On 21^st September, 2013 a Continuing Medical Education (CME) on Brain Death was organized at the Auditorium of the Super Specialty Block, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry. The CME was organized by MOHAN Foundation, Chennai in association with the Working Group on Organ Donation, Puducherry.

 

Dr. Sunil K Narayan, Professor of Neurology, JIPMER welcomed the delegates and said that getting the protocol and guidelines in place will assist the deceased donation programme to get a good start.

 

Dr. T. S. Ravikumar, Director, JIPMER inaugurated the CME and addressed the gathering. He said that JIPMER had received approval for organ retrieval from the Centre and had set up a brain death committee comprising of 24 persons who would be responsible for declaring a person brain dead. The Institute had also come up with Standard Operating Procedures (SOP) for brain death declaration. He also released the SOP at the event and said it will be shortly published on their website.

 

Presently, on an average there are nine or ten potential donors that arrive at JIPMER every month. That roughly translates into 45-50 transplant surgeries. Since, JIPMER and Pondicherry Institute of Medical Sciences (PIMS) have formed a brain death committee and also have the required permission for retrieval of organs; the deceased donor programme can begin in the State.

 

He said to give an impetus to the programme all the staff members within JIPMER should carry a donor card. At the end of the inaugural session; he felicitated Ms. Deepa Matthew, a staff nurse from Kerala who consented for organ donation after she lost her father.

Technical session:
 

• Brain death – Identification, diagnostic tests and certification
   

Chairperson:  Dr. G. Thiagarajan, Professor and Head, Department of Neurosurgery, PIMS

Speaker: Dr. K. Deiveegan, Professor, Department of Neurology, Madras Medical College (MMC)  

 

He said that only 1% of all the deaths that occur in the hospital are due to brain death. And only 20% of cases suffering from severe head injury end up as being declared brain dead. Since the stage of brain death is a brief period, it should be identified at the earliest. He emphasised on the role the nurses’ play in identifying brain dead patients. He listed out a series of tests that need to be carried out when a patient is suspected to be brain dead before certifying the same. He also stressed upon the importance of providing clear and precise information about brain death and also about the possibility of organ donation to the family members of the potential donor.

 

• American Academy of Neurology (AAN) and United Kingdom (UK) guidelines on Brain Stem Death Certification
   

Chairperson: Dr. Roopesh Kumar V. R, Additional Professor and Head, Department of Neurosurgery, JIPMER 

Speaker: Dr. Sunil Narayan, Professor and Head, Department of Neurology, JIPMER

 

He explained about the genesis of the concept of brain death and about the Dead Donor Rule. He further expanded about the evolution of the definitions of death in different countries which led to the idea of organ donation after cardiac death and after brain death. He also spoke about the practical guidelines for clinical and neurological assessment of brain death. He highlighted the salient features of the guidelines provided by National Health Service (NHS) and National Institute for Health and Care Excellence (NICE) in UK.

 

• Legal Aspects of Brain Stem Death
   

Chairperson: Dr. K. K. Saha, Assistant Professor, Forensic Medicine, JIPMER

Speaker: Dr. Hemal Kanvinde, Quality Officer, MOHAN Foundation, Chennai

She spoke about the Transplantation of Human Organs (THO) Act, 1994 and about the Amendment passed to the Act in 2011. She elucidated on how the law defines brain death and about the process of certification.  Further; she highlighted the role the police and the forensic experts play in medico-legal cases and the duties of the Registered Medical Practitioner (RMP) in case of deceased organ donation as per the THO Rules which were passed in 1995. She emphasised on the need to have a trained transplant coordinator to assist in the process.  She also touched upon the Government Orders passed by the Government of Tamil Nadu. Briefly; she spoke about the Tamil Nadu Network of Organ Sharing (TNOS) and about the Kerala Network of Organ Sharing (KNOS) websites and ended by noting that; once Puducherry has its own State Network we can envision establishing a regional network.

 

• Maintaining a Deceased Donor
   

Chairperson: Dr. Pankaj Kundra, Professor and Head, Department of Anaesthesiology, JIPMER

Speaker:  Dr. T. Venkatachalam, Professor and Head, Department of Anaesthesiology, MMC, Chennai and Rajiv Gandhi Government General Hospital (RGGGH), Chennai

He said according to him a critical care professional is best suited to maintain a deceased organ donor. He also explained about the criteria of exclusion and about the different stages of management. He specifically highlighted the rule of 100 for Blood Pressure (BP), Central Venous Pressure (CVP), and urine output. etc.  He gave an extensive talk on the complications that arise during the maintenance of a brain dead patient and how a potential donor needs to be treated.  He also noted that sometimes the Government Hospitals may not have the medicines required to maintain the donor and in such a situation the recipient hospitals help them out. 

 

• SOP for brain death certification - JIPMER model
   

Chairperson:  Dr. Anita Rustagi, Additional Medical Superintendent, JIPMER

Speaker: Dr. M. Venkatesh, Assistant Professor, Department of Neurosurgery, JIPMER

 

He highlighted the need of an SOP in order to determine brain death; in order to be within the gamut of the law; to give adequate allowance for the family and to keep with the religious and cultural norms.  The SOP states that suspicion of brain death shall be in case of: Glasgow Coma Scale (GCS) = 3, non reactive pupils, diabetes insipidus, hypotension and hypothermia. JIPMER has proposed a five step SOP towards certification of brain death. It will have two sets of clinical reflex tests and one apnoea test.

 

• Panel on how to proceed - Action plan to promote deceased organ donation in Puducherry
   

Panel: Dr. Udit Das, Medical Superintendent, PIMS; Dr. George Kurien, Professor and Head, Department of Gastroenterology, PIMS; Dr. Anita Rustogi and Dr K. Deiveegan.

 

Discussion points:
 

Reason for Brain Death Certification

PIMS: We shall follow the law  

JIPMER: Only for the purpose of organ donation

MMC: If apnoea test is positive all suspicions should be cleared out by carrying out the various tests and certifying the patient brain dead.

 

Where should the brain dead donor be kept?

PIMS: Shall provide dedicated ventilator and bed

JIPMER: Shall provide two dedicated ventilators and beds

MMC: Have two ventilators and beds in Post-Anaesthesia Care Unit (PACU) and when a potential donor is identified there is a staff nurse and a ward boy assigned to that patient.

 

How to begin organ sharing?

PIMS:  Need to get the Government of Puducherry involved in the process of organ sharing. We shall approach them again.
JIPMER:  Dr. P Balachandar, Medical Superintendent, JIPMER shall be in touch with PIMS and identify a suitable person to allocate organs for transplantation
MMC:  should identify an excellent senior person to coordinate the process of organ allocation.

 

Vote of Thanks:

Dr. Biju Pottakat, Assistant Professor, Surgical Gastroenterology, JIPMER thanked MOHAN Foundation and the doctors from MMC for participating in the workshop and for sharing their experiences.  He said that JIPMER will have an Organ Distribution Authority soon.  He promised that the hospitals shall work together to begin the certification of brain death on a regular basis and also to start the deceased donor programme in the State.