Clinical Diagnosis Of Brain Death

With increased reliance on clinical criteria for determining brain death, the approach to this diagnosis should be in a stepwise and systematic fashion. The clinical diagnosis of brain death involves three steps that are outlined below. Adherence to this logical and stepwise process assures that clinical testing is applied to properly selected patients in pooled series, there have been no survivors among patients fulfilling these criteria.3 The patient must be in deep coma on the ventilator....

Small Bowel Procurement

Small bowel retrieval can be a part of multivisceral procurement.17 The principles of multivisceral procurement were described by Starzl.18 In brief, a complete multivisceral specimen is removed as a grape cluster with a double central stem consisting of the celiac axis and superior mesenteric artery. If only the small bowel is to be procured then only the superior mesenteric artery is preserved. Venous outflow of the grafts that include the liver is with a segment of the retrohepatic inferior...

Phase 4the Grieving Process

Death is an inevitable part of the human experience yet we all have some level of emotional discomfort with death. It is only natural that we experience fears and concerns when we come in contact with the dead or dying and their loved ones. Even though we cannot do anything medically for those already dead, we can do a great deal to influence the way a family will begin coping with its loss. However, we must understand the grieving process so we can be optimally effective in our interactions.12...

Management Of Hypertension

Hypertension results from an intense sympathetic storm. Increased circulating catecholamines associated with rises in intracranial pressure produce marked hypertension as well as tachycardia and pronounced vasoconstriction. Electrocardiographic and enzyme changes indicative of myocardial ischemia have been documented during this phase. Acute left ventricular failure and pulmonary edema may result. Fortunately this period is usually self-limiting and requires no treatment. If treatment is...

Delayed Graft Function And Chronic Rejection

Delayed graft function(DGF) occurs in every organ preserved and transplanted. The magnitude and consequences of DGF, however, is different for each organ. In the kidney DGF is characterized as the need for dialysis because of insufficient renal function to regulate the composition of the blood. Most kidney transplant patients with DGF recover near-normal function within a few weeks or so after transplantation. In the liver, delayed graft function (initial poor function) leads to longer ICU...

Phase 6aftercare Of The Family

Several OPOs are currently obtaining follow-up information from families who choose not to donate. The intent of the follow-up is to identify those situations or circumstances that may have influenced the family's decision to decline. The importance of making a decision about donation and sharing that decision with family members is clear from this follow-up. Many families report that they did not know the wishes of their next of kin regarding donation. They chose not to donate because they...

Principles Of Organ Preservation

CaCl2 was omitted when the solution was used for the initial flush. This method involves flushout of the organ with a suitable solution to remove blood elements and to cool the organ. The organ is then stored in the preservative solution at a temperature of 0 to 4 C. The success of this method is dependent upon the use of hypothermia. Cooling the organ from 37 C to 0 to 4 C slows enzymatic reactions by 10-fold or more.18 The low temperature is one of the most critical components of successful...

Management Of Electrolyte Disorders

The impact of donor hypernatremia upon posttransplant organ function is controversial. Recent studies in liver recipients are conflicting suggesting either no effects or harmful effects in terms of graft outcome. The true significance of hypernatremia may well be masked by many other variables and changes which occur in organ donors. The presence of hypernatremia is however significant in that it indicates excessive water loss or excess sodium intake and should therefore serve as a guide to...

Discussion

Organs procured from brain-dead organ donors undergo a series of noxious events which are initiated in the potential organ donor such as shock, hypoxia-ischemia, multiple transfusions etc. During the death of the brain, two types of injury occur the first, as a result of the catecholamine storm and the second, as a result of the endocrine derangement and inhibition of the aerobic pathways. Further manipulation, such as prolonged cold preservation and reperfusion injury in the recipient,...

Optimal Management

Roza, Christopher A. Johnson, Mark B. Adams Management of Management of Management of Electrolyte Disorders Management of Management of Management of Management of Management of Nutritional Support of the Abdominal Organ Modulation of the Inflammatory Response 92 7. Optimal Thoracic Organ Donor Management 94 Dan M. Meyer, Michael A. Wait, Michael E. Jessen, W. Steves Ring Donor Selection (General) Donor Selection (Organ Donor Preoperative S. Surgical Technique for...

Historical Background

For many centuries death was determined based on cessation of cardiorespiratory function. Advances in medical technology have allowed for cardiac and respiratory functions to be maintained artificially even in the presence of irreversible loss of brain function. As early as 1959, published reports described clinical Organ Procurement and Preservation, edited by Goran B. Klintmalm and Marlon F. Levy. 1999 Landes Bioscience conditions similar to what we currently view as brain death.1,2 Mollaret...

Combined Donor Cardiectomy And Pneumonectomy

Prior to operative extraction of the lung block, a flexible fiberoptic bronchoscopic examinaton of the trachea, lobar, and segmental bronchi is performed. The airways are inspected for evidence of gastroesophageal aspiration including gross purulence, mucosal erythema, blood, foreign bodies, or gastric contents. Minor purulent endobronchial secretions that clear easily with bronchial lavage and are not associated with mucosal inflammation are not considered a contraindication to...

