Management of a Brain dead donor until retrieval

Management of a Brain dead donor until retrieval of organs ISCCM FOUNDATION DAY

General approach to these issues • Practice ‘good house-keeping’ • Use [your] standard approaches to issues • Maintain [extracranial] organ perfusion • Prevent adverse sequelae of brain death • Correct abnormal physiology if necessary to facilitate clinical brain death testing • Exclude contraindications to donation • Consult Organ Donation agency at any time for advice

Physiological support before brain death Brain oriented intensive treatments – Ventilation, MAP and CPP support, osmolar control, temperature control, CSF drainage Assessment of CNS function – Investigations and clinical assessment – Requires absence of CNS-active agents Withdrawal of brain-oriented treatments – After reliable prognosis and consensus – May include continuation of ventilation and MAP support for extra-cranial organ function

Physiological support after brain death Why do this? – To preserve best possible function of all organs that might be donated and transplanted How is this done? – ISCCM Donor Management Guidelines, consultation with Organ Donation Agency – Ventilation, fluids and inotropes, DDAVP, warming … – Usual basic treatments for a critically ill patient (turns, suction, surveillance, infection control) – Monitoring and investigations

ISCCM Statement 2017 Indian J Crit Care Med 2017; 21: 303 -16.

Overview of specific issues Respiratory care: – Routine suctioning, positioning and turning, ventilatory techniques that reduce atelectasis (e. g. PEEP, recruitment manoeuvres) and avoidance of interstitial fluid overload help to maintain adequate oxygenation and oxygen delivery to organs – Such an approach is vital for optimising lung utilisation and for successful lung transplantation outcomes

Overview of specific issues Management of the circulation: – Autonomic storm is transient. Use only shortacting agents (e. g. esmolol, sodium nitroprusside) – Arrhythmias – Electrolytes, Volume, Temperature and drugs – Bradycardia resistant to atropine; adrenaline, isoprenaline may be effective – In cardiac arrest, CPR may result in recovery of cardiac function and successful transplantation

Overview of specific issues Management of the circulation – Hypovolaemia – Volume state should be optimised by the administration of intravenous (IV) fluids. – Competing requirements for optimising organ function may produce conflicting strategies for fluid replacement. – Identifying early which organs are suitable for transplantation makes it possible to develop focused medical management strategies

Overview of specific issues Management of the circulation – Hypotension and/or low cardiac output – An adequate perfusion pressure should be targeted (e. g. MAP > 70 mm. Hg) by optimising volume state and use of inotropic agents. – >90% need inotropic support – ~ 85% receive Noradrenalin

Overview of specific issues Management of the circulation – Hormonal resuscitation – There is no Level I or Level II evidence to endorse the use of hormonal resuscitation – Recommended if persistent hemodynamic instability/ EF <45% – T 3 - 4 mcg IV , then 3 mcg/hour – Steroids – Methylprednisolone 15 mg/Kg Bolus

Overview of specific issues Diabetes insipidus (DI) – DDAVP or vasopressin should be administered early. – DDAVP usually given as IV bolus 2 to 4 μg (paediatric: 0. 25 to 2 μg) every 2 to 6 hours, or as required. – Vasopressin given as an IV infusion at a dose of 0. 5 to 2. 0 U/h (paediatric: 0. 002 to 0. 04 U/kg/h). – Volume replacements

Overview of specific issues Metabolic derangement – Appropriate IV fluid is required to maintain euvolaemia and electrolytes within normal range. – Serum sodium and potassium should be monitored every 2 – 4 hours to guide fluid replacement and electrolyte supplementation. – Insulin infusion may be given to maintain blood glucose in the normal range • Hypothermia is easier to prevent than reverse.

Overview of specific issues Anaemia and coagulopathy – Blood, coagulation factors and platelets transfusion may be required to correct severe anaemia and/or coagulopathy. – Procurement should be expedited if there is a worsening coagulopathy. Nutrition: – Continuing enteral feeding might have beneficial effects on organ function in transplant recipients. – Gastric stasis Neuromuscular Blocking Agents, Adequate IV access, Continued monitoring

Overview of specific issues Donor management during organ retrieval: – Anaesthetist should ensure adequate monitoring. – Blood products should be available – Normal ventilatory and circulatory parameters maintained. – Neuromuscular blocking drug. – Sympathetic responses could result in myocardial injury and exacerbate bleeding. – Opioid agents are also used but may not suppress catecholamine-mediated sympathetic activity.

Specific problems and solutions Severe oxygenation failure – What is the diagnosis? – Can lung function be improved? (diuretic, physiotherapy, position, suctioning, bronchoscopy) Spinal reflexes – These may occur during brain death testing – Warn everyone (especially family members) – Explain what these are when they occur – They may also occur during organ reterivalr – PLEASE EXTUBATE PATIENT IN OPERATION THEATRE

Some reassurance • • • Do what you usually do and do it well Maintain usual vigilance and attention Approach problems systematically Most problems are amenable to solution Serious problems are uncommon Advice is always available from me at any time of the day or night