Brain Death Policy

Brain Death Policy and Organ donation Medical Management Policy Alice Springs Intensive Care Unit

 

Prepared by Dr Penny Stewart thanks to St Vincent’s Hospital Sydney for the use of the endocrine package.

 

As Alice Springs is isolated and has limited services during the weekend consider the following logistic strategies:

1)      Blood tests may be sent to the laboratory prior to the formal diagnosis of brain stem testing but are not be processed until brain death is established and consent from the family has been obtained.

2)      Echocardiography organized early to aid resuscitation optimization.

 

Note all patients that have been severely brain injured should have there haemodynamic parameters optimized except if a decision between treating physician and family has been made not to do this. This is on the basis this gives the brain injury optimal chance of recovery.

 

Conditions Required for clinical diagnosis

         Irreversible and well defined etiology of unconsciousness

         No clinical evidence of cerebral function

         No clinical evidence of brainstem function

         No metabolic or structural condition or disease process that may obscured cerebral or brain stem function.

 

Testing must be done by 2 doctors of experience, expertise and authority to conduct the examinations. The list of designated doctors in Alice Springs is in Appendix 1.

The first testing must be done at least 4 hours following onset of coma, absent gag, cough and muscle activity. The second test after 6 hours i.e atleast 2 hours apart.

 

Diagnostic Tests to confirm brain death.

         No pupillary

         No corneal reflex

         No gag or cough reflex

         No oculovestibular reflex (the caloric response)

         No integrated motor response to pain within the distribution of the cranial nerves.

         No respiratory efforts on apnoea testing (pCO2 > 60mmHg) or pH<7.3 in those with chronically high CO2 levels.

 

Clinical Problems that occur in patients that are brain dead or severely brain injured

 

Diabetes Insipidus (DI) loss of ADH diagnosed by the passing of high volumes of urine with an osmolality that is inappropriately low compared to the osmolality of the serum.

–Hypernatreamia bad for graft function therefore DI should be recognized and treated early, either with a urine chase using 5% dextrose or DDVAP for those with proven DI and urine volumes grater than 4mls/kg/h.

DDAVP dose is 0.5-4 mcg iv start with 0.5-1mcg dose.

A diagnosis of DI is usually made when there is an elevated plasma osmolality due to increased sodium and an inappropriately low urine osmolality. The treatment is DDAVP doses of 0.5-4mcg used. (Start with low dose first.)

 

Usual plasma osmolality/ urine osmolality relationship:

 

Plasma Osmolality (mosmol/kg)

Urine Osmolality (mosmol/kg)

>288

>125

>290

>200

>292

>400

>294

>600

 

 

Hypergycaemia common increased catecholamine release, altered metabolism, use of dextrose solutions and steroids- treating hyperglycaemia is important for pancreatic islet cell function.

Control BSL using ICU actrapid protocol.

Hypothermia the body becomes poikilothermic because of loss of thalamic and hypothalamic central temperature control mechanisms.

The patient may require active warming with the use of the Bair Hugger. Consider warming iv fluids.

 

Coagulopathy secondary to:

         DIC

         Brain thromboplastin

         Hypothermia

         Dilutional (blood loss- transfused)

         Acidosis

Measure-coags, fibrinogen, platelets and FDP

e-aminocaproic acid should not be used because of the potential for inducing microvascular thrombosis.

 

Optimising Organ Retrieval Viability

 

Protective Ventilation strategies

Avoid high peak inspiratory pressures, adequate PEEP, limit tidal volumes and lowest possible FiO2 of maintaining adequate oxygenation

Protect against infection closed suctioning devices, treat any infection and good humidification

 

Renal Protection

         Maintain adequate systemic perfusion and urine output 1-2mls/kg

         Diagnose and treat DI early do not allow hypernatreamia to occur

         Avoid nephrotoxic drugs

 

Cardiovascular support

Usually requires vasoconstrictors

Ensure adequate filling

Large use of inotrope will interfere with heart retrieval so if haemodynamically unstable consider use of endocrine package.

Echocardiography to guide management and will be required for transplant potential.

