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NURS 428 - Critical Care > Class 7 (03|01|22) Brain death, organ donation and transplantation > Flashcards

Class 7 (03|01|22) Brain death, organ donation and transplantation Flashcards

1
Q

Define brain death

A

Irreversible cessation of all brain function, including brainstem function for up to 24 hour (normal body temp and not under the influence of drugs, or paralytics)

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2
Q

What are the beginning indications of brain death? (3)

A

in the beginning:

  • unable to maintain brain function
  • bradycardia
  • loss of basic neurological function (basic reflexes and pupils are fixed and dilated)
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3
Q

What criteria that that diagnosis brain death?

A

Coma: completely unresponsive
Absence of brainstem reflexes
Apnea: no spontaneous breathing

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4
Q

What are the brainstem reflexes that diagnose brain death? (6)

A
  • Pupillary response
  • Corneal reflex
  • Ocuocephalic Reflex
  • Oculovestibular Reflex “Cold caloric”
  • Cough and gag reflexes
  • Apnea test
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5
Q

Describe Pupillary response and the CN it effects.

A

Pupillary response (cranial nerves II and III): Pupil size does not change in response to bright light. Pupils are generally 4 mm to 6 mm in diameter and nonreactive, but they can be any shape

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6
Q

Describe Corneal reflex and the CN it effects.

A

Corneal reflex (cranial nerves V and VII): No eyelid movement occurs when the cornea is pressed with a cotton swab.

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7
Q

Describe Ocuocephalic Reflex and the CN it effects.

A

Ocular movements (cranial nerves III, IV, VI, VIII): During ocuocephalic testing (commonly called “doll’s eye testing”), no eye movements are noted when the head is briskly rotated horizontally and vertically.

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8
Q

Describe Oculovestibular Reflex “Cold caloric” and the CN it effects.

A

During oculovestibular testing (commonly called “cold caloric testing”), no eye movements are noted after 50 mL of ice water is injected into each ear, 5 minutes apart.
Cold water injected into ear until the patient demonstrates nystagmus: brainstem is intact and the eyes should deviate towards the tested ear.
Cold water in both ears should cause and downwarddeviation of the eyes, and warm water should cause an upwarddeviation. To remember this, consider using a stupid meteorological mnemonic device:you lookupatthehotmidday sun, andlook downat thecoldfallensnow

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9
Q

What is nystagmus?

A

nystagmus: brainstem is intact and the eyes should deviate towards the tested ear.
positive test of the Oculovestibular Reflex “Cold caloric”

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10
Q

Describe Cough and gag reflexes and the CN it effects.

A

Cough and gag reflexes (cranial nerves IX and X): When the posterior pharynx is suctioned or stimulated with a tongue blade, there is no cough or gag.

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11
Q

Describe the apnea test for brain death. What are positive and negative test results.

A
  • If respiratory movements are absent and PaCO2 is ≥ 60 mm Hg
  • the apnea test supports the diagnosis of brain death (respirator turned off for three minters to see if patient attempts to breath on their own)
  • If respiratory movements are observed, the apnea test result is negative (i.e., does not support the diagnosis of brain death).
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12
Q

Indication of brain death in the following tests.
Absent motor & reflex movements
EEG
Cerebral blood flow studies

A

Absent motor & reflex movements: shine a light in the eye to make sure pupils are dilated, muscles are tested, ice water poured ears
It is not unusual for the body to show signs go spinal reflexes: shows as little tiny spontaneous movements but still indicated breath death (family distress)
EEG: fat brain waves
Cerebral blood flow studies: angiogram (perfusion)

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13
Q

What are some challenges in determining brain death? (6)

A
  • Accurate and timely diagnosis (certain facilities; ICU, two physicians with specific training, testing needs to be done 12 hours apart)
  • Timely: patient who are diagnosed with brain death have opportunity to donate organs but cannot prolong deterioration
  • Use of medication, elicit drugs, & alcohol: in order to do testing, patient needs to be free of sedations and other drugs
  • Religious beliefs
  • Family dynamics
  • Media portrayal
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14
Q

What does HOPE stand for?

