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M INISTRY OF EDUCATION AND TRAINING

M INISTRY OF DEFENCE

108 INSTITUTE OF CLINICAL MEDICAL AND
PHARMACEUTICAL SCIENCES

DAO THI KIM DUNG

RESEARCH OF
RESUSCITATION EFFECTS TO ORGAN
FUNCTIONS IN BRAIN - DEAD POTENTIAL
DONORS

Speciality: ANESTHESIOLIGY
Code: 62720122

PhD. THESIS ABSTRACT

HA NOI– 2019


THIS WORK WAS COMPLETED AT 108 INSTITUTE OF
CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

Scientific Supervisors:
Prof. PhD. Nguyen Quoc Kinh

Reviewer 1:
Reviewer2:
Reviewer 3:

The thesis is presented at the Council of 108 Institute of Clinica l
Medical and Pharmaceutical Sciences at: …. h …. date

/

/2019

The thesis can be founded at:
1.

Vietnam National Library

2. Library of 108 Institute of Clinica l Medica l and Pharmaceutical
Sciences.
3.

Library of Viet Duc University Hospital


1
INTRODUCTION
1. The neccessary of the subject
Organ transplantation is the last -line treatment for patients with
end-stage organ failure which can help the patient to have a new life.
All over the world, the major problem is the shortage of donated
organes, numbers of donated organs only meet less than 10% of the
demand.
In Vietnam, the current estimate of all kinds organ donors only
meets 5% of transplant needs. In July 1st 2007, Vietnamese parliament

has officially issued the “Law on donation, tissue and organ
transplants, donating the cadaver" No.75/2006/QH11.
Number of living donors is limited, therefore the main source of
organ transplantation is now cadaveric donors. But in reality, using
organs from cadaveric donors still has a lot of difficulties. Nearly all
of brain death patients suffer from organ failures and many of them
have multiple organ failures. Unadequate resuscitation can limite one
organ’s quality or even affect the whole body. Another way,
resuscitation of an organ can negatively affect another organ. This
process reduces the number of organs which can be used in
transplantation.
There are already some studies in Vietnam whose aims is
providing the protections for single organs, so in this study, we would
like to study a strategy of multiple organ resuscitation in the purpose
that we can maximize the number of organs which can be donnated.
So, we performed the study "Research of res uscitation effects
on organ functions in brain-dead potential donors" with 2
objectives :
1. Review clinical and laboratory characteristics in brain dead
potential organ donors.
2. Evaluate the effectiveness of resuscitation methods on the


2
functions of some organs in brain-dead potential donors.
2. The main new scientific contributions of the thesis
The thesis is the first study which evaluates the results of
formultiple organs resuscitation strategy in brain death potential
donors. From the results of this study, it is recommended to optimize
the hemodynamics to adequately perfusion of organs after brain death

to ensure the functions of the transplanted organs later;the organs
should be used in the 24 first hours frombeginning of organ
resuscitation (about 12 hours after the declaring of Brain-dead
diagnosis Council) because the organ functionsare is the best.
3. Structure of the thesis
The thesisconsists of 129 pages (introduction 2 pages, overview
37 pages, subjects and methods 25 pages, results 30 pages, dicussion
32 pages, conclusion 2 pages, and recommendation 1 page; with 37
tables, 23 images, 17 graphs and 1 figure. The thesis also used 160
references, 18 refs. in Vietnamsese and 142 refs. in English.
CHAPTER 1
OVERVIEW
1.1. Summary of anatomical and physiological characteristics of
the organs related to brain death
1.1.1. Summary of characteristics of the CNS related to brain death.
1.1.2. Summary of characteristics of the organs related to brain
death
1.1.3. Pathophysiology and complications of brain death
1.1.3.1. Pathophysiology of brain death: Changes of cardiovascular;
Changes in hepatic and coagulated function; Changes of neurology;
Changes of hormone; Activating of inflammatory response; Increasing
of cytokine after brain death; Endothelin axis; Effecting on the


