Brain Death

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Brain Death Organ Donor ManagementRoni
Lawrence, RN, BSN, CPTCClinical ManagerOrgan
Procurement Coordinator

• University of Wisconsin
• Organ Procurement Organization
• 1-866-UWHC OPO
• (1-866-894-2676)

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Effective Donor Management

• Stabilize the donor Facilitate brain death exam
  or DCD Tool.
• Manage the donor To optimize the function and
  viability of all transplantable organs.
• In 2006, 6,805 patients with end organ failure
  died waiting for a life-saving transplant

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Effective Donor Management

• Requires clinical expertise, vigilance,
  flexibility, and the ability to address multiple
  complex clinical issues simultaneously and
  effectively.
• Requires collaboration among the OPO, donor
  hospital critical care staff and consultants, and
  transplant program staff.

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Effective Donor Management

• Donor care is not usually assumed until after
  consent for donation has been obtained.
• It is appropriate to collaborate prior to brain
  death, consent, etc, to prevent death and keep
  the option of organ donation open.

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Effective Donor Management

• Revision of existing orders or placement of new
  medical orders is intended to
• D/C medications no longer needed or appropriate
  (e.g., anticonvulsants, mannitol, sedatives,
  antipyretics)
• Continue needed medications, or therapy (e.g.,
  vasoactive drug infusions, IV fluids and vent
  settings)
• Create call orders that inform bedside
  personnel of the goals for physiologic parameters
  and alert OPC of changes in donor status.

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Diagnosing and Declaring Brain Death
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• Uniform Determination of Death Act
• An individual who has sustained either
• irreversible cessation of circulatory and
  respiratory function
• or
• (2) irreversible cessation of all functions of
  the entire brain, including the brain stem, is
  dead. A determination of death must be made in
  accordance with accepted medical standards.
• JAMA Nov 13, 1981 Vol 246, No. 19

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Diagnosis of Brain Death

• Brain death is a clinical diagnosis. It can be
  made without confirmatory testing if you are able
  to establish the etiology, eliminate reversible
  causes of coma, complete fully the neurologic
  examination and apnea testing.
• The diagnosis requires demonstration of the
  absence of both cortical and brain stem activity,
  and demonstration of the irreversibility of this
  state.
• R. Erff, D.O., Walter Reed Army Medical Center

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Etiology of Brain Death

• Severe head trauma
• Aneurismal subarachnoid hemorrhage
• Cerebrovascular injury
• Hypoxic-ischemic encephalopathy
• Fulminant hepatic necrosis
• Prolonged cardiac resuscitation or asphyxia
• Tumors
• R. Erff, D.O., Walter Reed Army Medical Center

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Prerequisites to the Diagnosis

• Evidence of acute CNS catastrophe
• compatible with brain death
• Clinical or Neuroimaging
• Exclusion of reversible medical conditions that
  can confuse the clinical assessment
• Severe electrolyte, acid base and endocrine
  disturbance
• Absence of drug intoxication and poisoning
• Absence of sedation and neuromuscular blockade
• Hypotension (suppresses EEG activity and CBF)
• Absence of severe hypothermia (core temp lt 32 C)

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Brain Stem Reflexes

• Cranial nerve examination
• No pupillary response to light. Pupils midline
  and dilated 4-6mm.
• No oculocephalic reflex (Dolls eyes)
  contraindicated in C- spine injury.
• No oculovestibular reflex (tonic deviation of
  eyes toward cold stimulus) contraindicated in
  ear trauma.
• Absence of corneal reflexes
• Absence of gag reflex and cough to tracheal
  suction.

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Apnea Testing

• Once coma and absence of brain stem reflexes have
  been confirmed ? Apnea testing.
• Verifies loss of most rostral brain stem function
• Confirmed by PaCO2 gt 60mmHg or PaCO2 gt 20mmHg
  over baseline value.
• Testing can cause hypotension, severe cardiac
  arrhythmias and elevated ICP.
• Therefore, apnea testing is performed last in the
  clinical assessment of brain death.
• Consider confirmatory tests if apnea test
  inconclusive.

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Apnea Testing

• Following conditions must be met before apnea
  test can be performed
• Core temp gt 32.0 C (90 F).
• Systolic blood pressure gt 90mmHg.
• Euvolemia
• Corrected diabetes insipitus
• Normal PaCO2 ( PaCO2 35 - 45 mmHg).
• Preoxygenation (PaO2 gt 200mmHg).

