BRAIN DEATH AND

ORGAN
TRANSPLANTATION
JOYDEEP GHOSH
PGT, 2ND YR
IPGMER AND SSKM HOSPITAL
TYPES OF ORGAN DONATION:

 LIVING RELATED

 LIVING NONRELATED

 CADAVERIC
WHY DO WE NEED CADAVERIC
ORGANS?
 ORGAN DONATION
vs WAITLISTED
PATIENTS
100,000
90,000
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Deceased Donors Transplants - Living and Deceased Donors Wait List

WHY THE FIGURES ARE SO
DISSAPOINTING?
 PROBLEMS:
 ORGAN ACQUISITION:
 SOCIAL
 RELIGIOUS
 MOTIVATIONAL
 LACK OF KNOWLEDGE
 MISBELIEFS
 PROBLEMS WITH IMPLEMENTATION:

 IRREGULARITIES IN PURCHASE AND SALE

 MALPRACTICE

 LACK OF SUFFICIENT ORGANIZATION

 THE TRANSPLANTATION OF HUMAN
ORGANS ACT WAS PASSED IN
PARLIAMENT ON 8TH JULY, 1994
 IT STATES THAT ORGAN MAY BE TAKEN
EITHER:
 BRAIN DEAD CADAVER, OR
 IMMIEDIATE NON-HEART BEATING
CADAVER SUCH AS FAILED CPR/DNR/ON
VENTILATOR
 The Act permits transplantation of various cadaveric
organs including the kidneys.
 The Act makes commercial trading in organs an
offence.
 The Act makes it mandatory for all institutions
conducting transplants to register with the authority
appointed by the government. All persons associated
in any way with hospitals conducting transplants
without such registration are liable for punishment.
 The human kidney was first successfully
transplanted in Boston in 1946.
Transplantation of the liver followed in 1963
and that of the heart in 1967. Many other
organs including the lung, pancreas and
intestines are now transplanted successfully
and such operations are recognized as
established therapy by the WHO.
BRAIN DEATH
DEFINITION:

IT IS DEFINED AS THE
COMPLETE AND
IRREVERSIBLE CESSATION OF
ALL BRAIN FUNCTION
INCLUDING THE BRAINSTEM
DIAGNOSIS
NEW YORK STATE

DEPARTMENT OF HEALTH

GUIDELINES FOR DETERMINING

BRAIN DEATH
DECEMBER 2005
Three essential findings in brain death are :

1. Coma

2. Absence of brainstem reflexes

3. Apnea

A patient determined to be brain dead is legally and

clinically dead.
 The diagnosis of brain death is primarily clinical.

 No other tests are required if the full clinical examination,

including each of two assessments of brain stem reflexes
and a single apnea test, are conclusively performed.

 In the absence of either complete clinical findings

consistent with brain death, or confirmatory tests
demonstrating brain death, brain death cannot be
diagnosed.
Responsibilities of Physicians
determining Brain Death

 Evaluate the irreversibility and potential

causes of coma
 Notification
 Conduct the first clinical assessment
 Observe for any clinical inconsistencies
with the diagnosis
 Conduct the second clinical assessment
 Perform and document the apnea test

 Perform confirmatory testing, if indicated

 Certify brain death

 Withdraw cardio-respiratory support in

accordance with hospital policies, including
those for organ donation.
STEP 1: EVALUATION OF
COMA
The determination of brain death requires the
identification of the proximate cause and
irreversibility of coma.
 SEVERE HEAD INJURY
 HYPERTENSIVE ICH
 MASSIVE SAH
 HYPOXIC ISCHAEMIC INJURY
 FULMINANT LIVER FAILURE etc
The evaluation should include:
 Clinical or neuro-imaging evidence of an acute
CNS catastrophe that is compatible with the clinical
diagnosis of brain death
 Exclusion of complicating medical conditions that
may confound clinical assessment like:
1. Severe electrolyte abnormalities
2. Severe acid base disorders
3. Endocrine disturbances like hypoglycemia,
myxedema coma etc
 Lack of significant hypothermia or
hypotension defined by:

1. Core temperature ≥ 32° C (89.6°F)

2. Systolic blood pressure ≥ 90 mm Hg

Applicable for ≥ 18yrs

 Exclusion of drug intoxication or
poisoning.