3
nervous - muscle system; Hypothermia.
1.1.3.2. Complications after brain death: unstable hemodynamics,
hypoxia, lack of circulation, increased blood osmotic pressure,
hyperglycemia, hypothermia, coagulopathy.
1.1.3.3. Electrolyte disorders after brain death: hypernatremia,

hypokalemia, hypoglycemia, hypocalcaemia, hypophosphatemia.
1.2. Several domestic and foreign studies on clinical and
laboratory characte ristics in brain-dead potential donors.
1.2.1. Brain death and brain death diagnosis in the world and in
Vietnam .
1.2.1.1. Definition: Brain death is defined as an “Irreversible cessation
of all functions of the entire brain, including the brainstem”
1.2.1.2. History.
In 1959, Mollaret - Goudon (France): mentioned "coma". In 1995,
the American Academy of Neurology (AAN) guideline: defined as
coma, absence of brainstem reflexes and apnoea - updated in 2010: A
patient determined to be brain dead is legally and c linical dead.
1.2.1.3. The diagnostic criteria of brain death in the world
UK (1976), France (1996), USA (1995) - updated (2010).
1.2.1.4. Criteria of brain death diagnosis of Vietnam
According to the "Law on donation, tissue and organ transplants,
donating the cadaver"and the Ministry of Health’s instruction
"Clinical and subclinical standards and cases of non-application of
clinical criteria to determine brain death".
1.2.2. Several studies on clinical and laboratory characteristics.
1.2.2.1. In the world: brain-dead patients have disorders such as
hypotension, coagulation disorders, diabetes mellitus, acidosis, kidney
failure, acute respiratory fa ilure, the cause of brain death is stroke and


4
head trauma.
1.2.2.2. In Vietnam: the authors have found a decrease in body
temperature and diabetes mellitus, organ functions deteriorated after
36 hours of brain death. The main cause is head trauma due to traffic

accidents.
1.3. Several domes tic and foreign studies on res uscitation and
maintenance of brain dead donors.
1.3.1. Resuscitation measures.
- Cardiovascular resuscitation: the adult hemodynamic targets in brain
dead potential donors, Law 100, Physiological target for cardiac or
cardio-pulmonary donation, Principles for resuscitation of cardiac
donors.
- Endocrine: treatment of hormonal disorders after brain death.
- Respiratory resuscitation: protectingpulmonary ventilation.
- Renal resuscitation: compensate for volume, MAP >60 mmHg.
- Hematologic resuscitation: maintain Hb ≥ 8 g/dl.
- Temperature resuscitation: maintaining body temperature 36 - 370 5.
1.3.2. Guidelines for resuscitation of different centers in the world.
- Pittsburgh Medical Univers ity and University of Houston Medical
(Texas) (2004).
- According to the Swiss Association (2006)
- Guidelines of the Australian Transplant Association (2008).
-The latest guide of New South Wales (Australia) on resuscitation of
brain dead potential donors (2016)
1.3.3. Take care of the brain dead potential donors: forensic
problems, cultural aspects, communication skills: basic skills should
be trained.


5
1.3.4. Several domestic and foreign studies on resuscitation and
maintenance of brain dead donors.
1.3.4.1. Several foreign studies on resuscitation and maintenance of
brain-dead donors: No matter which donor’s organ resuscitation, the

