Donation after Brain-Stem Death DBD

Donation after Brain-Stem Death DBD Dr Sri Nagaiyan Dr Dale Gardiner Dr Gerlinde Mandersloot 17 th May 2013 1

Session Objectives 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 2

MIDLANDS Regional Data Dr Sri Nagaiyan North Staffordshire CLOD 3

Donation after Brain Death (DBD) Mechanically ventilated patient where death has been confirmed using neurological criteria. 85 donors (2012-2013) Kidneys Liver Pancreas Lungs Heart Small Intestine 26.9% increase (last five years) MIDLANDS

Donations over time: Midlands Team 87.5 % MIDLANDS 26.9% 400% 5

Donations over time: Midlands Team MIDLANDS 26.9% 6

DCD DBD kidneys intestine lungs pancreas liver heart

MIDLANDS

MIDLANDS DBD- Neurological death testing rate 100 2nd 88 80 83 84 83 74 72 70 70 66 64 60 65 66 40 ND tested (%) 20 0 Eastern London Midlands North West Northern Northern Ireland Scotland South Central South East South Wales South West Yorkshire Team 1 April 2012 to 30 September 2012, data as at 4 October 2012 -------- National rate 9

100 80 60 40 87 82 76 74 86 78 73 76 76 74 76 74 Ireland Scotland South Central South East South Wales South West Yorkshire MIDLANDS Tied 5th with 3 others -------- National rate ND tested (%) 20 0 DBD- Neurological death testing rate Team Eastern London Midlands North West Northern Northern 1 April 2012 to 31 March 2013, data as at 4 April 2013 10

DBD- Midlands Neurological death testing rate ND tested (%) 100 80 60 40 20 3 19 6 1 9 1 0 2 7 8 1 1 1 1 7 1 6 1 2 1 1 8 5 4 05 0 5 10 15 20 25 30 35 40 Number of neurological death suspected patients 4 1 3 1 Walsall (hidden behind 9) 2 South Warwickshire 3 Mid Staffordshire 4 North Staffordshire 5 Burton 6 Sherwood Forest 7 Coventry 8 Wolverhampton 9 George Eliot 10 The Dudley Group 11 Birmingham Children s 12 Heart of England 13 QE 14 Derby 15 Leicester 16 Worcestershire 17 Nottingham 18 City & Sandwell 19 Shrewsbury and Telford 1 April 2012 to 31 March 2013, data as at 4 April 2013 11

Mean no. of organs donated per DBD donor Tied 3 rd MIDLANDS Northern (1 st ) : Every 5 donors save 1 more life than we do 1 April 2012 to 31 March 2013, data as at 4 April 2013 12

Diagnosis of brain stem death 1976 37 years on 2008 Dr Dale Gardiner Adult Intensive Care Consultant, Nottingham Midlands, Clinical Lead for Organ Donation Member of the UK Donation Ethics Committee 13

not inventors. We are explorers

Brain death: Discovered not Invented (by intensive care) 17

1964, Keith Simpson there is life so long as circulation of oxygenated blood is maintained to live brainstem centres 18

1976 (clarified 1979) UK Criteria for Diagnosing Death using Neurological Criteria Published. 19

Rene Laennec 1819 Eugene Bouchut 1846 2008 UK Criteria for Circulatory Criteria published for the 1 st time. 5 minutes. 20

UK Definition of Death irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe 2008 therefore irreversible cessation of the integrative function of the brain stem equates with the death of the individual. 21

UK Definition of Death irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe All human death is anatomically located to the brain. 2008 therefore irreversible cessation of the integrative function of the brain stem equates with the death of the individual. 22

1 death : 3 sets of criteria Neurological Criteria Circulatory Criteria DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe Somatic Criteria

Dx Death using Neurological 1. 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. Criteria DEATH Irreversible loss of the capacity for consciousness 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: Typical Hypoxia Atypical > 6 hours 24 hours? longer 24

> 10000 patients 10 years 37 years

D. Alan Shewmon, MD

Although we were unable to restore his consciousness or spontaneous breathing, the boy lived several more years. (page 195)

Dx Death using Neurological 1. 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. Criteria DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 2. An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. 30

Dx Death using Neurological Clinical judgement essential Impossible to create rules covering every situation Difficulties mainly with thiopentone and midazolam Criteria 2. An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. Plasma concentrations not good predictors of effect Use of antagonists DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 31

Dx Death using Neurological 1. 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. Criteria 2. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. 3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes. 32

Brain stem reflexes Pupils (II, III) Corneals (V, VII) Pain (V, VII) Gag (IX, X) Cough (IX, X) Oculovestibular (III, VI, VIII) Oculocephalic Paediatric Suck Consciousness Ascending reticular activity system Breathe Medulla Oblongata Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001;344:1215-1221 + AoMRC (2008) 33

Apnoea Test Starting: paco 2 > 6.0 Kpa ph <7.4 Stopping: 5 minutes observation paco 2 rise > 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 (eg Mapleson B). The apnoea test is performed only twice in total. 34

Dx Death using Neurological 1. 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. Criteria 2. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. 3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes. In 2012,1238 tests performed, death confirmed in 1220 =

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 36

WHY TEST?

