Brain Death

Question 1

Organ Donation is ___________ & tissue donation is .____________

Answer 1

lifesaving
life-enhancing

Question 2

In organ donation the donor patient must be:

Whereas in tissue donation the patient is:

Answer 2

Patient must be maintained by a mechanical ventilator

Donation occurs after death

Question 3

How long does organ donation vs tissue donation take?

Answer 3

The process is lengthy from referral to procurement 24-72 hours

Ocular Donation process takes about 8 hours.

Question 4

TIssue donation occurs:

Answer 4

after death.

Question 5

True or false: organ donation occurs while the individual is still alive

Answer 5

False
organ donation process must begin while the individual has a beating heart so that their organs are still being perfused. Only after death donation occurs.

Question 6

Criteria for Organ Donation

Answer 6

GIVE

1. Grave Prognosis
2. Injured brain/non-recoverable illness
3. Ventilated
4. End of Life Discussion Plan

Question 7

2 Types of Death

Answer 7

1. Death Determination by. Neurological Criteria (DNC - brain death)
2. Death Determination by Circulatory Criteria (DCC - cardio-pulmonary death)

Question 8

Define DNC

Answer 8

irreversible loss of the capacity for consciousness combined with the irreversible loss of all brainstem functions, including the capacity to breathe

Spinal cord reflexes may still be intact

Question 9

Define DCC

Answer 9

determination of physical death by circulatory based, still has blood flow to brainstem.

There is severe but incomplete brain damage where there is no chance of recovery or meaningful recovery. There is still blood flow to the vital brain centres.

Question 10

Explain patho of DNC

Answer 10

Known/Definitive Cause of Injury to brain

1. arrest of blood flow due to catastrophic intracranial HTN
2. brain injury/edema/mass increasing ICP
3. Impaired cerebral blood flow
4. pressure related ischemia; continued rise in ICP
5. Brain herniates through path of least resistance (brainstem/cerebellum)

Question 11

6 Physiological Criteria of DNC

Answer 11

• Complete and irreversible – stopping of all brain function
• Unresponsive & Irreversible coma
• Definitive cause
• Absent centrally mediated motor responses.
• Absent brainstem reflexes.
• Apnea

Question 12

DNC Organ Donor patients will always be cared for in the _____ and transferred to the OR for organ recovery still on ______________

Answer 12

ICU

Life support measures

Question 13

Clinical Manifestation of DNC

Answer 13

1. Conning
2. Period of instability characterized by HTN, Bradycardia, irregular respirations

AKA
Cushing triad is, unfortunately, a late sign of increasing ICP and indicative that brainstem herniation is imminent.
o Widening pulse pressure
o Bradycardia
o Cheyne Stokes

Question 14

Prerequisites required before DNC can be determined:

Answer 14

1. Clinical imaging showing evidence of a acute catastrophic injury, that supports a diagnosis of brain death.
2. No severe electrolyte imbalances.
3. No drastic acid base disturbance.
4. No endocrine abnormalities.
5. No drugs intoxication. Including medications given at hospital. (neuro blockade agents, sedation ect)
6. Appropriate core temp

Question 15

7 Determinants of Brain Death (DNC)

Answer 15

1. Definitive cause of death must be identified
2. Deep unresponsive Coma: GCS 3
3. Body temperature: >36 for Infants-adults
4. All sedation, narcotics and neuro-blockade agents stopped
5. Absence of spontaneous movements & elicited movements (seizures/posturing)
6. Absent brain stem reflex
7. DNC is determined by 2 attending physicians with skill and knowledge of patients with severe brain injury and DNC. The clinical assessment can be done concurrently.

Question 16

How is absence of cortical functions clinically determined in DNC

Answer 16

No spontaneous movements, eye opening or movement after auditory, verbal or visual commands.

Cerebral motor response to pain:
>Nail beds, traps, supraorbital ridge.
> Do not count spinal reflexes – can be intact.

Question 17

How is absence of brain function clinically determined in DNC

Answer 17

Cannot have:
o Gag
o Cough
o Corneal response
o Bilateral pupillary response to light & >3mm
o Bilateral Vestibulo-ocular response (caloric reflex)
o Suck reflex (neonates)
o Oculo-cephalic reflex has been removed (doll’s eyes)

Question 18

How is absence of gag reflex clinically determined in DNC?

Answer 18

Gag and cough reflexes are not present in brain death.
> Gag reflex can be encouraged by stimulating the posterior pharynx.
> Cough reflex can be elicited by the ETT suction.

Question 19

How is absence of corneal response clinically determined in DNC?

Answer 19

A corneal response will be absent with brain death.
o Tested by directly touching

Question 20

How and what pupillary response is present in the clinical determination of DNC?

Answer 20

• Pupils can be midsize to all the way dilated.
• Absent light reflex.
• Pupils will be fixed and unresponsive

Question 21

How is bilateral vestibulo-ocular response clinically determined in DNC?

Answer 21

Tested by putting 50ml of ice water into the ear canal, ensuring ice water reaches tympanic membrane.
o Normal response will have eye move towards painful stimuli. Absent movement after 3 min support a Dx of brain death.

