Facilitators: Dr Adam Stokes & Dr Dom Richardson
Summary by: Dr Adam Stokes
Diagnosis of Death and Brainstem Death Testing - Dr. Adam Stokes
- Based on “A Code of Practice for the diagnosis and confirmation of death” produced by Academy of Medical Royal Colleges
• Definition of death: “Death entails the irreversible loss of those essential characteristics which are necessary to the existence of a living human person and, thus, the definition of death should be regarded as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe.”
Conditions necessary to diagnose death:
Known aetiology of irreversible brain damage e.g. intra-cranial event, cardiac arrest, circ insufficiency.
Exclusion of potentially reversible causes of coma.
Circulatory, metabolic & endocrine
No evidence that this state is due to depressant drugs
Length of time between discontinuation & testing depends on total dose, duration, renal/hepatic function & drug level testing.
Use antagonists if possible.
Hypothermia must be excluded
Temp of >34 C recommended.Exclusion of potentially reversible causes of apnoea e.g. relaxants, opiates, sedatives, neuro disorders, c-spine injury.
Diagnosis and confirmation of death following irreversible cessation of brainstem function:
- Absence of brainstem reflexes
◦ Pupils fixed
◦ Absent corneal reflex
◦ Absent oculo-vestibular reflexes – No eye movement following 50ml ice water over 1 min in each ear.
◦ No motor responses within the cranial nerve distribution elicited by adequate stimulation of any somatic area.
◦ No cough reflex to suction catheter placed in trachea to the carina
◦ No gag reflex to posterior pharyngeal stimulation.
◦ No respiratory response to hypercarbia (apnoea test)
◦ Ancillary tests e.g. EEG, angio, may be used when neuro exam difficult.
Diagnosis / confirmation of death following cessation of cardio-resp function:
- Should observe pt for 5 mins to establish irreversible cardio-resp arrest.
◦ Absence of cardiac function confirmed by
- Absence of central pulse
◦ Absence of heart sounds
◦ Can be supplemented with
◦ Asystole on ECG
◦ Absence of flow on arterial line
◦ Absence of contractile activity on Echo
- Any spontaneous return of activity prompts further 5 mins observation
The following then tested
• Pupillary responses
• Corneal reflexes
• Motor response to supra-orbital pressure
The Nuts And Bolts of Organ Donation / Role of SNOD - Dr. Richardson and Bethan Thomas
- Defined clinical trigger factors in patients who have had a catastrophic brain injury
• The absence of one or more cranial nerve reflexes and a GCS of 4 or less that is not explained by sedation
• Unless there is clear reason why the above clinical triggers are not met and/or a decision has been made to perform brainstem death tests, whichever is earlier.
• “The intention to withdraw life sustaining treatment in patients with a life threatening or life limiting condition ”
Management of the Donor
Dr Richardson covered some of the physiological consequences of BSD.
Stabilisation to facilitate neuro exam
Have to balance the harm of inserting lines & giving drugs versus the harm of not fulfilling the patients wish to become a donor.
DBD Donor Optimisation Extended Care Bundle
Gives guidance on target values for CVS, resp, fluids, DVT prevention and lines to be inserted.
- Assess fluid status and correct hypovolaemia
- Perform lung recruitment as at risk of atelectasis
- Identify and treat diabetes insipidus (DI)
- Introduce vasopressin which reduces NA requirement and treats DI
- Give methylprednisolone 15mg/kg to max 1g asap.
- Vasopression – Reduces other vasoactive drugs (Dose 1-4 units/hr)
- Liothyronine (T3) – No clear evidence. May add haemodynamic stability (Dose 3 units/hr).
- Methylprednisolone in all cases (Dose 15mg/kg up to 1g).
The Process and the Role of the SNOD (with timescale)
At 0-4 hours
(1) Signs of BSD
(2) Referral to SNOD
(3) SNOD does initial assessment and checks organ donation register (ODR)
(4) SNOD discusses with Coroner
(5) SNOD goes to ICU to be present when bad news is broken to family.
