CHALLENGES IN MANAGEMENT OF BRAIN DEAD PATIENT TILL ORGAN RETRIEVAL

Dr. Naresh Tirpude, Prof. & Head,

Dept. Anaesthesiology, Govt. Medical College, Nagpur

“DON’T  TAKE  UR  ORGANS  TO  HEAVEN” : “HEAVEN  KNOWS  THEY  ARE  NEEDED  HERE”

Introduction: Nowadays organ donation of brain dead patient is not a new concept   Brain Death concept was first recognized in 1959 at Paris. In India, Transplantation of Human Organs act (THO act) is passed- 1994.  In India, the incidence of organ donation is very less as compared to other countries. This may be due to lack of knowledge, less awareness in the society, literacy rate, social & emotional issues, false beliefs etc.

Brain Death: It is an irreversible coma with patient being totally unreceptive & unresponsive. Apart from absence of all cranial reflexes, there are no spontaneous respiratory efforts. Brain Dead person is a patient till his or her organs are retrieved & then is being declared & certified as dead by treating/ attending doctor.

Guidelines for Brain Dead certification team (Non-Organ Retrieval Team of Hospital): The Members of Brain Dead certification team should not be a part/ member of Organ Retrieval team. Organs may be donated by: a) A living person by filling pledge form- after his death, b) After natural death by consent of relatives & c) After brain death of person/ patient by consent of his or her relatives. After Natural death: Only few tissues/ organs may be donated: Cornea, Bone, Skin, Blood vessels etc. List of Organs may be donated are: Kidney, Liver, Heart, Lungs, Cornea, Bone, Skin, Blood vessels etc.

Our Experience: A patient aged 57yrs, from a village 40 kms away from Nagpur was met with an accident & head on collision with high speed vehicle on highway & had head injury with no other major injuries to other parts of the body. He was initially admitted to private sector hospital. As patient was not recovering from the trauma; patient was on ventilator for a period of about 3weeks. The private hospital doctors (Team of Neurosurgeons) had suspected that patient is Brain Dead. He was shifted to trauma centre, Govt. Medical College, Nagpur.

On shifting the patient to Trauma Centre, GMC, Nagpur, the relatives were informed about the status (Brain Dead Status) of the patient condition & not much can be done as far as management is concerned. When this patient was labeled as brain dead, the process of Organ donation, Certification, Information to relevant agency for organ retrieval was activated on war basis. Examination of patient was done; Willingness for organ donations discussed with relatives (Son of patient); First Question was:  When body will be handed over? What is procedure?  Any charges? Investigations charges if any; Accommodation for patients relatives to stay nearby?  When body will be handed over? Our team told them that maximum 24 hrs but not sure & even may take some more time for completion of procedure & handing over the body for funeral. When relatives of patient got convinced & consented for organ donation, Non-organ retrieval team was called for certification. After convincing & consent of relatives (Elder son) for organ donation, the further process of testing & certification of brain dead was started at around 8.00pm; the information about that patient is probably brain dead & permission for further procedure was sought from the ZTCC committee, Nagpur. The permission about brain dead testing & other technical issues were informed to us by the ZTCC, Nagpur.

The non-organ retrieval committee of Govt. Medical College & Hospital was informed about the patient & willingness of patient’s relatives about organ donation. The first apnea test was performed at 10.30pm & 2^nd apnea test was performed after 6hrs (4.30am) by non-organ retrieval committee. On confirmation that patient is brain dead, the information was forwarded to ZTCC team of Nagpur. Also relatives were informed about the progress of patient & brain dead status. The consent for organ to be retrieved was obtained from relatives & the necessary ZTCC organ retrieval & donation forms were filled & signed by relatives. The organs to be retrieved were clarified & reported to ZTCC committee, Nagpur.

At this level & after 2^nd apnea test confirmation, the actual programme of organ retrieval & communication to various hospitals [who were in need of organs were informed] was started at war level via what’sapp group & by mobile phone network  through ZTCC team of Nagpur to ROTTO & SOTTO. The state & district level committee were informed about the brain dead patient & willingness of relatives about organ donation. Immediately the NOTTO & SOTTO were informed & were requested to send their requisition/ willingness to retrieve organs for the registered patients of their hospital list who are willing to undergo organ transplant.

Various Clinical tests to certify Brain Death: a) Pupillary light reflex, b) Corneal reflex, c) Cold Water Reflex, d) Doll’s Eye Reflex, e) Gag Reflex, f) Apnea test (Twice- 6hrs time duration between two tests).

Role of Anaesthesiologists:

When patient is admitted for elective/ emergency surgery is?  

Stress to Anaesthesiologist & Team:

Yes: It is always there to some extent. Extent of stress depends & varies from person to person [As far as anaesthesiologist is concerned].

Stress to patient & relatives:

Yes. It is more than the attending anaesthesia & surgical team. FAQ: Will the operation be successful? Success rate of operation?, Death during operation? Will there be any complications? Approximate Expenditure of operation etc.

Role of Anaesthesiologists team:

When patient is declared brain dead & planned for Organ Retrieval Surgery?

As soon as the pt. is declared brain dead & consent from relatives is obtained for organ donation, bills of such patient should not be charged to patient relatives. The transplant coordinator of ZTCC team will make sure that these bills may be handed over to/ shared by organ receiving hospitals (Including ambulance charges). Team leader of the retrieval team will write detailed operation notes mentioning the details of organ retrieved.

In this case, we had managed & executed the following issues:

• Preoperative / Pre-Retrieval: Maintaining haemodynamics
• Maintaining Hydration, perfusion & oxygenation & perfect ventilation support so as to prevent cardiac arrest.
• During Retrieval of Organs: Maintaining the haemodynamics, perfusion, SOS Muscle relaxation.
• At end of surgery- i.e. on organ retrieval, Patient was extubated. All supports were withdrawn.

