Neurosurgeon For A Social Cause

Neurosurgeon for a Social Cause :
Certification of Brain Stem Death

Bruno Mascarenhas JMA
Associate
Cadaver Transplant Programme
Government of Tamil Nadu
09 April 2013 SRMC, Porur, Chennai 2
Before we start

How to Keep this burning


Give me Oil in my Lamp,
keep it burning
Think about it !
We will revisit this
question after
some time


Neurocon 2012, New Delhi 6
What is meant by
Brain Stem Death
A Dead Brain stem in body whose heart
is still beating is what is Brain Stem Dead in
simple terms
This has become a reality because of
advancement in intensive care /
pharmacotherapy etc.
As per THOA 1994 brain-stem death
means the stage at which all functions
of the brain stem have permanently and
irreversibly ceased

Brain Stem Death
Do all human beings who die pass through this
stage?
No. Only 1% of all death pass through
this stage

Brain Stem Death
The state of Brain Stem Death is a brief
period in minutes during which one should
be able to catch these critically ill patients
Therefore it is essential for one to identify
who are all the patients who are likely to
become Brain Stem Dead
It is here lies the success of certification

Why Certify ?
Prompt and Proper certification of Brain Stem
Death
decreases the relatives agonising wait,
makes available ICU for another patient
with treatable conditions and
relieves ICU nurses pain of cleaning and
dressing a patient with no possibility of
survival.

Why Certify ?
Prompt and Proper certification of Brain Stem
Death
When properly networked, Each Brain Stem
Death Certification gives a fresh lease of
life to many suffering from CRF, Liver
Failure and Cardiac Dysfunctions
necessitating transplants

Why not certified in past?
Doubts in medical circles on the authority by
which doctors may declare "Brain Stem
Death" whenever required.
Certain Grey areas of THE
TRANSPLANTATION OF HUMAN ORGANS ACT
- 1994
Procedural Difficulties / Lack of Protocol /
Who to do what
Initiatives by Government
A series of GOs (Government Orders) by the
Government of Tamil Nadu (available at
http://www.dmrhs.org/tnos/orders-of-tn-
govt)
Establishing clear guidelines for brain
stem death certification and organ
sharing and Creation of awareness among
the neurosurgeons

Initiatives by Government
Cadaver Organ Transplant Programme,
run by a Convenor, Cadaver Transplant
Programme http://www.dmrhs.org/tnos/
Common online waitlist ( at
http://www.tnos.org/ ) for all potential
recipients in all hospitals under Tamil Nadu
Network for Organ Sharing and allotment of
organs by the Network

Procedures, Tests, Formats
G.O. (Ms) No. 75 Dated : 03.03.2008
Health and Family Welfare (Z1)
Department
Form 8 of the THO Act and Rules as found in
the Annexure-I to this order are prescribed as
the brain death certification format to be
utilised for any given situation requiring
certification that a person is dead on account
of permanent and irreversible cessation of all
functions of the brain stem.
The tests prescribed therein and the findings
required shall remain the same.

Who, When, What, Why
According to Form 8 of the said Act and
Rules, when such certification is required,
there shall be two medical examinations
conducted by a team of doctors after a
minimum interval of six hours and the
findings made based on the tests
prescribed therein.

How ?
One aspect of the above form requires
further clarification and this is provided in
Annexure-II of this order as Guidelines for
Apnoea Tests (G.O. (Ms) No. 75 Dated :
03.03.2008 Health and Family Welfare (Z1)
Department)

Initiatives at Hospital Level
Management of the patient at the Post
Anaesthetic Care Unit under the Anesthetists
or other ICUs.
Orders of Hospital Administration enabling
the Elective Operation theatre to be used at
the Night Time and Odd Hours for Organ
harvesting and Transplants

Transplant co ordinators
Counseling the relatives and Arranging a
Room in the Hospital for the bereaved family
Co Ordinating with the RMO Office, Matron
Office, Theatre, Labs etc for arranging
surgeries at short notice even at odd hours
Arranging Early Postmortem and Free /
subsidized transportation of the dead body to
the home.
Informing Transplant Co Ordinators of Other
Hospitals Involved and keeping in touch

Cadaver Tranplant in RGGGH
First Cadaver Transplant was done in GGH in
1996
After the initiation of Cadaver Organ
Transplant Programme, First Brain Stem
Death Certification following the new
guidelines was done on 26
th
Oct 2009
Kidneys were transplanted
One at RGGGH
One at Stanley Medical College Hospital
After 3 years
Clinical
Brain Stem
death
Identified
Two
examination
s done
(including
Apnea test)
and Brain
Stem Death
Certified
Relatives
Agreed for
Donation of
Organs
Organs
Donated
2008 0 0 0 0
2009 7 7 7 7
2010 25 25 24 24
2011 43 25 17 16
2012 34 25 19 18
2013
Total 109 82 67 65
Successful donations in 59 %
of Identifications
Identify, Certify, Consent,
Donate
0
1
2
3
4
5
6
7
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9
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Identi fi ed
Certi fi ed
Agreed to Donate
Donated
82 % Relatives Agreed for
Organ Donation
Brain Stem
Death
Ceritified but
Family did not
consent for
donation
18%
Brain Stem
Death Certified
and Family
Consented for
Donation
82%
82 % Relatives Agreed for Organ
Donation
This is a huge number
This is better than many western countries
with voluntary donation

