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  1. Donation after Brain-Stem DeathDBD Jerome McCann Arpan Guha 21st May 2013 1

  2. Session Objectives 2 • Present regional data for DBD • Understand that DBD gives better organs than DCD • Increase rate of neurological confirmation of death by increasing confidence in the Diagnosis of Death • Increase quality of DBD organs • adoption of extended care bundle and compliance with the six early interventions in donor optimisation • collaboration in Scout pilot Organ Donation Past, Present and Future

  3. Regional Data Jerome McCann NORTH WEST 3

  4. Donation after Brain Death (DBD) Mechanically ventilated patient where death has been confirmed using neurological criteria. 74 donors -5.1% increase Lungs Heart Small Intestine Kidneys Liver Pancreas NORTH WEST

  5. Donations over time: North West Team 26.6% -5.1% 181.3% NORTH WEST 5 Organ Donation Past, Present and Future

  6. DCD DBD kidneys intestine lungs pancreas liver heart

  7. 100 87 86 80 82 78 76 76 76 76 74 74 74 73 60 ND tested (%) 40 20 0 North South South South South Eastern London Midlands Northern Scotland Yorkshire Northern East West West Wales Ireland Central Team -------- National rate DBD- Neurological death testing rate Tied 9th with 3 others 1 April 2012 to 31 March 2013, data as at 4 April 2013 NORTH WEST 7 Organ Donation Past, Present and Future

  8. 100 25 19 14 10 29 3 33 24 17 8 20 31 12 13 9 32 1 80 16 11 22 26 7 28 15 60 6 ND tested (%) 2 4 40 30 20 23 0 18 21 5 27 0 5 10 15 20 25 30 Number of neurological death suspected patients Hospital National rate 95% Lower CL 95% Upper CL 99.8% Lower CL 99.8% Upper CL DBD- North West Neurological death testing rate 1 April 2012 to 31 March 2013, data as at 4 April 2013 8 Organ Donation Past, Present and Future

  9. Mean no. of organs donated per donor Tied 6’th 1 April 2012 to 31 March 2013, data as at 4 April 2013 NORTH WEST 9 Organ Donation Past, Present and Future

  10. Diagnosis of brain-stem death 37 years on 1976 2008 10

  11. Moses Maimonides: a decapitated person was immediately dead despite the presence of residual movement in the body History of Diagnosing Death 12th Century 11 Organ Donation Past, Present and Future

  12. Harvey Cushing describes increased brain pressure provoking respiratory arrest with preserved heartbeat. History of Diagnosing Death Early 20th Century 12 Organ Donation Past, Present and Future

  13. Brain death: Discovered not Invented (by intensive care) 1940s Danish medical students hand ventilate polio victims Mouth to Mouth Resuscitation gains prominence & Mechanical Ventilation becomes possible 1954 1stsuccessful kidney transplant between identical twins History of Diagnosing Death 1940s 1950s 1950s 1950s Cerebral circulatory arrest is demonstrated in comatose patients by angiography Neurological Criteria 1959, doctors discover empirical proof by the identification of mechanically ventilated patients in coma dépassé. 13 Organ Donation Past, Present and Future

  14. 1963 1st successful deceased donor liver & lung Tx 1968 1st successful deceased donor heart Tx 1966 1st successful deceased donor pancreas Tx 1962 1st successful deceased donor kidney Tx History of Diagnosing Death 1960s 1960s 1960s 1960s Proposed that the EEG can demonstrate death of the Central Nervous System. Ad Hoc Committee of the Harvard Medical School define irreversible coma as a new criterion for death. 1964, Keith Simpson “there is life so long as circulation of oxygenated blood is maintained to live brainstem centres” 14 Organ Donation Past, Present and Future

  15. Organ Donation from Brain Dead donors increases worldwide. Modern intensive care practice grows. History of Diagnosing Death Late 20th Century 1976 (clarified 1979) UK Criteria for Diagnosing Death using Neurological Criteria Published. 15 Organ Donation Past, Present and Future

  16. Growing use of ECMO and other techniques to support the circulation, establish that it is possible to be alive, without a heart-beat. Rene´ Laennec 1819 History of Diagnosing Death Eugene Bouchut 1846 21st Century 2008 UK Criteria for Circulatory Criteria published for the 1st time. 5 minutes. 16 Organ Donation Past, Present and Future

  17. UK Definition of Death “The definition of death should be regarded as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe… therefore irreversible cessation of the integrative function of the brain-stem equates with the death of the individual.” All human death is anatomically located to the brain. 17 Organ Donation Past, Present and Future

  18. A medical concept of death Neurological Criteria DEATH Circulatory Criteria Somatic Criteria Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe

  19. Dx Death using Neurological Criteria An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. • Cause tells you irreversibility, based on the natural history of the disease • Cause tells you how long you should observe before testing: • SAH 6 hours • Hypoxia 24 hours DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 19 Organ Donation Past, Present and Future

  20. Dx Death using Neurological Criteria An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 20 Organ Donation Past, Present and Future

  21. Dx Death using Neurological Criteria • Clinical judgement essential • Impossible to create rules covering every situation • Difficulties mainly with thiopentone and midazolam • Plasma concentrations not good predictors of effect • Use of antagonists may help An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 21 Organ Donation Past, Present and Future

  22. Dx Death using Neurological Criteria An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. 98.5% Death confirmed in 1220 of 1238 tests (2012 data) DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 22 Organ Donation Past, Present and Future

