Indian Organ Donation Day 2015 August 13 : Brain Death And Organ Donation

Indian Organ Donation Day 2015 August 13

Brain Death And Organ Donation

Dr.M.A.Aleem M.D.D.M. (Neuro)
Former of Vice Principal HOD & Professor of Neurology
KAPV Government Medical College & MGM Government Hospital
Consultant neurologist and Epileptologist (Trained at Institution of Neurology Queen,s Square. London.UK.)

ABC Hospital,
Trichy - 620018

President
Trichy Neuro Association
drmaaleem@hotmail.com
Brain Death

The concept of Brain death has been with serious inconsistencies and contradictions. The first serious systematic study was undertaken by the Adhoc committee of the Harvard Medical Scholl to examine the definition of brain Death, Which Published its report in 1968.

It can be determined in several ways:

I. No electrical activity in the brain (determined by EEG)

II. No blood flow to the brain (determined by blood flow studies)

III. Absence of function of all parts of the brain – as determined by clinical assessment (no movement, no response to stimulation, no breathing, no brain reflexes)

Causes of brain death

I. Anoxia

II. Ischemia

III. Intracranial hematoma

IV. A gunshot wound to the head

V. Intracranial Aneurysm

VI. Brain tumors

When any of these occur, they cause swelling of the brain. Because the brain is enclosed in the skull, it doesn’t have room to swell, thus intracranial pressure increases. This can stop blood flow to the brain, killing brain cells and causing herniation of the brain (pushing the brain outside its normal space). When brain cells die, they don’t grow back, thus any damage caused in permanent and irreversible.

Nowadays, modern resuscitative devices and techniques can maintain the function of heart, lungs and visceral organs for a period of time (hours or days) after the life maintaining centers of the brain stem tissue have stopped function which results in a medical dilemma of a dead brain in a otherwise living body.
On the other hand development of transplant surgery and the need of viable organs have focused ethical and legal attention on the desirability of agreeing on medical criteria of brain death.

Brain death is essential in current practice of organ retrieval because it legitimates organ removal from bodies that continue to have circulation and respiration, thereby avoiding ischemic injury to organs.

Preconditions

Reversible causes (must be excluded)

 Intoxication

 Depressant drugs

 Muscle relaxant

 Primary hypothermia

 Hypovolemic shock

 Metabolic and endocrinal disturbances

Criteria for Diagnosis of brain death

In 1981 – the president’s Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research (USA) developed standards for the determination of brain death which with some modifications are accepted world wide.

Some steps are important to be followed:

 Unresponsiveness

 Visual

 Auditory

 Tactile stimuli

 No communication in any manner

 Absence of cerebral and brain stem function

 (-)Absent:

 Pupillary response

 Vestibuloocular reflex (cold caloric test)

 Oculo – cephalic reflex (Doll’s eye movement)

 Corneal reflex

 Gag reflex

 Spontaneous movements of limbs & postural responses (Spinal and tendon reflexes may be present)

 Some peculiar movements of upper limbs have been noted to occur in the confirmed brain death patient & collectively are termed ‘Lazarus sign’

This could be confused with postural response (Hypotension and mechanical stimulation play a role )

Apnea test

 No spontaneous respiration present at PCO2 level of 60 mm Hg

 100% oxygenation maintained by a cannula inserted into endotracheal tube.

 This is consistent with medullary failure.

 Nature of coma must be known

 Some reversible causes must be ruled out

 Hypothermia (body temperature >32oC)

 Drug intoxication or neuromuscular blockade

 Shock etc.

 Persistence of brain dysfunction


 Six hours with a confirmatory isoelectric EEG i.e, “Electro – cerebral silence”

 Twelve hours without a confirmatory EEG.

 Twenty fours for anxic brain injury without a confirmatory isoelectric EEG.

 Confirmatory test (are not necessary to diagnose brain death )

 EEG with physiological brain activity. (False(+ve) and Flase (-ve) results may occur)

 No cerebral circulation present on angiographic examination (Principal legal sign) “Electro cerebral silence + Non – visualization of cerebral arteries’ = Brain death confirmed.

