Krishna Institute of Medical Sciences ( KIMS )

Dr. JAYASHREE PATKI MBBS, MD, PGDHHMSr. ConsultantKrishna Institute of Medical SciencesHyderabad

Transplantation of Human Organs Act, 1994

Aims

Regulate removal, storage and transplantation of human organs for therapeutic purposes

To prevent commercial dealings in organs

Recognise Brain Death

Historical Aspects – Cadaver Transplantation – India

1967 - First successful cadaver Kidney Transplant in India at KEM Hospital, Bombay

1994 - First successful heart transplant done at AIIMS, N.Delhi

1995 - First successful multi-organ transplant done at Apollo Hospital, Chennai

1998 – First Successful Lung transplant, Madras Medical Mission Hospital, Chennai

1999 – First Pancreas Transplant, Ahemdabad

Indian facts –Around 10 lakh ESRD patients

Only 2% (20,000) patients get treated

Only 500 dialysis centers

Only 3000 dialysis machines

Only 80 transplant centers

Only 3000 kidney transplants take place / year

98% are live related transplants

Only 2% are cadaveric transplants

MOHAN FOUNDATION MultiOrganHarvestingAidNetworkFormation1997

Type nongovernment charityPurposeOrganDonation

Headquarters Chennai, India

Founder SunilShroff

Website www.mohanfoundation.org

The anesthesiologist plays a pivotal role in organ procurement from the brain dead patient, as haemodynamics, thermoregulation, volume status, and skeletal muscle paralysis require active management which are vital to the procurement of healthy organs.

In the presence of brain death, spinal cord function is still intact and both somatic and visceral reflexes still remain.

Effective anesthetic management of donor requires an understanding of these effects .

Brain Death :Definition :

Cardiac death:Heartbeat and breathing stop

Brain death:Irreversible cessation of all functions of the entire brain, including the brain stem Irreversible coma and apnoeaLoss of brain stem functions

The declaration of brain death is based on :

The presence of unresponsive coma

The absence of brainstem reflexes

The absence of respiratory drive after CO2 challenge

Tests done : Apnoea testEEGCerebral angiographyTech 99 Isotope brain scan MR angioTranscranial USGSomatosensory evoked potential

live patient brain dead patient

Cerebral angio

Management of donor :

Starts in ICU and ends on OT

Continuation of ICU care till the organs are harvested

Main goal shifts from optimizing cerebral perfusion pressure to maintaining hemodynamic stability

Following the diagnosis of Brain Death:

The normal squeals of brain death results in cardiovascular instability & poor organ perfusion.

Anesthetist must focus on:- Providing hemodynamic stabilization.- Support of body homeostasis.- Maintenance of adequate cellular

oxygenation and donor organ perfusion.

Without appropriate intervention brain death is followed by severe injury to most other organ systems. Circulatory collapse will usually occur within 48hrs.

Common Clinical Problems Of Brain Stem Dead Patient :

HypotensionHypothermiaEndocrine DisturbancesElectrolyte ImbalanceArrhythmiasHypoxia

Uncommon Clinical Problems

CoagulopathyNeurogenic Pulmonary Oedema

Pathophysiology :

Loss of brain stem function results in systemic physiologic instability

Loss of vasomotor control leads to hyperdynamic state

Cardiac arrhythmias

Loss of respiratory function

Loss of temperature regulation Hypothrmia

Hormonal imbalence DI, Hypothyriodism

Cardiovascular management :

Rule of 100’s: SBP >100 mm HgU /O >100 ml / hrPaO2 >100 mm Hg Hb >100 gm / L HR > 100RBS = 100CVP = 10

Avoiding lactic acidosis (pH = 7.35 – 7.45) and hypothermia (temperature > 34o C)

Preoprative preperation :Check ----

ConsentMLC Formalities Police enquiryInvestigationsVitalsSupportsAntibioticsLines-CVC, art . LineTransfer to OT Work up of the Receipient

Intraoperative Management :Monitors –Pulse oximetry 5 lead electrocardiogram (ECG) Invasive arterial blood pressure Central venous pressure Urine output Temperature monitoring with nasopharyngeal probe P A Pressure and Cardiac output (in selected cases

having low LVEF )Fluid warmers n body warmersTransport- chance of disconnection of circuit and iv

lines leading to hypotention and hypoxia

Parameter TargetHeart rate 60–120 beats min−1

Arterial pressure Systolic pressure >100 mm HgMean pressure ≥70 mm Hg

Central venous pressure 6–10 mm HgUrine output 0.5–3 ml kg−1 h−1

Electrolytes Serum sodium 130–150 mmol litre−1

Normal potassium, calcium, magnesium, phosphateGlucose 4–8 mmol litre−1

Blood gases pH: 7.35–7.45: 4.7–6 kPa: ≥10.7 kPa saturation ≥95%

If pulmonary artery catheter inserted Pulmonary capillary wedge pressure 6–10 mm Hg Cardiac index 2.4 litre min−1 m−2