A

Human Organ Procurement & Exchange (HOPE) Program

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15
Q

What are some reasons that create high demand/shortage of organs and tissues? (6)

A
  • Discussions about death are uncommon
  • Donation is not routinely discussed as an end of life care option
  • Family members are unaware of each other’s intentions and wishes
  • Superstitious beliefs, myths
  • Only 2-3% of all deaths are eligible to donate organs
  • Growing recipient lists - transplant is successful
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16
Q

What are the 7 steps in organ donation process?

A 
Step 1 Donor Identification & Referral 
Step 2 Approaching Families 
Step 3 Consent
Step 4 Assessment 
Step 5 Allocation 
Step 6 Recovery 
Step 7 Family Follow up
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17
Q

In step 1 of the organ donation process, describe Neurological Determination of Death.

A

Neurological Determination of Death (NDD) AKA Brain death
the irreversible loss of consciousness and cessation of brain stem function
The equivalent to death even though the heart continues to beat while the patient is supported mechanically and pharmacologically

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18
Q

What does NDD mean?

A

Neurological Determination of Death (NDD) AKA Brain death

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19
Q

In step 1 or the organ donation process, what is the DCD process in diagnosing.

A

2 physicians confirm that there is a non-recoverable injury with no treatment options and withdrawal of life sustaining treatment (WLST) is appropriate
Family conference is held to discuss poor prognosis and WLST - held by ICU physician
The option of organ/tissue donation is offered
HOPE &/or CTC consulted

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20
Q

What is DCD?

What is the criteria of diagnosis?

A

Donation Options - DCD (small % of patient)
Donation after Cardiac Death DCD (small MI, stroke > cardiac death)
will not meet NDD
No heart beat
Organ &/or tissue recovery occurs after heart stops beating
Hearts are not considered for Transplantation
If family is not aware of patient wishes before DCD, it a difficult decision due to the small time constraint

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21
Q

In step 2 of the organ donation process, what are the three step in approaching families.

A
  1. Planning the approach
  2. confirming understanding and acceptance of loss
  3. Discussing donation
22
Q

When approaching families for organ donations, describe how you would plan the approach?

A

Clinical issue to be clarified: family questions
Evidence of registered intent: do they want to donate
Legal Next-of-Kin to be identified: individual making decision on behalf of patient
Family dynamics or any specific issues to be considered

23
Q

When approaching families for organ donations, describe how you would confirm their understanding and acceptance of a loss?

A

they understand Brain death is death (NDD) or the Poor prognosis with NO meaningful chance of recovery (DCD)

24
Q

When approaching families for organ donations, describe how you would discuss donation? (4)

A

Simple and clear communication
Positive language, emphasizing the potential benefits for recipients
Whether loved one’s wish to intent was previously known
Exploring family refusals

25
Q

In step 3 of the organ donation process, who would you obtain consent from?

A

Coordinator obtains consent from legal Next of Kin

individual organ and tissues

26
Q

In step 4 of the organ donation process, what info is gathered from the assessment? (4)

A
  • Medical & Social Questionnaire (high risk behaviour, medication)
  • Physical Exam
  • Lab & Diagnostic imaging
  • Organ specific assessment
27
Q

In step 5 of the organ transplant process, what is considered in the allocation of organs? (4)

A
  • transplant physicians & surgeons determine organ suitability & select recipient
  • Most critically ill person considered first
  • ABO, ht, wt, HLA: Human leukocyte antigen
  • Share: process in place where organs that don’t have a fit, can be offered to other centres across Canada
28
Q

What is the leading cause of death for organ donors?

A

Intracranial hemorrhage (54%)

29
Q

What are the two types of deferrals?

A

Absolute deferrals

relative deferrals

30
Q

What are absolute deferrals?

A

absolute deferrals for organ donation are metastatic caners and HIV infections

31
Q

What are relative deferrals? (2)

A

include positive serology (HEP B or various infectious diseases), high risk behaviour (multiple sexual partners, substance users)

32
Q

What are two challenges of beside nursing with organ donations?

A
  1. Ending of patients life

2. Gaming permission for donation from the patient or patient’s family

33
Q

How many lives can be saved from a full organ transplantation?

A

9

34
Q

Is an open casket funeral possible following organ & tissue donation?
What is done to ensure this?

