted.

There is no statute about a minimum time period or the time between

examinations but it is recommended the patient be observed for 4 hours to have

fixed pupils and no respiratory function and the 2 hours elapse between tests.

Diagnosis may be done clinically or by diagnostic investigation.

Preconditions to clinical testing:

Cause of Coma must be known and expected to cause brain death.

Cause must not be due to drugs or toxins

Metabolic causes have been excluded (electrolyte and endocrine)

Normal temperature >32 but preferably >35

Intact neuromuscular conduction

No physical reason to preclude eg no facial trauma, Cervical spine injury,

occlusion of EAM, glass eye

Clinical Testing of Brain Stem function:

No pupilary response to light

No response to painful stimuli applied in the cranial nerve territoryAbsent corneal, gag, cough and vestibuloocular reflexes

Absent respiratory function. PCO2 must rise above 60mmHg and pH

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Irreversible cessation of brain function

Absence of Sepsis

Absence of malignancy excluding isolated brain primary or isolated malignancy

Maintained on a ventilator with intact circulation.

Consent:

This should be in line with the patients expressed wishes antemortem. NOK

consent is not required but should be discussed with them.

Medical Management of the potential organ donor:

Maintain euvolaemia

Maintain MAP 60-70 mmHg, vasopressors if required.

Maintain electrolytes

Suspect and treat DI

Maintain Euglycaemia

Maintain temp>35

Maintain respiratory cares, eg suctioning, PEEP, positioning, turning etc

HB>80

Hormone replacement remains controversial. Treat according to local protocol.

May include T3, methylprednisolone, Vasopressin.

Useful links

www.legislation.nsw.gov.au

www.atca.org.au

www.anzics.com.au

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