resuscitation of hemodynamic (cardiovascular) and respiratory
(pulmonary) are still the decisive factors to enhance visceral
perfusion, increase oxygen for tissues and organstoprotect donors’s
organ functions.
1.3.4.2. Several domestic studies on resuscitation of brain-dead
donors: author Nguyen Viet Quang, Mai Xuan Hien and Vu Minh
Duong found the high cardiac arrest rates at 12, 24, 36 hours after
brain death, while Nguyen Quoc Kinh, Do Tat Cuong found the high
rate in the period of 36 - 48 hours.
1.3.5. The current situation of organ donation in the world and in
Vietnam.
1.2.1. The current situation of organ donation in the world.
In 1954, J Murray performed the 1st kidney transplant from a
living donor (twin). In 1962, Murray successfully performed the 1st
kidney transplant from a brain-dead donor. Southeast Asia marked the
1st transplants: Hongkong 1969 (kidney), Thailand 1987 (liver, heart).
1.2.2. The current situation of organ donation in Vietnam.
In Vietnam, the 1st kidney transplant from living donor in 1992
and the 1st organ transplants from brain-dead donor in 2010. According
to the National Organ Coordination Center, the number of transplants
from brain dead donors are 217 cases (6.4%).
CHAPTER 2 SUBJECTS AND METHODS
2.1. Subjects
2.1.1. Location and time of the study: In Center of Anesthesia and
Surgical intenssive care from 01-12/2015 at Vietduc U. Hospital.


6
2.1.2. Criteria of patients in to study
- Subjects: 47 severe head trauma patients with 3-point Glasgow,

eligible for admission to the ICU for diagnosis and resuscitation of
brain death, to carry out the diagnosis of brain death according to
Vietnamese law standards. Determined as a potential donor. The
family agreed to realize the diagnostic test of brain death and
resuscitation.
- Exclusion criterias: Head trauma with severe thoracic-abdominal
trauma. Multi-organ fa ilure before determining brain death. History of
chronic liver, kidney, cardiovascular, respiratorydiseases, endocrine
disease, systemic infection, drug addictions, HIV, hepatitis (B,C),
viral encephalitis, and progressive tuberculosis. Ultrasound screening
detecting kidney, liver, and heart disease. Brain tumors (malignant).
- Criteria to take the patient out of research: The patient's family
didn’t agree to diagnose and resuscitateof brain death. The patient
died before havingexmination of the organ functions. Patients were
not diagnosed with brain death according to Vietnamese law
standards. Patients werenot treated correctly according to the
regiment.
2.2. Methods
2.2.1. Design of study: Prospective, description, comparison before after study (intervention of goal resuscitation).
2.2.2. Sample size: applying the sample size formula to the beforeafter studies. N = 47.
2.2.3. Drugs and facilities.
- Drugs: infusion liquids, blood products, cathecolamine, endocrine.
- Facilities: Monitoring, ventilator, blood-air test, PiCCO monitoring.
2.2.4. The content of Research.
2.2.4.1. The stages of research: T0: Background time (1st clinical


7
diagnosis of brain death); T1: After 12 hours: 3rd brain dead diagnose
brain death 3 times (determined - conclusions); T2: After 24 hours of

resuscitation of brain death (organ resuscitation); T3: After 36 hours
of diagnosis and resuscitation of brain death; T4: After 48 hours of
diagnosis and resuscitation of brain; Tm: Time before harvesting
organs.
2.2.4.2. Criterias for evaluating
a. General characteristics of patients Criteria for evaluating general
characteristics of patients:
- Anthropometric characteristics of the brain dead potential donors.
+ Causes of brain death, brain damage.
+The need for using inotrops, vasopressine in the whole process.
+ Patient outcome after brain-dead resuscitation.
b. Study of clinica l and laboratory characteristics in brain dead
potential donors: We recorded the number of patients at the time T0
had the following clinical and laboratory indicators: The incidence of
organ dysfunction in 47 potential brain deaths; Functions of
cardiovascular; respiratory; kidney; liver and hematology; Fluid endocrine and body temperature. SOFA: Total SOFA, individual
SOFA, number of patients with multiple organ failure.
c. Evaluate the effects of resuscitation measures on the functions of
some organ in brain-dead potential donors.
- Results of hormone replacement therapy: The rate of
increased/decreased T3, T4, TSH, cortisol before and after treatment.
- We recorded the number of patients at different times (T0, T1, T2,
T3, T4, Tm) with the following changes in indicators:
+The demands of cathecolamine; the demands for the kind of
cathecolamine/ each patient; cathecolamine dose (Noradrenaline,
Adrenaline, Dobutamine, Dopamine).