A

Yes
Organ and tissues are always carefully removed and incisions are closed by a surgical team. Cosmetic reconstruction occurs if tissues are recovered
The body is treated with the utmost respect at all times

35
Q

What are the three types of organ rejection?

A
  1. Chronic
  2. Acute
  3. Hyperacute
36
Q

Describe chronic organ rejection.
What is happening to the immune system?
What are the results?
What is the treatment?

A

The transplanted organ is infiltrated with large numbers of T and B cells, which is characteristic of an
ongoing, low-grade, immune mediated injury
Results w fibrosis and scarring
No definitive therapy yet: option of retransplantation

37
Q

Describe acute organ rejection.
What is happening to the immune system?
What is the treatment?

A

recipient’s T cytotoxic lymphocytes, which attack the foreign organ
Humoral rejection: recipient develops antibodies to the transplanted organ
episodes are usually reversible with alteration in or additional immunosuppressive therapy that may include increased corticosteroid doses or polyclonal or monoclonal antibody treatment

38
Q

What is humoral rejection?

A

Humoral rejection: recipient develops antibodies to the transplanted organ
Usually with acute organ rejection

39
Q

Describe hyperacute organ rejection.

When is it most common?

A

Hyperacute rejection can occur within minutes but is not common in human-to-human transplants

40
Q

What are the group 1 immunosuppressive therapy??

A

Group 1: Cyclosporine & Tacrolimus

41
Q

Describe the mechanism of action for group 1 cyclosporine.

A

Cyclosporine works by penetrating helper T cells and binding to a protein inside, blocking the action of other proteins so that the cell cannot produce cytokines
This means it can not activate the rest of the immune system and very few mature B and T cells are formed

42
Q

Describe the mechanism of action for group 1 Tacrolimus.

A

Tacrolimus work directly on skin cells
It binds to receipt inside to inhibit a protein that reduces T cell activity
This Also prevents cytokine production
Inhibits calcineurin; prevents production and release of IL-2, IL-4, and α- interferon; inhibits production of T cytotoxic lymphocytes

43
Q

What are the group 3 Immunosuppressive therapy?

A

Group 3: Prednisone

44
Q

Describe the mechanism of action for group 3 Prednisolone.

A

Mimics the effect of hormones naturally produces by the adrenal glands
When the dose of prednisone exceed the body; natural level inflammation is suppressed
Suppress inflammatory response; inhibit cytokine production and T-cell activation

45
Q

What are the risk factors for AKI?

A

increase the risk of developing AKI are advanced age, massive trauma, major surgical procedures, extensive burns, cardiac failure, sepsis, obstetrical complications, and baseline renal insufficiency caused by hypertension or diabetes mellitus

46
Q

What is AKI?

A

Acute Kidney Injury

47
Q

What are the acute interventions for AKI? (3)

A

managing fluid and electrolyte balance during the oliguric and diuretic phases (sodium, potassium, electrolytes)

weights daily: excessive gains or losses of body fluid (1 kg is equivalent to 1 000 mL of fluid)

If antibiotics are used to treat an infection, the type, frequency, and dosage must be carefully considered because the kidneys are the primary route of excretion for many antibiotics

48
Q

Describe an oliguric phase

A

hypervolemia = oliguric phase

49
Q

Describe a diuretic phase.

A

hypovolemia = diuretic phase

50
Q

What criteria to confirm brain death? (7)

A
  1. irreversible and proximate cause of coma according to the medical history and the results of physical examination, neuroimaging, and laboratory testing
  2. no sedatives or narcotics are present in the patient’s system (of note, hypothermia or abnormal hepatic or renal function may extend a drug’s half-life)
  3. the blood alcohol level is less than 0.08 g/dL;
  4. no neuromuscular blocking agents have been administered recently or reversal of paralytic agents has been confirmed by using a train-of-4 test
  5. no severe electrolyte, acid-base, or endocrine derangements are present
  6. the patient’s body temperature is greater than 36 ̊C (this may require the use of a warming blanket)
  7. the patient’s systolic blood pressure is at least 100 mm Hg (this may require the use of vasopressors).

NURS 428 - Critical Care (10 decks)

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