Deceased donor. Solid organ transplantation

Transcription

1 Deceased donor Solid organ transplantation

2 Deceased donor donation process 1. Potential donor detection 2. Brain death diagnosis 3. Donor management 4. Organ allocation 5. Organ retrieval

3 Brain death Irreversible coma from Irreversible brain damage Cerebral and Brain stem

4 Potential donor 1. Complete irrecoverable brain stem damage from Head injury Subarachnoid hemorrhage Rupture aneurysm Cerebrovascular accidents (CVA) Hypoxic brain damage Primary brain tumor

5 Brain death Glasgow Coma Scale < 5 Spontaneously 4 To verbal stimuli 3 To pain 2 Eye Open No response 1 To verbal command Obeys 6 Localizes pain 5 Semi-purposeful 4 Decorticates 3 Best motor response To painful stimuli Decerebrates 2 No response 1 Oriented and converses 5 Disoriented and converses 4 Inappropriate words 3 Best verbal response Incomprehensible sounds 2 No response 1

6 Potential donor 2. No Contraindication HIV + Severe infection Malignancy : Except Primary brain tumor Early non metastatic skin cancer Early cervical cancer

7 Brain death diagnosis 1. Presence of condition that leads to brain death 2. Exclude other causes mimics brain death 3. Procedure to confirm brain death

8 1. Conditions that leads to brain death Severe head injury Intracranial bleeding from other cause Rupture cerebral aneurysm Rupture AVM Brain tumor Complication after brain injury Unconscious AND no spontaneous respiration > 6 hours

9 2. No conditions that mimics brain death Hypothermia : T < 32 C Brain hypoxia Drug intoxication Shock ; except neurogenic shock Recent major neurosurgery/head injury If the above condition is present. Make correction and observe conscious neurological sign Duration of observation?

10 ระยะเวลาท เหมาะสม ท จะทดสอบ ภาวะ apnoeic coma ภายหล งจากภาวะด งน Condition Duration (Hours) Major neurosurgery 4 Second subarachnoid bleeding Head injury Spontaneous hemorrhage Brain hypoxia 24 Suspicious drug intoxication 50 6

11 Drug intoxication Sedative Diazepam, Midazolam, Lorazepam Narcotic Fentanyl Pethidine Morphine Heroine Muscle relaxant Succinylcholine Atracurium, Pancuronium, Rocuronium, Vecuronium Guillian Barre syndrome

12 3. Procedure to confirm brain dead 1. No movement, except spinal reflex 2. Absence of brainstem reflex are Persist >= 6 hours AND Diagnosis by 3 MD : exclude transplant team 4. Apnea test + twice, 6 hours apart

13 1. Pupillary light reflex 2. Corneal reflex (blink reflex) Brainstem reflex 3. Motor response within the cranial nerve distribution (face & ocular muscle) 4. Vestibulo-ocular reflex (Caloric test) 5. Oculocephalic reflex (doll s eyes sign) 6. Cough reflex (suction) 7. Gag reflex

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15 3. Procedure to confirm brain dead 1. No movement, except spinal reflex 2. Absence of brainstem reflex are Persist >= 6 hours AND Diagnosis by 3 MD : exclude transplant team 4. Apnea test + twice, 6 hours apart

16 Apnea test 1. Maintain Body temperature > 36 C SBP > 80 mmhg 2. Preoxygenation : FiO 2 100%, RR 10/min, TV 10 ml/kg > 30 min ABG: PaO 2 > 200 and PaCO 2 = 40 mmhg

17 Apnea test 3. Remove respirator Insert NG tube no to carina, O 2 100% rate 6 L/min Monitor EKG, O 2 saturation, If no movement of chest or abdominal wall for 10 mins ABG : PCO 2 > 60 or increase > 20 mmhg from baseline + Apnea test

18 Perform apnea test x 2 Donor age Duration between apnea test (hrs) 2 months-1 year 24 >1-18 years 12 >18 years 6

19 Deceased donor donation process 1. Potential donor detection 2. Brain death diagnosis 3. Donor management 4. Organ allocation 5. Organ retrieval

20 Donor management Goal To maintain organ perfusion and function

21 Brain stem Hypothalamus Anti-Diuretic Hormone (ADH) Maintain consciousness Connect motor and sensory systems from the brain to the rest of the body Regulate cardiac and respiratory system Control Heart rate and Breathing

22 Brain stem death ADH deficiency (DI) Unconsciousness No spontaneous movement & sensation Arrhythmia & Apnea

23 Hypotension Etiology Management Goal Volume depletion Previous/on going bleeding Central diabetes insipidus U/A SpGr. < (DI) PRC ddavp 8ng/kg (1/2 Amp) (Desmopressin, Minirin) NG free H2O D5W <300 ml/min CVP 8-10 cm H 2 O < 8 for lung donor Urine ml/kg/hr ( ml/hr) BS < 150 mg/dl Cerebral salt wasting NSS /RLS Na meq/l Lack of sympathetic tone Adrenal insufficiency Dopamine max 10 mcg/kg/hr (Only if euvolumia + hypotension) ± NE Methylprednisolone 15 mg/kg SBP > 100 mmhg HR /min

24 Respiratory setting : Lung donor TV 6-8 ml/kg PEEP 5-10 cm H 2 O PIP <25 cm H 2 O ABG : ph : SpO 2 > 95% (FiO 2 < 0.4) Temp > 36 C

25 History taking Previous surgery TB HT DM Cardiac condition Kidney disease Cancer Animal bite Fever Admission Medication Drug abuse Alcohol Smoke Behavior Criminal Transfusion Travelling

26 Physical examination Surgical scar Tattoo Foreign body BW (estimate) Height (บ ตรประชาชน) Chest & Abdominal circumference

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33 บ นท กการตรวจว น จฉ ยสมองตาย

34 Process of brain death diagnosis

35 Donor Management

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38 Consent form

39 หากท านพบผ ป วยท อย ในเกณฑ ท จะบร จาคอว ยวะได กร ณาแจ งผ ประสานงานการปล กถ ายอว ยวะ เพ อดาเน นการต อไป โทร. 1666, FAX: โทรศ พท เคล อนท 24 ช วโมง