Organ Procurement

Brain Death & Declaration - Grim Gateway

• Definition: Irreversible cessation of all brain functions, including brainstem. Legal death, enabling organ donation.
• Prerequisites (THOTA, India):
  • Known irreversible brain damage.
  • No hypothermia (core temp >32°C), drug intoxication, NMBs, severe metabolic issues.
• Clinical Examination (Two Certifications, $\ge$6h apart, 4 Doctors):
  • Coma (GCS 3).
  • Absent brainstem reflexes: pupillary (>4mm, fixed), corneal, oculo-cephalic, oculo-vestibular (50ml ice water), gag, cough.
  • Apnea Test: No respiratory effort. $PaCO_2$ $\ge$60 mmHg or $\uparrow$20 mmHg from baseline after 8-10 min off vent ($PaO_2$ >200 mmHg pre-test).

⭐ Apnea test is the most critical confirmatory test for brainstem death; mandatory unless contraindicated.

Donor Evaluation & Types - Giver's Profile

• Donor Types & Key Differences:

  Feature	Living Donor (LD)	Deceased Donor (DD)
  Source	Healthy (related/unrelated per THOA)	Brainstem Death (DBD) / Circulatory Death (DCD)
  Consent	Donor's informed consent	Family consent / Donor pledge (THOA)
  Organs	Kidney, part of liver/lung	Multiple organs & tissues

  • DBD: Heart-beating (common). DCD: Non-heart-beating (Maastricht types).

• General Evaluation (All Donors):

  • Age: Generally <70 years; paediatric for paediatric.
  • ABO compatibility: Mandatory. HLA typing (kidney, pancreas).
  • Contraindications: Active sepsis, HIV (exceptions evolving), most metastatic cancers.
  • Governed by THOA, 1994.

⭐ Brainstem death in India: certified by four medical experts (one neuro specialist) per THOA.

Organ Retrieval & Preservation - Precious Cargo Care

• Brain Death Criteria: Irreversible coma, absent brainstem reflexes, positive apnea test.
• Donor Optimization: Maintain normotension, normothermia, euvolemia; correct coagulopathy & electrolyte imbalance.
• Retrieval Sequence (MOR):
  • Thoracic organs (Heart, Lungs) first.
  • Abdominal: Liver → Pancreas → Kidneys.
  • Aorta cannulation & in-situ cold perfusion.
• Preservation Solutions:
  • University of Wisconsin (UW): Standard for liver, pancreas, kidney. 📌 UW: "HAGAR" (HES, Allopurinol, Glutathione, Adenosine, Raffinose).
  • HTK (Custodiol): For heart, kidney, liver. Low viscosity, rapid cooling.
  • Collins/Euro-Collins: Older, mainly for kidneys.
• Ischemia Times:
  • Warm Ischemia: Blood supply cessation to cold perfusion. Minimize!
  • Cold Ischemia: Cold perfusion to reperfusion.
  • Heart: 4-6 hrs
  • Lungs: 6-8 hrs
  • Liver: 8-12 hrs
  • Pancreas: 12-18 hrs
  • Kidneys: 24-36 hrs

⭐ The "no-touch" technique during liver retrieval, minimizing manipulation before flush, is crucial for graft viability and reducing primary non-function risk.

Legal Framework (India) - Rules of the Road

• THOTA Act, 1994 (Amended 2011): India's primary legislation.
  • Regulates removal, storage, transplantation of human organs/tissues.
  • Aims to prevent commercial dealings; defines brain-stem death.
  • Establishes Appropriate Authorities (AA) & Advisory Committees.
• Donor Categories & Consent:
  • Living Donors: Near-relatives (spouse, parents, children, siblings, grandparents, grandchildren). Others: AA approval for altruism.
  • Deceased Donors (Brain-Stem Death): Consent from family/lawful possessor. Certified by four doctors (Form 10).
• NOTTO (National Organ & Tissue Transplant Organization):
  • Apex national body: coordination, networking, procurement, allocation, registry.

⭐ Brain-stem death certification (THOTA Form 10) requires four medical experts: treating physician, independent specialist, neurologist/neurosurgeon, and medical head of hospital/nominee.

High‑Yield Points - ⚡ Biggest Takeaways

• Brainstem death declaration is paramount for deceased donor procurement.
• THOA (Transplantation of Human Organs Act) is India's legal framework.
• Critical donor maintenance: MAP >65 mmHg, UO >1 ml/kg/hr.
• Cold ischemia times differ: Kidney 24-36 hrs, Liver 8-12 hrs, Heart 4-6 hrs.
• Mandatory informed consent: from next-of-kin (deceased) or donor (living).
• NOTTO: India's apex body for organ donation and transplantation.
• Organ allocation prioritizes blood group, HLA match, urgency, and wait time.