At 4-8 hours
(6) BSD tests performed
(7) SNOD and ICU staff approach family collaboratively
(8) SNOD consents family and does PMH assessment
(9) SNOD does physical assessment of patient
(10) Bloods are taken for tissue typing and virology
(11) Organ function assessment
(12) Donor management instigated
- Ongoing ICU care, lines, recruitment, bloods, CXR, urinalysis, pregnancy test, echo, ABGs, drug treatment
At 8-14 hours
(13) Potential donor registered with NHSBT duty office via electronic offering system (EOS)
(14) Organs offered to recipient centres
At 11-17 hours
(15) Theatre team mobilised
(16) Ongoing donor management and NOK support
At 14-23 hours
(17) Retrieval can take up to 6 hours
(18) Perfusion of organs
(19) Organs packed for transport
(20) NOK follow-up
Ethical Issues in Organ Donation - Dr. Tom Pratt
- Religious and cultural differences of opinion as to whether brainstem death represents true death
- Organ donation after assisted suicide – in Belgium and Switzerland
- Incentives in Israel have increased donations
- Wales to introduce presumed consent
Dr Adrian Wong - ST7 ICM & Anaesthesia, Wessex
Dr Matt Williams - Consultant in ICM & CLOD, QA Hospital, Portsmouth
South Central Collaborative - Tuesday 13th May 2014
Royal College of Anaesthetists
09.30 - Coffee and Registration
10.00 - Welcome - Susan Richards. Regional Manager
10:05 - Feedback from CLOD/Chair Survey Monkey & End of year Donation Data - Dr Malcolm Watters, Regional CLOD
10.15 - Transplantation Liver - Mr Hector Vilca-Melendez, Consultant Transplant Surgeon, Kings College Hospital
10.45 - Renal, Pancreas & Bowel Transplantation, Mr James Gilbert, Consultant Transplant Surgeon, Oxford University Hospital
11.15 - Coffee
11.30 - Cardiothoracic Transplantation - Dr Bart ZychLead, Transplant Fellow, Harefield Hospital
12.00 - Panel Discussion
12.15 - Performance Management to 2020 - Andrew Jackson, Performance & Business Manager NHSBT
12.45 - Lunch
13.45 - 2020 Strategy – A local hospital level, Andrew Jackson
14.15 - Consent Research - Feedback, Neil Phillips – Head of Strategic Marketing NHSBT
15.00 - Coffee
15.15 -16.00 - Public engagement
Cheltenham’s Experience, Ian Mean – Chair of Cheltenham & Gloucester Hospitals
Northampton Experience, Peter Martin – Chair of Northampton General Hospital ODC
16.00 - Close and Future meetings
End of year Donation Outcome Data – Dr Malcolm Watters, Regional CLOD
Donation after Brain Death (DBD)
• Increased numbers nationally (n=780) but decreased in South Central (SC) Region (n=60)
• Mean number of organs after DBD – 4.2
• Significant rise in heart & heart lung donors (n=203)
• DBD testing rate in SC region – 74% (target 80% nationally)
• Numbers across individual trusts fairly consistent across region
• SNOD involvement high
• Consent rate after brain death – 71%
Donation after Cardiac Death (DCD)
• Considerable variation in rates nationally and within region reflective of uncertainty surrounding DCD
• Referral rates in SC for DCD – 62% (amongst lowest nationally. Lowest in England)
• Consent rate after cardiac death – 56% (just above national average)
• If No SNOD involved, the consent rate drops to 10%
Liver Transplantation – Mr Hector Vilca-Melendez, Consultant Transplant Surgeon, King’s College Hospital
7 liver transplant units in UK (3 paediatrics)
Kings College Hospital (KCH) – 494 active waiting list in 2013
12% of patients on waiting list will die waiting for a transplant
King’s acceptance rate about 1/3 only ½ will be retrieved only 40% of these will be transplanted
20% of offers will be transplanted
King’s acceptance rate 56% 100% will be retrieved 86% will be transplanted
49% of offers will be transplanted
Overall outcome in King’s in 2012-13 (better than other centres, also shown over a 10y period)
• 90 day mortality – 0%
• 90 day graft loss – 0.8%
In super urgent transplants
• 90 day mortality – 0%
• 90 day graft loss – 0%
Cardiothoracic Transplantation – Mr Bart Zych, Lead Transplant Fellow, Harefield Hospital
Heart transplant numbers have plateaued but waiting list numbers have increased
Lung transplant numbers and waiting list numbers both slowly increasing. DCD = DBD lungs outcomes at 1y, perhaps better at 4y outcome (but small numbers).
UK Donor Scout Project (pilot)
• Aggressive donor assessment and management
• Invasive monitoring
• Performed by dedicated team of cardiothoracic transplant team
After brain death, sympathetic storm leads to permanent myocardial damage in 25% of patients.