High Energy Phosphates

Creatine phosphate (CP) measured in hearts procured from (A) alive animals, (B) brain-dead, (C) brain-dead T3 treated, (D) brain-dead stored, and (E) brain-dead, T3 treated and stored. A vs. B p < 0.02, D vs. A p < 0.05. The CP in T3 treated animals remained unchanged or improved C vs. A ns and E vs. A p < 0.05. Fig. 3.10. Creatine phosphate (CP) measured in hearts procured from (A) alive animals, (B) brain-dead, (C) brain-dead T3 treated, (D) brain-dead stored, and (E)...

Confirmatory Tests For Brain Death

Examination for brain death can be frequently completed based on the clinical criteria outlined above without the need for confirmatory testing. In published reports on adult patients diagnosed as brain dead using these criteria there have been no survivors.11 However, in a significant number of patients where these criteria are not met (hypoxic brain injury, chronic obstructive pulmonary disease, young children), there may be an indication to shorten the observation period (hemodynamic...

Phase 3understanding Brain Death

One of the greatest challenges for any physician or OPR is explaining death to a family. The definition of death with which most people are familiar is the permanent cessation of respiration and circulation. The concept of brain death is extremely challenging to explain not only to family members, but also to hospital personnel. In fact, it was not until 1968 that the major step was taken toward redefining death to include brain death. The Harvard criteria, developed at the Harvard Medical...

Future Of Organ Preservation

Improving organ preservation by developing a new cold storage solution is a goal of many investigators. Currently, a common approach is to make minor changes in the UW solution and make a claim for an improved and different preservation. It may be difficult to dramatically improve organ preservation by simple cold storage and we may have reached the limits of safe storage (about 24 to 48 hours). The reason for this conclusion is based upon the organ's need for a source of energy to prevent...

Kidney Procurement

The main principle of donor kidney procurement is en bloc removal of both kidneys with an intact segment of aorta and inferior vena cava.10-12 This allows safe and rapid excision of kidneys with maximal vessel length available for anastomosis. Operative trauma to renal vessels and vascular supply of the ureter is kept minimal with this technique. Organ donors can be expected to have a renal vascular or ureteric anomaly in up to 49 of cases (Table 8.2).13 Kidney Procurement as a Part of Multiple...

Artificial Organs And Other Body Parts

The search for artificial organs and tissues has been proceeding for the past four decades as advances in tissue engineering and bioengineering generally have made possible all sorts of off-the-shelf life-sustaining products.52 Research is currently ongoing in the development of artificial lungs, livers, hearts, pancreases, corneas and other organs and tissues and the expectation is that we will have these available in the 21st century.53 Earlier clinical efforts with implanting mechanical...

Pancreas Procurement

Pancreas retrieval is usually a part of a multiple intra-abdominal organ procurement. Combined liver and pancreas procurement requires meticulous surgical technique.14 The main technical consideration in combined liver and pancreas procurement is preservation of arterial blood supply and adequate length of portal vein for both organs.15 As the liver and pancreas share the same arterial supply and arterial anomalies are common, careful dissection and good communication between pancreas and liver...

Donor Preoperative Management

Invasive Hemodynamic Monitoring Initial Management Invasive hemodynamic monitoring is used selectively in donors to assist in optimizing cardiovascular management prior to organ procurement. In the unstable donor it is essential to determine the relative need for volume expansion versus inotropes versus vasopressors, since appropriate therapy will maximize the number of suitable organs. An arterial line is used for close monitoring of all donors. Central venous pressure monitoring is also...

Liver Procurement

According to the degree of preliminary dissection, liver procurement can be classified into standard and rapid perfusion techniques.5 In the standard technique, preliminary dissections of the hepatic artery, celiac axis and portal vein are carried out before aortic and portal flushing with preservation solutions. Standard technique allows the dissection of vascular structures to an extent that anatomy is clarified.6 The rest of the dissection is then completed easily and safely after...

Management Of Coagulopathy

Coagulopathy is common in the brain injured potential organ donor. Disseminated intravascular coagulation DIC or fibrinolysis may occur after penetrating or severe closed head injury. This results from the release into the circulation of tissue thromboplastin and plasminogen. Hypothermia and catecholamines both affect platelet function further contributing to coagulopathy. Resuscitation may also result in a dilutional coagulopathy resulting from decreased numbers of platelets. In the massively...

Histological Changes

As result of the adrenergic storm, tissue injury has been observed in the experimental animal and in organs procured from brain-dead organ donors. The injury pattern is widely distributed through the examined organs and follows the pattern observed in conditions in which ischemia and reperfusion play an important role. Thus, the role of calcium overload and oxygen free radicals are interrelated to the Autonomic storm.3 In the heart, under light microscopy, approximately 75 of the experimental...