 Brain stem – evoked responses with absent function in vital brain stem structures

 Xenon Computed tomography (CT) scan

 Digital subtraction angiography

 Atropine bolus test

 Transcranial Doppler sonogrraphy which records arterial blood flow at the base of brain (TCD)

 99 mTc HMPAO test (Most premising confirmatory test)

 Single positron emission tomography (PET scan) Best teat

Medico – legal implications

Medically and legally the patients is death. The same time appears on death certificate.

Brain death needs to be certified by board of doctor’s consisting of:

I. Registered Medical Practioner (RMP) in charge of hospital where brain death has occurred.

II. An independent RMP – a specialist.

III. A Neurologist/Neurosurgeon nominated by panel.

IV. RMP treating the patient.

 The patient must be examined by team of doctor’s at least trice with a reasonable gab of time in between (at least 6b hours )

 None of the doctor’s who participate in diagnosis of brain death should have any interest in transplantation or organ removal from cadaver.

i. Organ donation

unless damaged by injury or disease, the organ from a brain dead body may be used by another individual through an organ transplant.

Incase the family wishes to donate the organs / tissue, medications are usually continued until the time the patient is declared brain dead. These medications help to keep the blood pressure and heart rate under control and some reduces swelling in brain.

Organ / tissue transplant offers life or a better quality of life to another person. It gives the donor family the opportunity to help others at this time tragedy and loss.

Organs or tissues that can be donated

 Heart

 Liver

 Lungs

 Pancreas

 Kidney

 Heart valves

 Cornea

 Tissue

 Skin, tendons, ligaments, bones

Organ Donation

It offers to donor an opportunity to help and to recipient’s life or better quality of life.

Transplantation of human organ Act 1994 came in to force in 1995 in India.

Highlights of this act are:

1. Statuary sanction to the brain drain death concept.

2. Regulation of removal storage and transplantation of human organs for therapeutic purposes.

3. Commercial dealings in human organs prevented

Level of awareness about transplantation, brain death & cadaver organ donation:

It is extremely low. Only a small number of individuals are aware that brain death is legal in India. Awareness about brain death is especially low among villagers.

Education about various aspects, its immense importance for organ donation and legality of brain death in India needs to be highlighted.

II. Removal of life supporting system

There is a line of demarcation i.e. when the artificial aide should be stopped so that the docter may not get involved in the offence of culpable homicide not amounting to murder or one of rash and negligent act, if he has removed the aids indiscriminately. Thus he should first consult with other doctors.

Clinician should make it clear to the relatives that ventilation is not being withdrawn to let the patient die but because continued ventilation is immaterial for a patient who is already dead except in case of organ transplant.

III. Other applications:

Akabayashi & Morioka reviewed the feasible uses of brain dead bodies, especially of dead fetus and anencephalics. They are following:

 Donor for organ transplantation including marrow.

 For storage and preservation of organs for transplant

 Factory to produce hormones and antibodies.

 For experimentation

a) In basic medicine to help determine physiologic functions in human in place of animal experimentation.

b) Inclinical medicine I. To serve as disease models II. For use in technological development III. For use in preliminary test of new drugs

c) For education purpose in practical raining and anatomic dissection

 Parkinson’s disease (>1 million sufferers in USA)

They may get potential benefit from tissue (Foetal brain tissue) transplantation.

Relevant facts:

 All over world, Brain death is viewed in difference ways in different countries and different laws have been framed likewise.

 In Canada two physicians who are not associated with a transplant team to certify death.

Reluctance to accept brain death

 Lack of understanding the concept.

 Special emotional attachment to the dead person

 Loss of confidence in medical practice

 Ethical questions related to earlier organ transplant procedure

 Perceived insufficient participation of government and medical associations.


Conclusion

Today much greater attention must be given to understanding the public and professional perceptions of brain death and to educate both groups, to assist in the development of improved and appropriate medical criteria.

Proper laws should be framed perhaps to assure legal and ethical exemption for those who by reason of conscience cannot accept the concept of brain death.