8
+The changes of basic hemodynamic through heart rate, MAP, CVP;

the number of patients with decreased MAP< 70 mmHg, hypothermia
≤ 350 C and diabetes insipidus.
+ The changes of SOFA scores; of lactat; of prothrombin rate; of
plate let number.
+ The changes of respiratory and acidosis through parameters PaCO2 ,
PaO2 , PaO2 / FiO2 ; The changes of hepatic functions through blood
glucose parameters, SGOT, SGPT, direct bilirubin; The changes of
renal functions through blood ure, blood creatinine, urine output and
dopamine dose.
+ Resuscitation results according to the target "rule 100", target "rule
100 *" amended through parameters maxBP, Hb, PaO2 , urine output,
Number of eligible patients.
+ Evolution of PiCCo invasive hemodynamic parameters through
parameters CI, SVRI, GEDI and ELWI; Resuscitation results
according to PiCCo instructions: CI ≥ 3 ml/min/m2 , GEDI ≥ 680
ml/m2 , ELWI ≤ 10%, the number of patients meeting the criteria of 3
PiCCo parameters.
- We record the number of patients after treatment by destination with
the following indicators:
+ Cardiac arrest group vs or organ donation outcome in patients.
+ Number of organs eligible for transplant after resuscitation of 47
patients with brain death; number of organs eligible for transplant
among resuscitated patients; organ transplantation results from a
group of 47 patients with brain death considering organ donation;
Transplant rate from 47 patients with brain death.
+ The percentage of organ transplants from 25 organ donors; Average
number of days hospitalized after a transplant.
2.2.5. Method to proceed.
2.2.3.1. Step 1: Receive head trauma patients and install monitoring.

9
2.2.3.2.Step2: Thyroid hormone (T3,T4,TSH), Troponin T, cortisol;
SVO2 /SCVO2 , blood-gas test, blood cell test, biochemistry test,
coagulation test, urine test, SOFA score every 12 hours.
2.2.3.3. Step 3: Intensive resuscitation
Table 2.1. The targets of resuscitation.

Targets

Re suscitation measures.

Law 100*

Systolic blood pressure ≥ 100, Urine output ≥
100 ml/hour, PaO2 ≥ 100 mmHg , Hb ≥ 80 g/L

PiCCo hemodynamic
regimen

CI ≥ 3 ml/ min/ m2 GEDI ≥ 680 ml/ m2
ELWI ≤ 10 %.

Lung protected
ventilation

Donation: PaO2/FiO2> 300; FiO2 ≤ 0.5.
No donation: PaO2>70 mmHg; SaO2> 88%.

Hormone replacement

therapy

Levothyrox (belthyro x) 2,5 mcg/kg/24h
Methylpresnisolon 15 mg/kg IV
Maintain blood glucos e 4-9 mmol/l.

Treatment of diabetes
mellitus

Maintain Na + ≤ 155 mmol/L
Maintain the volume o f urine 1-2 ml/kg/hour

Maintain body
temperature

36 - 370 5

2.2.6. Criteria and definitions used in research.
2.2.7. Data analysis: SPSS 16.0 for Window.
2.2.8. Ethics in research.
The research is a branch in the State-level project, which is
approved by the Vietnam-Germany Professional and Ethical Council
as well as by the Ministry of Science and Technology. In the process
of implementing the research, we strictly adhere to the law on organ
transplants of the National Assembly, regulations of the Ministry of
Health. Resuscitation process has been approved by Vietduc Hospital.