WHY TEST? 1. To eliminate all possible doubt regarding survivability 2. To confirm diagnosis for families 3. To protect doctors in cases subject to medico legal scrutiny 4. To provide choice regarding organ donation

diagnosis decision

Brainstem death in the

TWO TESTS or ONE? 2008 Dr A performs Dr B observes SWAP Dr B performs Dr A observes = 2 TESTS (regardless of organ donation) Legal support from case law & Bolam & Bolithio tests

TWO TESTS or ONE? 2008 Dr A performs Dr B observes SWAP ALIVE Test 1 Time of Death Dr B performs Dr A observes ALIVE = 2 TESTS (regardless of organ donation) Legal support from case law & Bolam & Bolithio tests Test 2 DECEASED

1976 2008 Lesson 1

Lesson 2

Lesson 3 Take your time Slow down (minimum 6 hours) Don t over-read coning on CT Atypical presentation = wait Hypoxic brain injury >24 hours

Lesson 4 Induced hypothermia has unpredictable consequences See Lesson 3 Advice: warm to normothermia and then wait 24 hours

Lesson 5 NO EEG

Lesson 6 Start with Lesson 2 = use your brain and examine your patient 1. Clinical brain death + NO flow = Death 2. Clinical brain death + flow = Wait See Lesson 3 = take your time and ask Is reversibility possible?

www.clodlog.com Gardiner, Shemie, Manara & Opdam International Perspective on the Diagnosis of Death Br J Anaesthesia Supplement January 2012 Username: Password: Dale Gardiner www.odt.nhs.uk

Optimising the brainstem dead donor Dr Gerlinde Mandersloot National Clinical Lead - Donor Optimisation Dr Gerlinde Mandersloot 20 th April 2012 52

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 55

Collateral damage Hormonal Diabetes insipidus Hypovolaemia Hypernatraemia T3 / T4 reduces ACTH Blood glucose Hypothermia 56

Incidence of organ involvement Hypotension 81% Diabetes insipidus 65% DIC 28% Cardiac dysrrhythmias 25% Pulmonary oedema 18% Metabolic acidosis 11% J Heart Lung Transplantation 2004 (suppl) 57

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. Snell J Heart Lung Transplant 2008;27:662-7 54% of Australian lung donations used for transplant vs. 13% in UK 59

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 60

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/m 2 Guidelines Australian Canadian Map of Medicine ICS NHSBT 61

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/m 2 (can be higher, be aware of myocardial stunning) Filling targets: no good evidence for any specific targets, depends on device SvO 2 > 60% SVRI target Secondary target Dehydration temptation to maintain MAP with vasopressors rather than filling 62

Respiratory management Recruitment manoeuvre Post BSD testing: apnoea test resulting in atelectasis After suctioning / disconnection When SpO 2 drops / FiO 2 increases Lung protective ventilation: 4 8 ml/kg ideal body weight Permissive hypercapnia with ph > 7.25 Optimum PEEP (5 10 cm H 2 O) and FiO 2 (aim for < 0.4 as able) Head up positioning (30-45 ) Suctioning, physiotherapy as required Antibiotics for purulent secretions: local microbiology surveillance Avoid over-hydration 63

Managing Diabetes insipidus Very common occurrence Pathophysiology Posterior pituitary failure Polyuria: output > 4ml/kg/h Dehydration with Na + Usually at least partially addressed with stabilisation for BSD testing Treatment: Fluids Vasopressin DDAVP Aim for u-output 0.5 2.0 ml / kg / h 64

Hormonal treatment Vasopressin Reduction in other vaso-active drugs Dose: 1 4 units/h (can start with boluses of 1 unit at a time) Liothyronine (T3) No clear evidence yet for either use or not May add haemodynamic stability in very unstable donor Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team Methylprednisolone in all cases Dose: 15 mg/kg up to 1g Insulin At least 1 unit/h (Occasionally may need to add glucose infusion) Tight glycaemic control (4-10 mmol/l) 65

Haematological management DIC seen occasionally as direct consequence of BSD May require correcting prior to BSD testing if bleeding Hb > 8 g/dl (~ 10 g/dl traditionally advocated) (even > 7g/dl?) No evidence on harm with lower Hb, but some evidence of harm with blood transfusions and organ function post transplant Where Hb borderline, ensure blood available for retrieval procedure: local protocols and antibodies will determine whether G&S only, or units to be cross matched Use of clotting factors Only where bleeding is an issue Monitor clotting status Use local hospital protocol Retrieval procedure may require additional products 66

General measures Maintain normothermia (active warming may be required) Thrombo-embolism prophylaxis Stockings Sequential compression devices LMWH Positioning Head-up Side to side Attention to cuff pressures and leaks to prevent aspiration Continue NG feeding (may be reduced/ stopped for bowel transplant) Antibiotics according to sensitivities or empirical according to Trust guidelines 67

Monitoring optimisation Implementation: use of care bundle Adherence easy to monitor Audit first 5 priorities Results of optimisation evaluated Number of organs retrieved Increase in cardiothoracic organs retrieved Quality of organs: organ function in recipients Delayed graft function Quality: biomarkers Duration of graft function: long term project 68