At this point, the patient was declared dead & body was sent for postmortem/ autopsy to mortuary. Body was handed over (without delay) to relatives at earliest. During the whole procedure of starting apnea test to organ retrieval by retrieval team, the relatives of patient were about the time duration & approximate time of handing over of body for funeral process.

Stress to Anaesthesiologist & Team:

Yes. The stress is to maintain the patient vitals, ventilator support, perfusion of organs & investigations. It was very difficult to convince the relatives about status of patient that their patient is ‘Brain Dead’. Sometime relatives are not willing for organ donation & may not accept the concept of organ donation & transplant. Sometime relatives may refuse the organ donation consent due to emotional outburst.

Stress of patient relatives: (Brain Dead patient & Stress to relatives): FAQ:

• Relatives are annoyed; can you bring some other specialist to examine?
• Are you sure that my patient is brain dead? Problem starts with consent for organ donation?;
• Who will give consent? ; Vested Interest of Doctor & Retrieval team/ Centre
• Not ready to sign the form; Will ask many relatives; Religious issues;
• When body will be handed over for funeral: time of body for funeral etc.
• Refusal for organ donation during the whole procedure of apnea testing to organ retrieval.
• What we will get (monetary gain)

Green Corridor:

To transport & transplant the retrieved organs: The coordination between organ retrieval team, transplant team, transplant centre & local traffic police & airport authority is to be arranged well in advance & is to communicated from time to time. The retrieved organs are to be transported to transplant centre by organ retrieval team at earliest.

Various important issues to be kept in mind:

• Declaring/ certifying Brain dead ; Coordination- pt’s relatives (Emotional Balance) • Coordination- ZTCC state committee ; Coordination-Non-organ retrieval committee • Coordinating with Organ retrieval team (NOTTO/ SOTTO) • Coordination with Administration of Hospital

[Photo: Obtaining the Relatives consent for Organ Donation]

During the procedure, simultaneously, we formed what’sapp group, for fast communication between Anaesthesiologists team; Surgeons team of Trauma Centre, Nagpur; Operation theatres; Laboratory personnel’s; Radiology dept.; Forensic Dept.- Postmortem dept.; Non-organ Retrieval certification team & Administration of Trauma Centre, Govt. Medical College & Hospital, Nagpur; Mohan Foundations- Dr. Ravi Wankhede- Hon. Secretary, ZTCC ; Dr. Vibhavari Dani- Hon President ZTCC committee- Maharashtra Govt.; Social Workers of GMCH, Nagpur & ZTCC Committee; Transplant Centres; NOTTO & SOTTO; Recipient registry; Organs to be retrieved & allotment of organs to transplant centre; Plan of journey of Organ retrieval team; Local traffic police authority; Municipal corporation.

[Photo: Non-Organ Retrieval Team performing First Apnea Test- 11pm]

Important task of Anaesthesiologist’s & Intensivist’s Team were:

• Is to maintain blood pressure, heart rate & perfusion
• Care of Ventilator support; To check ABG, Blood Sugar, Lactates, LFT, KFT
• To maintain the ABG levels to near normal limits
• USG Abdomen, TEE, Echocardiography
• Two apnea test at the interval of 6 hrs. by Non organ Retrieval team
• Then only team can proceed for other formalities; Communicating to relatives
• Communication to ZTCC committee/ NOTTO/SOTTO
• Communication to Organ retrieval team to invite.
• Providing proper hospitality & comfort zone to Organ retrieval team & relatives.

Challenges we faced at Trauma Centre, GMC, Nagpur (Govt./ Public sector Hospital)

• Procurement of emergency drugs in night hours. e.g. Vasopressors & other drugs
• Doing emergency investigations in night hours e.g. TEE, Echocardiography.
• Frequent ABG analysis, other investigations as per need or as requested by transplant team till organ retrieval surgery.
• Coordination failure? ………………
• Tuning between Anaesthesiologist team/ Intensivist team & Organ Retrieval team till organ retrieval

In this patient, with coordination amongst Anaesthesiology team, Surgeon’s team of trauma centre, Consultants of SSH, Nagpur & support from ZTCC, Nagpur, Social workers, all concerned groups & authority, we could succeed in Retrieval of Heart & Liver & Cornea within stipulated time. Heart was allocated to & transported by Air to Transplant centre Chennai. Liver was allocated to & transported by Air to transplant centre, Pune. Retrieved Cornea was transferred to transplant Centre, GMC, Nagpur.

[Handing over certificate of Organ Donation to Patient’s Son]

After Organ Retrieval, the death Certification was done by treating doctor; the body was sent for postmortem at earliest. During the completion of all these procedures, the emotional care of deceased relatives was taken care off. Our team was present at the site right from organ retrieval till organ transportation, green corridor & handing over of body to relatives from the mortuary for funeral.

Legal Issues: Hospital is to be authorized as Transplant centre; Authorized Organ Retrieval transplant team; Authorized Non Organ Retrieval Transplant Team; Communication with ZTCC/NOTTO/ SOTTO/ Local Municipal Authority; Record Keeping.

Organ Donation Helpline Toll Free No: 1800 103 7100

Our Thanks & Gratitude to: Patient’s Son & family; Anaesthesiology Team & Surgery team- Trauma Centre; Dean, GMC, Nagpur; Dr. Ravi Wankhede  Hon. Secretary ZTCC, Nagpur, Dr. V. Dani- Hon. President ZTCC, Nagpur; Social Workers; Labs  Personnel; Paramedics & Sanitary Dept.; Post-mortem Dept.