10
CHAPTER 3 - RESULTS

3.1. General characte ristics
3.1. General characte ristics of research patients.
3.1.1. Anthropometric characteristics.
Table 3.1. Age characteristics of brain death patients in the study.
Comments: The average age is 32.91 ± 12.08 years old.
Chart 3.1. Gender distribution of patients in the study. Comments:
men account for 85.1% and females account for 14.9%.
Table 3.2. Characteristics of we ight and BMI of patients in the study.
Comments: Average weight and BMI are suitable for VNese people.
3.1.2. Characteristics of injuries in brain-dead patients in the study.
Table 3.3. Characteristics of cranial injuries of patients in the study.
Comments: 17% of multiple injuries, 83% of head trauma alone.
Intracranial hematoma, brain suppression, subarachnoid hemorrhage
accounted for 76.6%.
3.1.3. Characteristics of cathecolamins use during resuscitation
Table 3.4. Demands for cathecolamins in whole resuscitation process.
Comments: The number of patients are treated noradrenalin accounted
for the highest of 95.7%.
3.1.4. The outcome of the patients in the study.
Chart 3.2. The patient's outcome after resuscitation. Comments:
100% death (46.8% biological death and 53.2% organ donation after
brain death).
3.2. Clinical and laboratory characte ristics in brain-dead potential
donors.
3.2.1. Characteristics of complications and disorders after brain
death.
Table 3.5. Monitor body’s fluid - temperature status.
Status

Non diabetes ( X ±SD)

Diabetes ( X ±SD)

p


11

Body temperature ( C)

14 (29,8% )
36,41 ± 1,31

33 (70,2% )
36,10 ± 1,58

0,60

Urine output (ml/kg/giờ)

0,14 ± 0,11

0,55 ± 0,38

<0,001

148,21 ± 13,04
300,78 ± 24,99

152,36 ± 14,92

337,05 ± 20,07

(n)/ (%)
0

Na+/plasma (mmol/l)
BOP (mosmol/kg)

0,35
<0,001

Comments: The average of urine output and blood osmolarity pressure
in group with diabetes is significantly higher than the other.
Table 3.6. The incidences of cardiac and pulmonary function index
disorders before organ resuscitations.
Organ

Data
MAP
CI

Heart

GEDI
SVRI
PaO2 /FiO2
PaCO2

Lung

pH
ELW I
AOP

Unit

Criteria

mmHg

< 70
<3
l/ min/ m
>5
< 680
2
ml/ m
> 800
< 1970
5 2
dynes/cm /m
> 2390
< 300
< 35
mmHg
> 45
< 7,25
> 7,45
ml/kg
> 10

pink foa m intubation
2

No.(n)

Ratio(% )

10
23
2
47
0
24
15
16
29
2
0
31
10
4

21,3
48,9
4,3
100
0
51,1
31,9
33

61,7
4,3
0
66,0
21,3
8,5

Comments: 21.3% of patients havehypotension <70 mmHg, 33% of
patients had PaO 2 /FiO2 reduction <300 and 21.3% of patients have
ELWI> 10.
Table 3.7. The incidences of renal, hepatic and hematological
function disorders before organ resuscitations.
Organ

Data

Unit

Criteria

No.(n)

Ratio
(%)

Kidney

Oliguria
Diabetes inspidusis

ml/kg/h
ml/kg/h

< 0,5
>4

0
33

0
70,2

Creatinine/plasma

mmo l/ l

> 110

8

17,1


12
Natri plasma
Kali plasma
S GPT
Liver

Glucose plasma

Bilirubin total
Platelet No.

