Organ Retrieval: Role of Anaesthesiologist

1. Krishna Institute of Medical Sciences ( KIMS )

2. DR.JAYASHREE PATKI
MBBS, MD,PGDHHM
Sr. Consultant
Krishna Institute of
Medical Sciences
Hyderabad

3. Organ donation is the process
of removing tissues or organs
from a live, or recently dead,
person to be used in another.
The former is the donor and
the latter is the recipient.
People of all ages can become
donors.

6. Transplantation of Human
Organs Act, 1994 :
Aims:
To Regulate removal, storage and
transplantation of human organs for
therapeutic purposes
To prevent commercial dealings in
organs

7. 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

9. 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

11. •The formation of organ sharing networks
supported by state governments has shown a
substantial increase in the numbers of deceased
donors primarily by creating awareness and
ensuring protocols in caring for the donor.
•Critical care management of potential organ
donor is crucial in maximizing the number and
the quality of transplanted organs

12. •The complexity of transplant procedures requires
constant interaction between the anesthesiologist and
the rest of the transplant team.
•Anaesthesiologist have ample knowledge about
brain death and organ donation
•So involved in the diagnosis of irreversible cerebral
damage, and maintenance of sufficient perfusion and
oxygenation until the organs are removed.

13. Management of donor :
•Starts in ICU and ends on OT
•Continuation of ICU care till the organs are harvested
•Primary principles of palliative care medicine, which
states that patients deserve continuity of care and
consistent caregivers throughout the dying process.
•The person who provides anaesthesia for donation
after brain death should usually the same anaesthetist
who provides a good care to optimize organ perfusion
in a potentially unstable donor.
•Main goal shifts from optimizing cerebral perfusion
pressure to maintaining hemodynamic stability.

14. Steps in the Management :
• Protocol formation
• Declaration of brain death
• Consent
• MLC Formalities
• Police Clearence
• Preoperative checkup:
Investigations ,Vitals ,Supports, Antibiotics ,
Lines-CVC, art . Line
• Transfer to OT
• Intraoperative management

15. Protocol formation :
• Importance to ethical and medicolegal issues
-e.g. Declaration of brain death, consent etc
• Management of donor to ensures clinical consistency,
effectiveness and safety for both donors and recipients.
• Protocols for preoperative evaluation,
intraoperative management, postoperative care
(ICU and floor) .

16. Brain Death :
Cardiac death:
Heartbeat and breathing stop
Brain death:
•Irreversible cessation of all functions of the
entire brain, including the brain stem
•Irreversible coma and apnoea
•Loss of brain stem functions

18. The declaration of brain death :
•Diagnosis of brain death is clinical and can be
confirmed by apnea testing. Ancillary tests can be
considered when the apnea test cannot be
completed or is inconclusive
•Declaration is based on :
•The presence of unresponsive coma
•The absence of brainstem reflexes
•The absence of respiratory drive after CO2
challenge

19. Management of Donor:
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.
Maintenance of adequate cellular oxygenation and
donor organ perfusion.
Support of body homeostasis.
•Without appropriate intervention brain death is
followed by severe injury to most other organ systems.
Circulatory collapse will usually occur within 48hrs.

20. Common Clinical Problems Of Brain Stem
Dead Patient :
•Hypotension
•Hypothermia
•Endocrine Disturbances
•Electrolyte Imbalance
•Arrhythmias
•Hypoxia
•Uncommon Clinical Problems
•Coagulopathy
•Neurogenic Pulmonary Oedema

21. Cardiovascular management :
Rule of 100’s:
SBP >100 mm Hg
U /O >100 ml / hr
PaO2 >100 mm Hg
Hb >100 gm / L
HR > 100
RBS = 100
CVP = 10
Avoiding lactic acidosis (pH = 7.35 – 7.45)
and
hypothermia (temperature > 34o C)

22. Ethical and legal issues :
Consent
MLC Formalities
Police enquiry
Consent
• TO verify the brain-dead certificates as per the
policy of the hospital.
• It should be ensured once again that the consent
from the family members or from the one, who
are in possession of the body, is in order.
• To check listing on the organ donor register
(ODR).

23. MLC Formalities and Police clearence :
In the medico legal cases, he should also satisfy
himself that the proper authorities have been
informed and permission taken to carry on the
process of retrieval of organs.

24. Preoperative Assessment:
• To look at any absolute contra-indication to the organ
donation, like prsence of any transmittable infective
diseases.
•To be assessed as for any major surgical procedure.
• Review previous history
• Review degree of ventilator and inotropic support.
• Review Electrocardiogram, chest x-ray, arterial
blood gases, echocardiography,
• Examine all the recent biochemistry reports and
results of specialized investigations)
• Check the patency of arterial line and CVP lines and
also the ongoing drug infusion therapy.

25. Transfer to OT :
• Special care as donor is vulnerable to episodes of
haemodynamic instability anytime.
• Transfer with the continuous monitoring since
transport frequently precipitates instability, often
because of change in ventilation or delivery of
infusions.
• Special attention must be paid to airway and
particularly infusion pumps delivering vasopressors.
• Chance of disconnection of circuit and iv lines
leading to hypotention and hypoxia .
• Emotional outburst

26. 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 warmers

27. Anaesthetic Management: Goals
•Pt. preservation to organ preservation
•Maintain hemodynamic stability
• Avoid ischemia
•Maintain adequate urine volume
•Prevention of hypothermia

28. •The anaesthesiologist should be familiar with
surgical steps so as to keep pace with requirements
of various surgical teams, more so in case of multi-
organ harvesting
•Ventilation may be discontinued at the time of
aortic cross-clamping, and this time should be
noted on the anaesthetic record.
•At the end of the operation it is important that the
body is closed with proper skin suture in a
continuous manner and is cleaned and packed in a
respectful way before being handed over to the
relatives.

29. Summary :
•Vital member of the organ donation team.
•Anaesthetizing for organ donation can be time-pressured,
stressful and emotionally difficult.
•As involved in all the steps starting from admission to
discharge of the patient including administration and
training.
•Since virtually every phase of the process poses a full
menu of ethical dilemmas, he should be involved in
prospective planning , careful implementation and proper
documentation.