Question 22

Describe the apnea test used in determination of DNC?

Answer 22

Attempt to achieve normal ABG

1. Pre-Oxygenate with 100% Oxygen for 10 minutes
2. Change ventilator setting to spontaneous
3. Observe chest and abdomen for respiratory effort
4. Measure ABGs 5 min, 8 min, and 10 min (if needed)
5. Apnea test confirms brain death if at 8 min or 10 min
   - PaC02 ≥ 60 mmHg
   - PaC02 ≥ 20 mmHg above baseline
   - PH ≤ 7.28

Brain death is determined if there is an Absent Respiratory Effort
- Driving up PaC02 to elicit a respiratory response
- If patients is not tolerating this test – BP dropping test is stopped

Question 23

Describe ancillary testing in determination of DNC

Answer 23

Testing Brain Blood Flow
> Radionuclide Cerebral Blood Flow Study
> CT Angiography
> MR Angiography

Question 24

When is DCC donation a possibility?

Answer 24

1. plan to withdraw life sustaining therapy after health care team determined there is no long term prognosis for recovery
2. DNC not met
3. May have catastrophic brain injury but do not meet DNC criteria
4. Wihtdrawal of support is planned

Question 25

Explain timeline of asystole for donation in DCC

Answer 25

- Asystole must occur in 2 hour time frame - Two physicians must pronounce the patient deceased 5 minutes after asystole - The donor will be transferred to the OR with no beating heart, ventilator, or monitoring equipment - Must be declared dead before transport, unlike DNC where they can be taken to OR with beating heart.

Question 26

6 Key Components of Care of Organ Donation

Answer 26

1. Vasopressin: constricts arterioles and reduces free water loss from kidneys (antidiuretic hormone). Most donors develop both hypotension and diabetes insipidus (polyuria as main side effect) 2. Corticosteroids: to hypotensive donors requiring vasopressor therapy – brainstem ischemia can lead to shock; improve vascular tone, suppress inflammation and stabilize capillary integrity to reduce fluid shift 3. T 34-45: hypothermia may reduce systemic inflammation, particularly in kidney donors; 36 C for assessment, 34-35 for care. 4. PRBCS for Hgb > 70 5. Enteral nutrition: Inflammation increases metabolic demands contributing to nutritional derangements and further inflammation. Inflammation can be transmitted from donor organs to recipients. 6. Compassionate care

Question 27

8 Steps of Organ Donation Process

Answer 27

1. Diagnosis 2. Referral 3. Family Discussion 4. Medical Evaluation 5. Matching 6. Surgery Recovery 7. Preservation transport 8. Transplantation

Question 28

What is the human tissue gift act?

Answer 28

Human Tissue Gift Act: must speak with legal NOK to obtain consent. Legal NOK must make decision: (a) the legally married spouse of the person or a person with whom the person cohabits and has cohabited as a spouse in a relationship of some permanence, unless immediately before the death or injury or illness of the person, that person and his or her spouse were living separate and apart from each other. (b) an adult son or daughter. (c) a parent or legal custodian. (d) an adult brother or sister. (e) a grandparent. (f) an adult grandchild. (g) an adult uncle or aunt. (h) an adult nephew or niece.

Question 29

IGG indicates ____ infection IgM indicates ______ infection

Answer 29

* IgG past infect * IgM current infection

Question 30

What is exceptional distribution?

Answer 30

organs have some risk to the recipient. We are fully open with any and all Exceptional Distribution We do not hide information to the Transplant programs to trick them into accepting the organs. Programs may defer an organ based on the Exceptional Distribution. Recipients are made aware of Exceptional Distribution and can refuse the organ

Question 31

How does the organ donation OR process differ between DNC and DCC?

Answer 31

Brain Death (DNC): We will walk down to the OR with family following if they wish. We take our time as Organs are being perfused. Circulatory Death (DCC): Once the heart has stopped, needs to happen within 2 hours of withdrawal of care, we wait 5 minutes to ensure no spontaneous return of circulation, then we RUN to the OR as the organs are not being perfused anymore. > Chance after withdrawal of life support that patient remains alive for > 2 hours and is thus no longer a viable donor.

Question 32

Complications to recipient in organ transplant

Answer 32

1. infection 2, bleeding 3. graft thrombosis 4. urine leak 5. ureteral obstruction 6. CMV of EBV 7. Delayed graft function 8. Diabetic challenges 9. Cancer (anti-rejection meds)

Question 33

3 Types of Rejection

Answer 33

1. Hyperacute: suddently, unexpectedly, very rare, during surgery/first few hours after, complete failure, cannot be reversed 2. Acute: most common, 2-3 months after, treated with plasmapheresis/anti-rejection med adjustment 3. Chronic: gradully, after the first year

Question 34

5 Ways to Prevent Rejection and Complications

Answer 34

1. Tissue typing 2, Medications (anti-rejection for life) 3. Regular clinic visits 4. Regular blood work to determine therapeutic ranges 5. Management of HTN, diabetes