Hematology

Prothrombine
Hemoglobine

mmo l/ l
mmo l/ l
UI
mmo l/ l
µmol/l
G/ l
%
g/dl

> 155
< 3,5
> 2 lần
>10
> 20
< 150
< 60
> 10

20
22
4
13

8
24
17
47

42,6
46,8
8,5
27,7
17,1
51,1
36,2
100,0

Comments: diabetes inspidusis 70.2%; 17.1% of liver dysfunction and
17.1% of renal dysfunction; 51.1% of decreased platelets <150 G/l;
Table 3.8. Results of some cardiac function indicators in the
resuscitation of brain death. Comments: Average EF = 63.09 ± 6.77%.
Table 3.9. Results of screening ultrasound of livers and kidneys in
resuscitation of brain death. Comments:abnormality of structure and
image founded in 4 cases.
Table 3.10. Hormone concentrationsof brain-dead potential donor
patients before hormone therapies. Comments: before hormone
therapies, decreased T3 is 91.5%, decreased cortisol is 27.6%.
3.2.2. The incidence of organ dysfunctions according to the SOFA
score right before organ resuscitation.
Table 3.11. The incidences of organ dysfunctions according to SOFA
scorebefore organ resuscitation. Comments: Cardiovascular system:
83% of patients have SOFA 3 and 8.5% of patients have SOFA 4.
4.3% lungs with SOFA 3. 4.3% of patients has kidney with SOFA 2.

Liver: 4.3% patients have SOFA2. hematologica l disorder: 4.3%
patients have SOFA 3.
3.3. Evaluate the e ffects of res uscitation measures on the function
of some organ in brain-dead potential donors
3.3.1. Results on hormone replacement therapy


13
Chart 3.3. The rate of increased/decreased T3 before and after
treatment. Comments: After hormone therapies, the number of patients
with decreased T3 is 44.7% (21/47).
Chart 3.4. The rate of increased/decreased T4 before and after
treatment. Comments: After hormone therapies, the number of patients
with decreased T3 is 40.4% (19/47).
Chart 3.5. The rate of increased/decreased TSH before and after
treatment. Comments: After hormone therapies, the number of patients
with normal TSH is 72.3% (34/47).
Chart 3.6. The rate of increased/decreased cortisol before and after
treatment. Comments: After hormone therapies, the number of patients
with decreased cortisol is 8.5% (4/47).
3.3.2. The results of resuscitation for brain death stages after 12, 24,
36, 48 hours.
Table 3.12. The demands of cathecolamine on each stage of organ
resuscitation. Comments: the rate of noradrenaline using is very high
all the stages, 100% in T3.
Table 3.13. The demands for the kind of cathecolamine/ each
patientin every resuscitation stages. Comments: using 1 kind of
cathecolamine is highest (66%) at T0; using 2 kind of cathecolamine
is highest (40%) at T4.
Table 3.14. Cathecolamine dose in every resuscitation stages.

Comments: The dose of noradrenaline significantly decreased at T1,
T2, Tm.
Table 3.15. The changes of basic hemodynamic after brain death
diagnosis. Comments: MAP increased significantly every postresuscitation stages. CVP increased significantly after T2.
Table 3.16. The rates of complications in hypotension, hypothermia
and diabetesin every stages. Comments: the rates of hypotension <70


14
mmHg gradually decreases after T1 (6.4%), T2 (2.7%), reincreases
after T3, T4 (14.6% and 20%), the rates of hypothermia ≤ 350 C and
diabetes insipidus gradually decrease after resuscitation stages.
Chart 3.7. The changes of SOFA scores in the brain-dead
resuscitation stages. Comments: The averages of mean SOFA increase
after every stages.
Chart 3.8. The changes of lactat in brain-dead resuscitation stages.
Comments: Blood lactate decreased significantly at T1, T2, Tm.
Table 3.17. The changes of respiratory and acidosis during
resuscitations. Comments: PaO2/FiO2- significantly reduced after T3.
Chart 3.9. The changes of prothrombine rate in brain-dead
resuscitation stages. Comments: The ratio of prothrombine has
reduced significantly every stages.
Chart 3.10. The changes of platelet during brain-dead resuscitation
stages. Comments: Platelet reduces significantly during the
resuscitations
Table 3.18. The changes of hepatic functions during brain-dead
resuscitation stages. Comments: The blood glucose of the patients
significantly decreased in the T1, T3. Directed bilirubine increased
significantly at T1, T2.
Table 3.19. The changes of renal functions during brain-dead

resuscitation stages. Comments: The output of urine decreases
significantly in every stages.
3.3.3. Progress of archieving the organresuscitation targets inevery
stages.
Table 3.20. The results of resuscitation target according to Law 100.
Comments: 60% of patients archieve the law 100 targets (highest) in
Tm and 51.4% in T2.
Table 3.21. The results of resuscitation target according to Law 100*.