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Brain Death in Children

• Clinical exam is same as in adults.
• Testing criteria depends on age of child.
• - Neonate lt 7 days ? Brain death testing is not
  valid.
• - 7 days 2 months
• - Two clinical exams and two EEG 48 hrs apart.
• - 2 months 1 year
• - Two clinical exams and two EEG 24 hrs apart.
• - or two clinical exams, EEG and blood flow
  study.
• - Age gt 1 year to 18 years
• - Two clinical exams 12 hrs apart,
  confirmatory study - Optional

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Confirmatory Testing

• Purely optional when the clinical criteria are
  met unambiguously.
• A confirmatory test is needed for patients in
  whom specific components of clinical testing
  cannot be reliably evaluated
• - Coma of undetermined origin
• - Incomplete brain stem reflex testing
• - Incomplete apnea testing
• - Toxic drug levels
• - Children younger than 1 year old.
• - Required by institutional policy
• R. Erff, D.O., Walter Reed Army Medical Center

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Confirmatory Tests for Brain Death

• Cerebral Blood Flow (CBF) Studies
• Cerebral Angiography
• Nuclear Flow Study
• EEG (when brain scan is not utilized)

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Cerebral Angiography
No Blood Flow
Normal Blood Flow
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Nuclear Flow Study
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Elements of brain death declaration

• Date
• Time
• Detailed documentation of Clinical Exam including
  specifics of Apnea Testing
• Physician signature

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What to expect after brain death
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Pathophysiology

• Loss of brain stem function results in systemic
  physiologic instability
• Loss of vasomotor control leads to a hyperdynamic
  state.
• Cardiac arrhythmias
• Loss of respiratory function
• Loss of temperature regulation ? Hypothermia
• Hormonal imbalance ? DI, hypothyroidism

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Perioperative Management

• Following the diagnosis of Brain Death
• Therapy shifts in emphasis from cerebral
  resuscitation to optimizing organ fxn for
  subsequent transplantation.
• The normal sequelae of brain death results in
  cardiovascular instability poor organ
  perfusion.
• Medical staff must focus on
• - Providing hemodynamic stabilization.
• - Support of body homeostasis.
• - Maintenance of adequate cellular oxygenation
  and donor organ perfusion.
• Without appropriate intervention brain death is
  followed by severe injury to most other organ
  systems. Circulatory collapse will usually occur
  within 48hrs.

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Autonomic/Sympathetic Storm

• Release of catecholamines from adrenals
  (Epinephrine and Norepinephrine) results in a
  hyper-dynamic state
• Tachycardia
• Elevated C.O.
• Vasoconstriction
• Hypertension

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Failure of the Hypothalamus results in

• Impaired temperature regulation - hypothermia or
  hyperthermia
• Leads to vasodilation without the ability to
  vasoconstrict or shiver (loss of vasomotor tone)
• Leads to problems with the pituitary ...

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Normal Pituitary Gland

• Controlled by the hypothalamus
• Releases ADH to conserve water
• Stimulates the release of thyroid hormone

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Pituitary Failure results in

• ADH ceases to be produced Diabetes Insipidus
• Can lead to hypovolemia and electrolyte
  imbalances
• Leads to problems with the thyroid gland

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Normal Thyroid Gland

• Produces hormones that increase the metabolic
  rate and sensitivity of the cardiovascular system
• Levothyroxine (T4)
• Triiodothyronine (T3)

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Thyroid Failure

• Leads to
• Cardiac instability
• Labile blood pressure
• Potential coagulation problems

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Cardiovascular System

• Intensive care management
• Rules of 100s
• - Maintain SBP gt 100mmHG
• - HR lt 100 BPM
• - UOP gt 100ml/hr
• - PaO2 gt 100mmHg
• Aggressive fluid resuscitative therapy directed
  at restoring and maintaining intravascular
  volume. SBP gt 90mmHg (MAP gt 60mmHg) or CVP 10
  mmHg.

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Neurogenic Pulmonary Edema

• Brain death is associated with numerous
  pulmonary problems
• The lungs are highly susceptible to
  injury resulting from the rapid changes that
  occur during the catecholamine storm
• Left-sided heart pressures exceed pulmonary
  pressure, temporarily halting pulmonary blood
  flow
• The exposed lung tissue is severely
  injured, resulting in interstitial edema and
  alveolar hemorrhage, a state commonly
  referred to as neurogenic pulmonary edema

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Release of Plasminogen Activator ? DIC

• Results from the passage of necrotic brain
  tissue into the circulation
• Leads to coagulopathy and sometimes progresses
  further to DIC
• DIC may persist despite factor replacement
  requiring early organ recovery
• (Also affected by hypothermia, release of
  catecholamines hemodilution as a result of
  fluid resuscitation)

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Organ Donor Management(in a nutshell)

• Hypertension ? Hypotension
• Excessive Urinary Output
• Impaired Gas Exchange
• Electrolyte Imbalances
• Hypothermia

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Hypotension Management

• Fluid Bolus NS or LR (Followed by MIVF NS or
  .45 NS)
• Consider colloids (seriously)
• Dopamine
• Neosynephrine
• Vasopressin
• Thyroxine (T4 protocol)

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T4 ProtocolBackground

• Brain death leads to sudden reduction in
  circulating pituitary hormones
• May be responsible for impairment in myocardial
  cell metabolism and contractility which leads to
  myocardial dysfunction
• Severe dysfunction may lead to extreme
  hypotension and loss of organs for transplant

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T4 Protocol

• Bolus
• 15 mg/kg Methylpred
• 20 mcg T4 (Levothyroxine)
• 20 units of Regular Insulin
• 1 amp D50W
• Infusion
• 200 mcg T4 in 500 cc NS
• Run at 25 cc/hr (10 mcg/hr)
• Titrate to keep SBP gt100
• Monitor Potassium levels closely!