Donations from RGGGH
0
10
20
30
40
50
60
70
Oct-09 Feb-10 Jun-10 Oct-10 Feb-11 Jun-11 Oct-11 Feb-12 Jun-12 Oct-12
143 Patients on Dialysis in
Government Hospitals
Kidney to
Government
Hospital Patients
Kidney to
Private
Hospitals
Kidney not
used
Kidney
Received from
Private
Hospitals
2008 0 0 0 4
2009 13 1 0 20
2010 37 6 5 0
2011 26 0 6 7
2012 31 0 8 5
Total 107 7 19 36
29 Patients with Liver Failure In
Liver to
Stanley
Liver to Private Liver not used
Liver Received
from Private
Hospitals
2008 0 0 0 0
2009 1 2 4 2
2010 10 12 2 0
2011 12 3 1 1
2012 2 16 1 1
Total 25 33 8 4
4 Heart Transplants in
Heart to
RGGGH
Heart to
Private
Heart Not
Used
Heart
Received from
Private
Hospitals
2008 0 0 0 0
2009 1 0 6 1
2010 1 4 19 1
2011 0 0 16 0
2012 0 5 13 0
Total 2 9 54 2
Patients Benefited
Renal Transplant 143 Patients
Liver Transplant 29 Patients
Heart Transplant 4 Patients

Patients Benefited
All over Tamil Nadu, from Oct 2008 to Mar
2013, there has been 324 donors
52 Hearts, 15 Lungs, 296 Livers, 595 Kidneys
(958 Total Major Organs have been
harvested)
356 Heart Valves, 504 Corneas, 1 Skin and
1819 Organs in Total have been harvested

Skeletal Protocol
If patient (in Trauma Ward, ICU) is clinically
brain death Shifting patient to PACU under
the care of Anaesthesiologists
If patient is Hemodynamically stable and
other criteria as per GO are met, First
Examination (including Apnea Test) by 4
doctors viz (1) Neurosurgeon (2)
Anaesthesiologist (3) RMO (4) Independent
Doctor, usually Physician

Protocol
If Apnea Test is positive in first examination,
Transplant Coordinators counsel the relatives
and if they are willing, inform the Convenor,
Cadaver Transplant Programme, who alerts
hospitals with patients who are top in the
waiting list
The likely recipients hospitals are informed to
the Transplant Coordinators who liaise with
those hospitals

Protocol
After a 6 hour interval, second examination
(including Apnea Test) is done by the team of
4 doctors and if it is positive, Brain Death is
Certified in the Prescribed format
Written Consent of the Relatives are obtained
in the prescribed format
After retrieval of organs, early postmortem
and transport of the dead body
Protocol
Protocol is MANDATORY
Each Hospital must frame its own protocol, in
accordance to their workflow based on
the Guidelines issued in GO
Each step of the certification process to
be listed and the job responsibility
(primary as well as backup) fixed
Successful Programme needs
Brain Stem Death Certification Made
Mandatory
Extremely dedicated Neuro consultants
Intensivists who are willing to manage the
patients with severe Brain Stem Dysfunction
Anaesthesiologists who are willing to do
Apnea testing
Administration who are willing to support
this programme

Successful Programme needs
Work towards a full scope Regulatory
Framework that takes into account local
circumstances and values acceptable to
society.
Strike the right balance between the profit
motive of private healthcare and patient-
centric fair allocation.
Prioritize medical ethics and involve civil
society as stakeholder.
Identify key individuals who have the
passion to take the movement forward.

What is the need for this?
There is a big gap between demand & supply
of organs in Patients with Renal, Hepatic and
Cardiac Failure.
The THOA 1994 authorised Deceased donor
transplantation (DDT). But in our country the
national average is 0.1 / million population /
year
DDT has great potential to abolish illegal
trade of Human Organs

What is the need for this?
Deceased Donor Transplant will eradicate
women slavery where more than 90% of
living related Kidney Donors are women
This is a social responsibility of the Neuro
Scientists for the Society from which they
should not shy away
Though Tamilnadu is way ahead other states
in Deceased Donor Transplant we still have to
work hard to move forward in other states
and centres

Mismatch
15 Lakh Patient with End Stage Liver Disease
in India at present
Of which 1 Lakh are waiting for Liver
Transplant
Around 900 liver transplants (cadaver + live
related) are done in India every
Burden of CKD
North India (Sr creat >1.8) 785 pmp (SK
Agarwal,2005)
South India 870 pmp (MK Mani, 2006)
Central India Incidence of ESRD (End Stage
Renal Disease)151 232 pmp (Modi & Jha,
2006)
SEEK community camps,prevalence 17.4%
2,00,000 develop ESRD annually

World map redrawn based on the
expected burden of ESRD

The Burden of Chronic Kidney Disease on Developing Nations: A 21st Century Challenge
in Global Health Rachel A. Nugent, Sana F. Fathima, Andrea B. Feigl, Dorothy Chyung
Nephron Clin Pract 2011;118:c269c277 DOI: 10.1159/000321382

How to Keep these burning

Can you keep this candle burning
What will you do when the candle is
about to extinguish
Transfer the Flame . . . .

One candle can light many

Take Home Message
Remember that there is Life even
after Brain Stem Death
For other needy patients who can be given
life support instead of it being used for the
brain dead patients
For the Recipients

Save Five Lives
By Proper and Timely Certification of Brain
Stem death, we are giving life to (1) Patient
Who is going to use this life support
system
(2), (3) Two Patients with End Stage Renal
Diseases
(4) One Patient with Liver Failure
(5) One Patient in need of Heart
transplantation
52


20 Dec 2012
20-Dec-2012

Neurosurgeon For A Social Cause

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