15
Comments: 100% of patients archieve the law 100* targets (highest)
in Tm and 86.5% in T2.
Table 3.22. The changes of invasive hemodynamic parameters
mesured by PiCCo after brain-dead diagnosis. Comments: GEDI
significantly increased in T1, T2, T3, Tm. ELWI increased
significantly at T3.
Table 3.23. The results of resuscitation target according to PiCCo
guidelines. Comments: After 24 hours (T2), 35.1% of patients
archieve the PiCCo targets (highest).
Table 3.24. The results of resuscitation folowing targets.
Pe riod

No. of patients No. of patients No. of patients
archieve PiCCO archieve 100 archieve 100*
(1) n(%)
(2) n(%)
(3) n(%)

No. of

No. of
patients
patients
archieve
archieve
(1)+(2) n(%) (1)+(3) n(%)

T0 (n =47)

0

17 (36,2)

27 (57,4)

0

T1 (n =47)

6 (12,8)

18 (38,3)

37 (78,7)

1 (2,13)

5 (10,6)

T2 (n =37)

13 (35,1)

19 (51,4)

32 (86,5)

9 (24,3)

13 (35,1)

T3 (n =16)

2 (12,5)

6 (37,5)

9 (56,3)

1 (6,3)

2 (12,5)

T4 (n =5)

0

0

0

0

0

0

14 (56)

Tm (n=25)

14 (56)

15 (60)

25 (100,0)

0

Comments: The highest number of patients achieve all targets is in
stage T2.
3.3.4. The results achieved the treatment goals of the donor group
and cardiac arrest during each resuscitation period.
Table 3.25. Cardiac arrest group vs donor group. Comments: The
number of patients who achieved all targets at T2 and statistica lly
different between groups of donors and cardiac arrest.
3.3.5. The number of organs eligible for transplant after
resuscitation of 47 brain-dead potential donors.

16

Chart 3.11. The number of organs is suitable for transplantation
among resuscitated patients. Comments: eligibility for kidney and
heart donation are highest at T2 (54% and 48.6%); eligibility for liver
and lung donation are highest at T4 (60% and 20%).
3.3.6. Outcomes of transplanted organs from 47 brain-dead potential
donors.

Chart 3.12. The proportion of new grafts from 47 brain-deadpatients.
Comments: The number of grafted kidney is 50% (47/94) (highest),
the grafted liver is 46.8% (22/47) and the grafted heart is 23.4%
(11/47).
Chart 3.13. The proportion of new grafts from 25 brain-dead donors.
Comments: The number of grafted kidneys is 94% (47/50) (highest),
the grafted livers is 88% (22/25) and the grafted hearts is 44% (11/25).
Chart 3.14. The average numbers of hospitalization after
transplantation. Comments: The longest hospitalized heart transplant
patient, the shortest kidney transplant patient.
CHAPTER4 - DISCUSSION
4.1. General characte ristics of patients.
4.1.1. Characteristics of age, gender, weight.
The average age was 32.91 ± 12.08 years old, lower than Weiss’s


17
study (54 ± 19.7). The rate of male is higher than of female (chart 3.1)
and the majority of 40/47 (85.1%), female is 7/40 (14.9%). The
average weight is 55.57 ± 6.30 kg and BMI is 18.62 ± 5.13 (Table 3.2)
is suitable for the average size of Vietnam.