  23. Dx Death using Neurological Criteria An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 23 Organ Donation Past, Present and Future

  24. Brain-stem reflexes • Pupils (II, III) • Corneal (V, VII) • Pain (V, VII) • Gag (IX, X) • Cough (IX, X) • Oculovestibular (III, VI, VIII) • Oculocephalic • Suck } Paediatric 24 Organ Donation Past, Present and Future

  25. Apnoea Test Starting paCO2 > 6.0 KPa StartingpH<7.4 5 minutes with paCO2> 0.5 KPa Recommended method: After pre-oxygenation, disconnect the patient from the ventilator and administer oxygen via a suction catheter in the endotracheal tube at a rate of >6 L/minute. If oxygenation is a problem, consider the use of a CPAP circuit (egMapleson B). The apnoea test is performed only twice in total. 25 Organ Donation Past, Present and Future

  26. Testing for Brain-stem Death “This form is consistent with and should be used in conjunction with, the AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of Death and has been endorsed for use by the following institutions: Faculty of Intensive Care Medicine, Intensive Care Society and the National Organ Donation Committee.” Abbreviated Full 26 Organ Donation Past, Present and Future

  27. 27 Organ Donation Past, Present and Future

  28. WHY TEST?

  29. A guiding dignity consistent approach to declaring death • Dying, is a process, which effects different functions and cells of the body at different rates of decay. • Doctors must decide at what moment along this process there is permanence and death can be appropriately declared.

  30. A doctors duty Diagnose the dead Safe – no coming back to life after death declared Timely – no unnecessary delay

  31. WHY TEST? Where Brain Stem Death (BSD) is suspected, it is highly desirable to confirm this by Brain Stem Testing: • To eliminate all possible doubt regarding survivability • To confirm diagnosis for families • In cases subject to medico-legal scrutiny • To provide choice regarding organ donation

  32. diagnosis decision

  33. TWO TESTS or ONE? • National professional guidance mandates two tests to be performed regardless of organ donation (Bolam&Bolithio). • Same two doctors carry out the second set of tests immediately after the first set (update family and stabilise patient). • Death is retrospectively confirmed at the conclusion of the second test. Until then, as a matter of law and ethics, it is necessary to treat the patient as alive.

  34. 1976 2008 Lesson 1

  35. Lesson 2 To Dx Use

  36. Lesson 3 • Take your time • Atypical presentation • Hypoxic brain injury • >24 hours

  37. Lesson 4 Induced hypothermia has unpredictable consequences See Lesson 3

  38. Lesson 5 NO EEG

  39. Lesson 6 Start with Lesson 2 = use your brain and examine your patient Clinical brain death + NO flow = Death Clinical brain death + flow = Wait See Lesson 3 = take your time and ask ‘Is reversibility possible?’

  40. Optimising the brainstem dead donor 40 Organ Donation Past, Present and Future

  41. Donor optimisation • Ameliorate ‘systemic’ effects of brain stem death • Why? • Increase number of donors • Increase number of organs per donor • Increase quality of organs • Who takes responsibility? • ICU staff: medical and nursing • SN-ODs • Retrieval teams • ‘Scout’ • Cardio-thoracic teams 43 Organ Donation Past, Present and Future

  42. ‘Collateral damage’ • Hormonal • Diabetes insipidus • Hypovolaemia • Hypernatraemia • T3 / T4 reduces • ACTH • Blood glucose • Hypothermia 44 Organ Donation Past, Present and Future

  43. Incidence of organ involvement Hypotension 81% Diabetes insipidus65% DIC 28% Cardiac dysrrhythmias 25% Pulmonary oedema 18% Metabolic acidosis 11% J Heart Lung Transplantation 2004 (suppl) 45 Organ Donation Past, Present and Future

  44. 46 Organ Donation Past, Present and Future

  45. Evidence Totsuka Transplant Proc. 2000; 32;322-326 High sodium in liver donor doubles graft loss Rosendale Transplantation 2003. 75 (4): 482-487 Protocol increased organs per donor 3.1 to 3.8. Increased probability of transplant. SnellJ Heart Lung Transplant 2008;27:662-7 54% of Australian lung donations used for transplant vs. 13% in UK 47 Organ Donation Past, Present and Future

  46. Principles Ameliorate ‘systemic’ effects of brain stem death Why? Increase number of donors Increase number of organs per donor Increase quality of organs Who takes responsibility? ICU staff: medical and nursing SN-ODs Retrieval teams ‘Scout’: who are they attached to? Cardio-thoracic teams Abdominal teams Free standing 48 Organ Donation Past, Present and Future

  47. What do we aim for ? General stability Examples of target values MAP: 60 – 80 mm Hg Heart rate: 60 – 100 / min SR CI: > 2.1 l/min/m2 Guidelines Australian Canadian Map of Medicine ICS NHSBT 49 Organ Donation Past, Present and Future

  48. Cardiovascular management Summary of cardio vascular target values MAP: 60 – 80 mm Hg CVP: 4 – 10 mm Hg Heart rate: 60 – 100/min SR CI: > 2.1 l/min/m2 (can be higher, be aware of myocardial stunning) Filling targets: no good evidence for any specific targets, depends on device SvO2> 60% SVRI target Secondary target Dehydration  temptation to maintain MAP with vasopressors rather than filling 50 Organ Donation Past, Present and Future