 Systemic vascular resistance 800–1200 dyn s cm−5

Suggested cardiovascular goals for the active management of potential organ donors

Anaesthetic Management: Goals

Pt. preservation to organ preservation

Maintain hemodynamic stability

Avoid ischemia

Maintain adequate urine volume

Prevention of hypothermia

Critical care management of potential organ donor is crucial in maximizing the number and the quality of transplanted organs

Goal is to provide adequate oxygen supply and tissue perfusion

Cardiac Myocardial injury Loss of vascular tone Hemodynamic instability Hypovolemia

Pulmonary • Increased pulmonary capillary permeability

• Pulmonary edema

Endocrine • Pituitary infarction may lead to diabetes

insipidus and obliteration of thyroid axis • Hyperglycemia • Hypernatremia

Hematologic • Coagulopathy, which may progress to

disseminated intravascular coagulation

Skeletal muscles

Restore intravascular volume, replacing evaporative and DI urinary losses.

• Use vasopressors as necessary to maintain adequate organ perfusion.

• Maintain SBP > 100 mmHg, MAP > 70, HR 60-120 beats·min−1.

• “Lung-protective” ventilatory strategy: TV 6-8 mL·kg−1 of predicted body weight, PEEP 8-10 cm H2O.

• Judicious intravenous fluid; CVP 4-8 (< 10) mmHg.

• Vasopressin to support hemodynamics and control polyuria. • Insulin infusion to maintain serum glucose < 180 mg·dL−1

• Consider hormone replacement—thyroxine or T3 infusion, corticosteroids

• Transfuse for hemoglobin < 7 or 8 g·dL−1 for optimal oxygen delivery to organs.

• Correct coagulopathy with clotting factors or platelets if evidence of ongoing bleeding.

• Reflex somatic movements mediated by spinal reflexes • Skeletal muscle relaxents

Intraoperative Management :

Faced with the knowledge of the persistence of higher brain and spinal function in some donors,

the inability to test the reticular formation directly

And the dramatic peroperative haemodynamic

changes that occur

--- sedation and analgesia should be given with muscle relaxation for organ donation

Haemodynamic response could be considered to represent an organism in distress and probably occurs at a spinal level, although we are unaware of EEG studies during organ collection to confirm this.

There is as yet no way to know whether these cases indeed have no sensation.

Anaesthetic Agents :

Isoflurane and sevoflurane cause ischemic preconditioning of organs and improve graft organ function by offering protection against cold and warm ischemia .

They may have a beneficial effect by causing peripheral vasodilation.

Neuromuscular blockade required to inhibit spinal motor reflexes.

Brain death may cause hemodynamic response to noxious stimuli like pain which need to be abolished

Muscle relaxants (Vecuronium 0.1mg/kg) are given to allow adequate surgical exposure and suppress the possibility of spinal-reflex-induced patient movement.

Analgesia can be provided with Narcotic analgesic-Fentany1 1-5 µg/kg.

Air and oxygen mixture with inhalation agent can be given

In 2003, Fitzgerald et al19 hypothesized that the administration of

fentanyl could suppress this intraoperative release of catecholamines associated with the hemodynamic changes during the organ procurement surgery.

Fitzgerald RD, Hieber Schweitze E, Luo A, Oczenski W, Lackner -- Eur J Anaesthesiol. 2003;20(12):952-956

Better organ function post transplant and less acute rejection in the recipient

Potential Benefits for Organ Recipients When Inhalational Anesthetic Agents are Administered During Organ Procurement Surgery

De Hert SG, Turani F, Mathur S, Stowe DF. Cardioprotection with volatile anesthetics:

mechanisms and clinical implications. Anesth Analg. 2005;100(6):1584-1593.

Reducing the release of TNF-α and other proinflammatory substances reduces incidence of infiltration into donor organs that can increase probability of acute rejection

Anesthetic preconditioning could reduce ischemia reperfusion injury and resulting organ dysfunction in heart, liver and kidney

Preventing or reducing adrenergic responses could lead to less ischemia reperfusion injury and infiltration of inflammatory substances into transplanted organs

These findings call into question the routine recommendations of the organ procurement agencies that the donors require no anesthesia.

Elliot JM. Brain death. Trauma. 2003;5:23-42.