 

Endocrine Package

 

Algorithm for Implementation

-         The algorithm is designed to implement a standard Hormonal Resuscitation protocol where a patient is haemodynamically unstable, after formal certification of Brain Death.

-         The aim is to increase retrieval rate of organs (in particular heart and lungs) in a multiorgan donor.

-         A broad set of parameters (CVP, MAP, Noradrenaline dosage) are used to determine haemodynamic status (see below).

-         The impact of the treatment is assessed every 15 mins to ensure parameters are maintained, for a minimum period of 2 hours before assessing whether retrieval of heart and lungs can proceed.

 

 

 

6.         Clinical Parameters:

 

Parameter

Target

Comments

CVP

6-12 mmHg

Guide only to ensure patient is appropriately filled. Discussion may be required re impact of PEEP.

If patient does not have a central line, and therefore unable to measure CVP, use MAP and Noradrenaline dosage as clinical parameters.

MAP

>60mmHg

Guide to ensure patient is adequately filled. Further discussion may be required with Liver team if low systolic pressure.

Noradrenaline

< 0.2 mg/kg/min

Used to maintain BP. Aim is to minimise doses of NAD by the addition of vasopressin to start at low dose, then titrate at 15 mins.

 

 

7.         Algorithm

The algorithm is divided into 2 sections:

1.      Algorithm I-  Echocardiogram available

2.      Algorithm II- Echocardiogram not available

   

Assessment Criteria

Application of the algorithm will be considered under the following circumstances:

 

-         Patient meets TSANZ Heart/Lung criteria (with the exception of the inotrope requirement)

-         Intensivist agrees to implement algorithm


 

Algorithm I (Echo available)

 


Conventional Management

·         Adjust volume status: target CVP = 6-12 mmHg

·         Adjust noradrenaline to keep MAP > 60 mmHg

(target noradrenaline dose < 0.2 mg/kg/min)

·         Correct acidosis: target pH = 7.35-7.45

·         Correct hypoxaemia: target pO2 > 80 mmHg, O2 sat. > 95%

·         Insulin: 1 Unit/hr titrate to BGL 6-10 mmol/l

 

 


Obtain initial Echo

·         Rule out structural  abnormalities

(substantial LVH, valvular disease, congenital lesions)

 

 

 


Normal Echo and                                                                                 Abnormal Echo* and/or

Stable haemodynamics                                                                       Unstable heamodynamics#

 

 


Proceed with                                                        

Recovery                                                               Hormonal Resuscitation (HR)

·         Start Vasopressin: infusion 2.4 Units/hr

·         Methylprednisolone: 15 mg/kg IV bolus

·         T3: 4 mg  IV bolus + infusion 4 mg/hr

 

 

 

 


Ongoing Haemodynamic Management

Adjust fluids and noradrenaline infusion rate at 15 minutely intervals to minimise

use of noradrenaline and meet the following target criteria:

·         MAP > 60 mmHg

·         CVP = 6-12 mmHg

·         Noradrenaline < 0.2 mg/kg/min

 

 


Criteria Met                                                 Criteria Not Met

 

 


Recover                                                                         Discuss with Heart Transplant Team

Heart                                                                              regarding recovery of the heart      

 

 

* LVEF < 45% or major LV wall motion abnormality

#  MAP < 60 mmHg, CVP > 12 mmHg, NA > 0.2 mg/kg/min


Algorithm  II (Echo not available)

 


Conventional Management

·         Adjust volume status: target CVP = 6-12 mmHg

·         Adjust noradrenaline to keep MAP > 60 mmHg

(target noradrenaline dose < 0.2 mg/kg/min)

·         Correct acidosis: target pH = 7.35-7.45

·         Correct hypoxaemia: target pO2 > 80 mmHg, O2 sat. > 95%

·         Insulin: 1 Unit/hr titrate to BGL 6-10 mmol/l

 

 


Stable Haemodynamics                          Unstable Haemodynamics

·         MAP > 60 mmHg                                                                          MAP < 60 mmHg