Transmedic organ care system
Continuous perfusion of retrieved organ at 34 degrees
Organs can be kept at this state for 8 hours compared to 4 hours when kept on ice
Harefield have used to aid 30 heart transplants in 2012-13.
Management of the heartbeating brain-dead organ donor. McKeown et al. BJA 2012;108(1):i96-i107
Renal, Pancreas and Bowel Transplantation – Mr James Gilbert, Consultant Transplant Surgeon, Oxford University Hospital
• Over 6300 people waiting for kidney transplant
• Transplantation improves quality and quantity of life; doubles life expectancy.
• 1 year of HD = 1 tranplant (cost)
• Over 100 altruistic kidney donors last year
• Longer spent on dialysis, the poorer the outcome post transplant
Definitive treatment for type 1 DM
230 transplants last year in UK, Oxford performed 79
Pancreas donor score index – there is an app for that (https://itunes.apple.com/gb/app/pancreas-transplant-donor/id396068767?mt=8)
• Simultaneous pancreas kidney transplant (pancreas exocrine secretions plumbed to duodenum; kidney function marker of both kidney and pancreas graft function.
• Pancreas after kidney
• Pancreas only transplant
Graft function normally monitored by measuring urinary amylase in pancreas-only transplants
Indication – intestinal failure: short gut (<40cm) or non-functioning bowel e.g. ischaemia
Technically, may be difficult to close the abdomen – multiple laparotomies, fistulas, etc. Some now require abdominal wall transplantation (retrieved from deceased donors). Transplanted skin acts as a marker of graft rejection. Possible role of sentinel skin graft (radial forearm).
There is no national coordination for the activities of the various transplant teams. The limited resources may be better utilised by a more central body. This possibility is being reviewed.
Feedback from CLOD/Chair survey monkey – Dr Malcolm Watters, Regional CLOD
Majority of Organ Donation Chairs are from clinical background despite previous recommendations that they are not. Majority of CLODs are Intensivists.
Majority of CLODs and Chairs want further training for their roles and a significant proportion did not attend the 2010 PDP programme.
Case Presentation – Dr Dale Gardiner, Consultant ICM, Deputy National CLOD
2 cases discussed
Redflag discussed – Brainstem testing in context of patients with underlying neuromuscular condition.
Some slight alterations to ICS guidance for brainstem death testing (written originally by Dr Gardiner) have been submitted by Dr Gardiner.
Keep open and transparent communications with families.
Consent Research – Neil Phillips, Head of Strategic Marketing NHSBT
Research around consent for organ donation
• Attitudes towards consent
• Organ donor cards
1) Organ donation not a topic that people are exposed to
a) 50% ever spoken to others about organ donation
b) Women more likely to have chat
2) Theoretical support for organ donation doesn’t translate to personal support
3) Number of strong motivation to discuss donation
a) Improve/save other lives
b) Organ do not go to waste
c) Feel good
d) I would accept and therefore I will donate
a) Worry that staff won’t do all to help save their lives
b) Do not want to think about death
c) Worry over family if organs donated
5) Support less likely with ethnic minority (despite National Faith leaders saying otherwise and agreeing statements).
6) Misconception surrounding process
a) Organ donor register is not well understood
7) Appetite for organ donor cards
a) Majority of people who donate are not actually on ODR
b) Should donor cards be more readily available?
8) Raising awareness that family will still be asked for consent
a) 91% think it important to discuss but only 37% have actually done it
9) Respect individual’s wishes
10) Prior discussion is the most compelling factor
a) On ODR but not discussed wishes 57% consent compared to 90% consent rate if on ODR and discussed
11) When views unknown, not agreeing is seen as the safest option
12) Common misconceptions are widespread
a) BUT 1 in 5 will change view if presented with key facts
The key is to encourage discussion. For every 1 million people more on ODR, only 5 more transplants occur.
• Cheltenham’s Experience – Ian Mean, Chair of Cheltenham and Gloucester Hospitals
• Northampton Experience – Peter Martin, Chair of Northampton General Hospital
2 talks on how the Donation Committees are engaging their local communities.
NHSBT - NHS Blood and Transplant
NHSBT - NHS Blood and Transplant Organ Donation
Supplementary: The presentations on the day are now available on the Organ Donation & Transplant website here