 Screening test for drugs may be useful but not for

drugs like fentanyl, lithium, cyanide etc..
 The drug level should below the therapeutic range
 Should be observed at least four times the
elimination half life of the drug
 If the particular drug is not known but high
suspicion persists, the patient should be observed
for 48hours to determine whether a change in
brain-stem reflexes occurs; if no change is
observed, a confirmatory test should be performed.
STEP 2: NOTIFICATION
 The facility must make diligent efforts to
notify the person closest to the patient that the
process for determining brain death is
underway.
 Religious and moral objections should be taken
into account and referred to the concerned
hospital staff accordingly
 Where family members object to invasive
confirmatory tests, physicians should rely on
the guidance of hospital counsel and the ethics
committee.
STEP 3: CLINICAL
ASSESSMENT
 COMA OR UNRESPONSIVENESS:

No cerebral motor response to pain

in all extremities (nail-bed pressure)
and supraorbital pressure
ABSENCE OF BRAINSTEM
RESPONSES:
 PUPILS:

 NO RESPONSE TO BRIGHT LIGHT

 SIZE MID POSITION(4MM) TO DILATED

(9MM)
 OCULAR MOVEMENT:
 No oculocephalic reflex (testing only when no
fracture or instability of the cervical spine or skull
base is apparent)

 No deviation of the eyes to irrigation in each ear

with 50 ml of cold water (tympanic membranes
intact; allow 1 minute after injection and at least 5
minutes between testing on each side)
 Facial sensation and facial motor response :

 No corneal reflex

 No jaw reflex (optional)

 No grimacing to deep pressure on nail bed,

supraorbital ridge, or temporomandibular joint
 Pharyngeal and tracheal reflexes:

 No response after stimulation of the posterior

pharynx

 No cough response to tracheobronchial

suctioning
CONFOUNDING FACTORS:
 FOLLOWING CONDITIONS:
 Severe facial or cervical spine trauma
 Preexisting pupillary abnormalities
 Toxic levels of any sedative drugs,
aminoglycosides, tricyclic antidepressants,
anticholinergics, antiepileptic drugs,
chemotherapeutic agents, or neuromuscular
blocking agents
 Sleep apnea or severe pulmonary disease resulting
in chronic retention of CO2
STEP 4: INTERVAL
OBSERVATION PERIOD
 After the first clinical exam, the patient should be
observed for a defined period of time for clinical
manifestations that are inconsistent with the diagnosis
of brain death. Most experts agree that a 6 hour
observation period is sufficient and reasonable
 When a confirmatory test confirms the diagnosis of
brain death, the interval between clinical assessments
can be shortened to 2 hours. If any part of the clinical
determination including the apnea test cannot be
completed, one of the confirmatory tests is required
and the interval may be shortened to 2 hours.
STEP 5: APNEA TEST
 BEFORE TESTNG, THE PHYSICIAN
SHOULD ENSURE THE FOLLOWING:
 Core temperature ≥ 36.5°C or 97.7°F
 Euvolemia. Option: positive fluid balance in the
previous 6 hours
 Normal PCO2. Option: arterial PCO2 ≥ 40 mm Hg
 Normal PO2. Option: pre-oxygenation to arterial
PO2 ≥ 200 mm Hg
PREOCEDURE:
 Connect a pulse oximeter and disconnect the
ventilator
 Deliver 100% O2, 6 l/min, into the trachea.
Option: place a cannula at the level of the
carina
 Look closely for respiratory movements
(abdominal or chest excursions that produce
adequate tidal volumes)
CONTD.
 Measure arterial PO2, PCO2, and pH after
approximately 8 minutes and reconnect the ventilator
 If respiratory movements are absent and arterial PCO2
is ≥ 60 mm Hg (option: 20 mm Hg increase in PCO2
over a baseline normal PCO2), the apnea test result is
positive (i.e. it supports the diagnosis of brain death)
 If respiratory movements are observed, the apnea test
result is negative (i.e. it does not support the clinical
diagnosis of brain death)
CONTD:
 Connect the ventilator if, during testing, the systolic blood
pressure becomes < 90 mmHg (or below age appropriate
thresholds in children less than 18 years of age) or the
pulse oximeter indicates significant oxygen de saturation,
or cardiac arrhythmias develop; immediately draw an
arterial blood sample and analyze arterial blood gas. If
PCO2 is ≥ 60mm Hg or PCO2 increase is ≥ 20 mm Hg
over baseline normal PCO2, the apnea test result is
positive (it supports the clinical diagnosis of brain death);
if PCO2 is < 60 mm Hg and PCO2 increase is < 20 mm
Hg over baseline normal PCO2, the result is indeterminate
and a confirmatory test can be considered.
Confirmatory Testing as
Indicated
 When the full clinical examination, including
both assessments of brain stem reflexes and
the apnea test, is conclusively performed, no
additional testing is required to determine
brain death
 skull or cervical injuries, cardiovascular
instability
 may also be used to reassure family members
and medical staff
AVIALABLE METHODS:
 Angiography (conventional, computerized
tomographic, magnetic resonance, and
radionuclide):