·         CVP = 6-12 mmHg                                                                        CVP > 12 mmHg                   

·         Noradrenaline  < 0.2 mg/kg/min                                  Noradrenaline > 0.2 mg/kg/min

 

 

 

 


Hormonal Resuscitation (HR)

·         Start Vasopressin: infusion 2.4 Units/hr

·         Methylprednisolone: 15 mg/kg IV bolus

·         T3: 4 mg  IV bolus + infusion 4 mg/hr

 

                                                                       

 

 


Proceed with Recovery                                              

 

 


Ongoing Haemodynamic Management

Adjust fluids and noradrenaline infusion rate at 15 minutely intervals to minimise  use of noradrenaline and meet the following target criteria:

MAP > 60 mmHg

CVP = 6-12 mmHg

Noradrenaline < 0.2 mg/kg/min

 

 

 

 


Criteria Met                                                 Criteria Not Met

 

 


Recover                                                                 Discuss with Heart

  Heart                                                                                    Transplant Team

 

   

 

 

 

 

 

DRUG INFORMATION (Provided by St Vincent’s Hospital Pharmacy Department):

 

Special Access Scheme (SAS) Considerations for Liothyronine (T3)

·        Liothyronine is only obtainable under the Special Access Scheme as it is not a registered product in Australia.

·        To obtain supply of Liothyronine a SAS Category A Form needs to be completed by the prescribing Doctor and forwarded to the Pharmacy Department.

·        In the ‘Patient Details” and “Diagnosis” section of the SAS form the prescriber records: “FOR USE IN DONOR ORGAN FOR TRANSPLANTATION”. No patient details are to be recorded on the form.

·        No SAS Consent Form needs to be completed (per the Therapeutics Goods Administration (TGA) and Link Pharmaceuticals).

 

Starter Packs

·        Starter packs available from Area Donor Coordinator.

·        Content

            2 vials Liothyronine (T3) 20 mcg/vial

            2 vials Vasopressin 20 units per ml

·        Two (2) vials of each required to implement Hormonal Resuscitation Protocol

·        Replacement

o       Hospital Pharmacy to replace content of starter packs

o       Contact the Manager, Organ Donation Network NSW/ACT, for reimbursement on (W) 9229 4004, (M) 0408 115 856.

 

Dosage and Administration

Vasopressin

o       Vial size= 20 units/ml

o       Add 20 units (1ml) of Vasopressin to 100ml Normal Saline

o       Dose: Using infusion pump commence infusion at 2.4 units/ hour (12 ml/hr)

 

Liothyronine (Triiodothyronine, T3)

o       Vial size =20 micrograms

o       Dilute each 20 microgram vial with 2ml WFI

o       Add 40 micrograms of Liothyronine (4ml) to 50 ml syringe and make up to 50mL with Normal Saline

o       Use a low absorptive or minimum volume syringe set.

o       Wrap the syringe (not the IV line) with aluminium foil or similar cover to protect from light.

o       Dose= using infusion pump give 4 microgram (5ml) IV bolus followed by infusion of 4 microgram/hr (5ml/hr)

 

FOR FURTHER INFORMATION REGARDING SIDE EFFECT PROFILE PLEASE REFER TO MICROMEDEX ON LINE VIA CIAP AND CONSULT TRANSPLANT PHYSICIAN.

 

References:

o       Australian Injectables Handbook 2nd Edition

o       The Handbook of Parenteral Drug Administration 4th Edition by JB Carlton

   

TRANSFER FROM NORADRENALINE TO VASOPRESSIN:

 

-         Do not change from Noradrenaline to Vasopressin without  titration

-         Down-titrate NA aiming for a MAP around 60 (estimated timeframe – 30 mins.)

-         If the dose of NA is still too high, ADD vasopressin at the fixed dose, THEN look to down-titrate NA dose every 10 to 15 minutes again aiming for a MAP around 60 mmHg.

 

 

Appendix 1

 

Doctors in Alice Springs who are able to declared Brain Death:

Dr Sydney Jacob

Dr Siriam Sampath

Dr Penny Stewart

Dr Steve Brady

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