MANAGEMENT OF BRAIN DEATH

MISCELLANEOUS PROBLEMS

Infection

Systemic infection is a relative contraindication to organdonation. All unnecessary indwelling devices should be removed. Alllines and catheters must be inserted aseptically and meticulous care ofdressings and wounds is vital. Tracheal suction should be done withsterile precautions. Appropriate samples from suspected sources ofinfection should be sent for cultures. Treatment should be initiatedbased on culture reports. Prophylactic antibiotics are indicated onlyimmediately prior to organ retrieval.

Coagulopathy

Disseminated intravascular coagulation is common in patients withtraumatic head injuries. This is due to the release of thromboplastinfrom the injured brain. If it results in clinically significantmucocutaneous bleeding, treatment with appropriate blood components isneeded.

Hypothermia

Core temperature should be monitored using rectal thermometers. Thecore temperature should be maintained above 350C after brain death, thebody becomes poikilothermic because of the loss of central temperaturecontrol mechanisms. Treatment includes use of humidified and warmedventilator gases ; warmed intravenous fluids and blood products ; andheating blankets. Sometimes a hot blower next to the patient is thebest solution to maintain the body temperature.

Brain stem dead organ donors are managed in the intensive careunit. Supportive care is directed towards optimizing organ function asthis will improve graft survival and function.

CONCLUSION:

A severe shortage of organs the world over has led to increased pressure on the intensive
care staff for early identification of the brain dead donor and optimum management of 
this condition. The diagnosis of brain death as per the Transplantation Human Organ Act 
is based as simple clinical bedside tests. The passing of this Act in 1994 and its 
subsequent adaptation by many Indian States has made it possible in India to use this 
pool of patients for organ retrieval and transplantation.

Table  1. States that have accepted THO Act 

Table  II. Form VIII of Transplantation of Human Organ Act

S.No	Brainstem Reflexes	Sensory cranial nerve	Motor cranial nerve
1.	Absence of pupillary response to light	II	III (parasympathetic Nerve fibres)
2.	Absence of corneal reflexes	V	VII
3.	Absence of cranial nerve response to pain	V	VII (and limb motor responses)
4.	Absence of Vestibulo-ocular	VIII	III, VI
5.	Absence of gag and cough reflexes	X	IX

Table II. Clinical Testing For Absence Of Brainstem Reflexes

The PaCo2 should be 5.33 kPa (.40mmHg) prior to testing and should rise to at least 6.66kPa (50mmHg) during the test. The patient should be pre-oxygenated with 100% oxygen for 10 minutesprior to testing & baseline arterial blood gases should be taken. Disconnect patient from ventilator but oxygen should be administered at 6 litres/min via a fine bore catheter down the endo-tracheal tube Observe patient for 5 to10 minutes for any respiratory effort andensure PaCo2 has risen above 6.66kPa (50mmHg) by repeating arterialblood gases. Reconnect patient to the ventilator. Discontinue testing if any hypotension, cardiac arrhythmia's or hypoxia occurs

Table III. Aponea Test For Confirming 'Brainstem Death' 


Table IV. 'Ramachandra Protocol' To Ask For Organs 


Table V. Organizing multi-organ donation in abrain death

Corneas	0  100 years	(poor eyesight not a contraindication)
Heart Valves	0  60 years	(Heart Attack not a contraindication)
Trachea	15  60 years
Skin	16  85 years
Kidneys	0  75 years	(Paediatric donors are assessed according to weight and size)
Liver	0 70 years	(size matching is usually recommended)
Heart	0  60 years	(if unsuitable heart valves may be donated)
Lungs	0  60 years	(individual assessment of each lung performed

Table VI. Different Age criteria for organ donation

Testing for HIV, Hep B & C on all donors. Additional tests for syphilis, cytomegalovirus and toxoplasmosis may be necessary  Virology testing is performed after the completion of brain stem death tests but before the ventilator is discontinued. Virology screening is done after consent from next to kin.

Table VII - Virology Screen For Brain Dead Patient When Organ Donation is Being Considered

Common Clinical Problems Of Brain Stem Dead Patient Hypotension Hypothermia Endocrine Disturbances Electrolyte Imbalance Arrhythmias Hypoxia Uncommon Clinical Problems Coagulopathy Neurogenic Pulmonary Oedema

Table VIII. Common & Uncommon Clinical Problems in Brain dead patients

CARDIOPULMONARY
Systolic blood pressure	100-120mmHg
Mean arterial pressure	>60mmHg
Central venous pressure	8-10 mmHg
Hemoglobin	10gm/dl
Hematocrit	30?
(Arterial blood gas)pH	7.37-7.45
Pa	O2 >75mmHg
PaCO	2 40mmHg
SpO	2 95?
RENAL
Urine output	1-2ml/kg/hr
Core temperature (rectal)	>35 *C
METABOLIC
Correct glucose and electrolyte abnormalities	Na+, K+, Ca++, PO4-, Mg++

 Table IX. Management goals supporting the brain stem organ donor

Table  I.Form 8 of THO Act

Table II.Cranial nerve reflexes

Table III. Apnoea Test 

Test- IV. Ramachandras Protocol

Test-V. Transparent Co-ordination 

Test-VI. Age for organ donation

Table VII - Virology Screen For Brain Dead Patient When Organ Donation is Being Considered

Table VIII. Common & Uncommon Clinical Problems in Brain dead patients

Table IX. Management goals supporting the brain stem organ donor

Fig.1. Cause of Brain Death

Fig .2. Testing for Brain Death