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Vasopressin (AVP, Pitressin)

• Low dose shown to reduce inotrope use
• Plays a critical role in restoring vasomotor tone
• Vasopressin Protocol
• 4 unit bolus
• 1- 4 u/hour titrate to keep SBP gt100 or MAP gt60

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Diabetes Insipidus Management

• Treatment is aimed at correcting hypovolemia
• Desmopressin (DDAVP) 1 mcg IV, may repeat x 1
  after 1 hour.
• Replace hourly U.O. on a volume per volume basis
  with MIVF to avoid volume depletion
• Leads to electrolyte depletion/instability
  monitor closely to avoid hypernatremia and
  hypokalemia

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Diabetes Insipidus

• Goal is UOP 1-3 ml/kg/hr
• Rule of thumb 500 ml UOP per hour x 2 hours is
  DI
• Severe cases Notify OPC. Assess clinical
  situation.

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Impaired Gas Exchange Management

• Maintain PaO2 of gt100 and a saturation gt95
• Monitor ABGs q2h or as requested by OPO
• PEEP 5 cm, HOB up 30o
• Increase ET cuff pressure immediately after BD
  declaration
• Aggressive pulmonary toilet (Keep suctioning
  turning q2h)
• CXR (Radiologist to provide measurements
  interpretation)
• OPO may request bronchoscopy
• CT of chest requested in some cases

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Correct Impaired Gas Exchange and Maximize
Oxygenation!

• Most organ donors are referred with
• Chest trauma
• Aspiration
• Long Hospitalization with bed rest resulting in
  atelectasis or pneumonia
• Impending Neurogenic Pulmonary Edema
• Brain Death contributes to and complicates all of
  these conditions

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Impaired Gas ExchangeGoals

• Goals are to maintain health of lungs for
  transplant while optimizing oxygen delivery to
  other transplantable organs
• Avoid over-hydration
• Ventilatory strategies aimed to protect the lung
• Avoid oxygen toxicity by limiting Fi02 to achieve
  a Pa02 100mmHg PIP lt 30mmHg.

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Electrolyte Imbalance Management

• Hypokalemia
• If K lt 3.4 Add KCL to MIVF
• (anticipate low K with DI T4 administration)
• Hypernatremia
• If NA gt155 Change MIVF to include more free
  H20, Free H20 boluses down NG tube (this is often
  the result of dehydration, NA administration,
  and free H20 loss 2o to diuretics or DI)
• Calcium, Magnesium, and Phosphorus
• Deficiencies here commonoften related to
  polyuria associated with osmotic diuresis,
  diuretics DI.

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Hypothermia Management

• Monitor temperature continuously
• NO tympanic, axillary or oral temperatures.
  Central only.
• Place patient on hypothermia blanket to maintain
  normal body temperature
• In severe cases (lt95 degrees F) consider
• warming lights
• covering patients head with blankets
• hot packs in the axilla
• warmed IV fluids
• warm inspired gas

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Anemia

• Hematocrit lt 30 must be treated
• Transfuse 2 units PRBCs immediately
• Reassess 1o after completion of 2nd unit and
  repeat infusion of 2 units if HCT remains below
  30
• Assess for source of blood loss and treat
  accordingly

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Incidence of pathophysiologic changes following
Brain Death

• - Hypotension 81
• - Diabetes Insipidus 65
• - DIC 28
• - Cardiac arrhythmias 25
• - Pulmonary edema 18
• - Metabolic acidosis 11
• Physiologic changes During Brain Stem Death
  Lessons for Management of the Organ Donor.
• The Journal of Heart Lung Transplantation
  Sept 2004 (suppl)

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Organ Donation Process

• Evaluate organ function
• Labs ( UA) within 6 hours of surgery
• Type and Screen
• Consent signed
• Serology testing
• Medical Social History
• Locate potential recipients
• Manage hemodynamics
• Arrange operating room

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The Teams...

• Your Hospital
• - Anesthesia
• - Primary Care Physician or Intensivist (For
  DCD)
• Surgical Technician/Scrub Nurse
• Circulating Nurse
• Abdominal Transplant Team
• - Surgeon
• - Physician Assistant
• - Surgical Recovery Coordinator
• Cardiothoracic Team
• - Surgeon
• - Surgical Fellow
• - Surgical Recovery Coordinator

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Organ Preservation Time

• Heart 4-6 hours
• Lungs 4-6 hours
• Liver 12 hours
• Pancreas 12-18 hours
• Kidneys 72 hours
• Small Intestines 4-6 hours

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