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.