Brain death confirmed by demonstrating the

absence of intracerebral filling at the level of
the carotid bifurcation or Circle of Willis
 Electroencephalography: Brain death
confirmed by documenting the absence of
electrical activity during at least 30 minutes of
recording that adheres to the minimal
technical criteria for EEG recording in
suspected brain death as adopted by the
American Electroencephalographic Society,
including 16-channel EEG instruments.
 Nuclear brain scanning:
Brain death confirmed by absence of uptake of
isotope in brain parenchyma and/or vasculature,
depending on isotope and technique used
 Transcranial doppler ultrasonography:
Small systolic peaks in early systole without
diastolic flow
 Somatosensory evoked potentials:
Brain death confirmed by bilateral absence of N20-
P22response with median nerve stimulation
 Interval between two evaluations, according to patient’s age:
Term to 2 mo old, 48 hr
>2 mo to 1 yr old, 24 hr
>1 yr to <18 yr old, 12 hr
»18 yr old, interval optional
 Confirmatory tests:
Term to 2 mo old, 2 confirmatory tests
>2 mo to 1 yr old, 1 confirmatory test
>1 yr to <18 yr old, optional
»18 yr old, optional

N Engl J Med, Vol. 344, No.

16April 19, 2001 www.nejm.org
Problems in donor management:
 Hypotension, hypovolemia: CVP 10-14mm hg
 Low hemoglobin
 Cardiac contractility: MBP > 60mm hg
 DI: vasopressin
 Arrythmias
 Sepsis
 Aspiration pneumonitis
 Hypothermia
 Hyperglycemia
 Coagulopathy
 Hormonal deficiencies
ROUTINE TESTS FOR BRAIN
DEAD:
 Blood group, tissue matching, LFT/RFT, CBC
 After consent – HIV, HbsAg, Anti-HCV, CMV, VDRL
 Kidney donation – HLA typing (arranged by the
transplant coordinator), USG kidney
 Liver - +/- USG liver
 Heart – 12 lead ECG, echocardiogram, if donor > 50
years old, coronary angiogram
 Lung – CXR, ABG, bronchoscopy by lung transplant
surgeons
CONTRAINDICATIONS FOR
ORGAN DONATION:
 Age criteria: Donor age is evaluated relative to organ function rather than in
absolute chronologic terms. Cadaveric donors has increased 30%, the number
of donors older than 65 years of age has increased 535% .In spite of this
trend, however, the ideal donor age is still considered to be 10 to 50 years
 Infection: Donors with a recent history of infection documented by a positive
blood, sputum, or urine culture must receive appropriate antibiotic coverage
and have negative culture results to be considered for donation. The common
infections that should be rule out are HIV, syphilis, HBV, HCV and CMV.
 Malignancy: Low-grade skin cancers, low-grade solid organ tumors with a
greater than 5-year documented tumor-free interval, and primary brain tumors
that have not undergone previous surgery usually do not preclude organ
donation
 Severe Systemic Disease: The ideal organ donor is relatively young, and is
free of and with no history of end-organ disease. Each organ system is
evaluated separately. Other than carcinoma (except primary brain tumor), no
disease by itself should be considered a contraindication to organ donation.
PROBLEMS IN IMPLEMENTATION
OF THE ACT:
 Misperceptions that hinder donor registration  like:
 People erroneously believe that a person can recover from ‘brain death’ 
 Some people think doctors may not try very hard to save their lives if
they know about their wish to be a donor 
 Superstitious belief that the dead body without the vital organs is
incomplete and the dead person will not ‘rest in peace’ 
  People assume there is a buy-sell black market for organs and tissue
transplant 
 Many people who wish to donate their organs and tissues are not sure
that they will be acceptable as donors. Actually, age or health conditions
should not prevent people from becoming potential donors 
 Socio cultural issues
 Lack of awareness
Is a Person Diagnosed as Brain Dead in a
Comatose State or Dead?
Dead

Coma /
Don't Know
Donor

63% 37%

Non-Donor

45% 55%
0% 20% 40% 60% 80% 100%

Franz, et.al. 1997.

 True or False: People Cannot Recover
When They are Brain Dead
True

Not True /
Don't Know
Donor

74% 26%

Non-Donor

34% 66%
0% 20% 40% 60% 80% 100%

Franz, et.al. 1997.

 Poor Understanding of brain death is
associated with significantly lower rates of
consent to donate organs of the deceased.

Journal of Transplant Coordination

Vol. 7, Number 1, March 1997
An last but not the least:
 Malpractice: can involve any level.
 There are four thieves:
 Intensivist and team with certifying
neurologist
 Organ transplant surgeons and physicians
 Administrative authority
 Ethical committee-to sort out the conflict
arising out of these
 THE MOST TRANSPLANTED ORGANS
ARE KIDNEYS, LIVER AND SOME LESS
COMMON ONES ARE
HEART,PANCREASE,GUT ETC
 IPGMER IS SELECTED AS ONE OF THE
ORGAN TRANSPLANT CENTRES
HOW TO INCREASE?
 Increasing organ availability
 Directive on quality and safety
 Organising transplant systems more
efficiently
 Mobilization of more centres
 Involving voluntary nongovernment
organizations
And finally…….
And finally:….

Motivating people
Thank you

Thank you