4.1.2. Causes and traits of brain death patients in the study.
100% of severe head trauma in which 83% of severe cranial
injury, 17% suffered from multiple injuries (severe cranial injury
mainly of brain hematoma, cerebral hemorrhage and haemorrhagic
hemorrhage (up to 76.6%) (table 3.3).
4.2. Clinical and laboratory subclinical characte ristics in brain
dead potential donors.
4.2.1. Diabetes insipidus, electrolyte disturbances and body
temperature.
The rate of diabetes insipidus is 70.2%, urineoutput is 0.55
ml/kg/hour, and natriemia increase 152 mmol/l (Table 3.5). This rate
in the study of Nguyen Quoc Kinh is 62.5%; Wood is 65%; Salim
(2001) is 84%. The average temperature of diabetes insipidus group
36.10 ± 1.58 are different not significant for the group without
diabetes insipidus, 36.41 ± 1.31 (p = 0.6) (Table 3.5). Hypernatremia
> 155 are 42.6% in the study (Table 3.5). Cywinski has 20.4%
hypernatremia > 155 mmol/l.
4.2.2. Hemodynamic and endocrine disorders.
According to Salim, demands for cathecolamine is 97.1%,
thrombocytopenia 53.6%, coagulopathy 55.1%, diabetes insipidus
46.4%, lactic acidosis 24.6%, renal failure 20.3%, and ARDS 13%.
The results of our study have the rate of cathecolamine using
(especially noradrenalin) is 95.7% (table 3.4), thrombocytopenia <150
G/L is 50.1% (table 3.7), coagulopathy (rate of prothombine time
<60%) is 36.2% (Table 3.7), diabetes insipidus is 70.2% (Table 3.5),
kidney failure is 17.1% (Table 3.7), respiratory dysfunction
(PaO2/FiO2 < 300) is 33% (table 3.6). The period before brain-dead
resuscitation, 91.5% (43/47) of our patients treated noradrenaline right
from the beginning, higher than the results of the above authors,
adrenaline was 12.8% (6/47), dobutamine is 10.6% (5/47) and

dopamine is 10.6% (5/47) (table 3.12). Hoege (2007) and Schnuelle
(2004) suggest that dopamine is the first cathecolamine due to
effective vasoconstriction.
The results of thyroid hormones in our study before treatment of


18
(nasal gastricsond) belthyrox corresponding to decreased T3, T4 by
43/47 (91.5%), 35/47 (74.5%); and normal/ increase TSH is 25/3
(total 59.6%) (table 3.10). But after treating belthyrox, decreased T3,
T4 respectively to 21/47 (44.7%), 19/47 (40.4%); and the normal/
increase TSH level reached 37/47 (78.7%) (charts 3.3, 3.4, 3.5). In the
study, normal and high cortisol before treatment was 42.6% and
29.8% (table 3.10). Kainz (2010), Barkin (2009) mentioned system
inflammatory response syndrome (SIRS) in brain-dead.
4.2.3. Disorders of respiratory and acidosis
We have 10/47 (21.3%) with a slight decrease of PaO2/FiO2 ratio
in the range of 301-400, 4/47 patients (8.5%) had mild lung les ions
PaO2/FiO2 (201-300) and 2/47 patients (4.3%) had severe lung
lesions PaO2/FiO2 (<200) (ARDS) (table 3.11). Clinical acute
pulmonary oedema (APO) with neurological cause was 8.5% (4/47)
(table 3.6), compared with Smith (2004) and Salim (2006) ranging
from 13-18%, also mainly neurological pulmonary edema. There were
21.3% of patients with extralung water index (ELWI> 10) (Table 3.6),
which showed that the massively infusion liquids after brain-death due
to prevent hypotension. About acidosis disorders, pH> 7.45 is quite
high at 66% due to the high-volume ventilations of the before entering
ICU (Table 3.6).
4.2.4. Disorder of blood glucose
We had 27.7% (13/47) patients with hyperglycemia> 10 mmol / l

(Table 3.7). Parekh (2011) studied over 40 recipients of kidney
transplants from living kidney donors also found blood glucose>
8.8mmol/l related to impaired renal function after transplantation.
4.2.5. Organ dysfunction according to SOFA score
In the pre-resuscitation period, the SOFA score corresponds to ≥
2 points (SOFA score 2, 3 and 4) for cardiovasculars are 91.5%,
respiratory 12.8%, livers 4.3%, kidneys 4.3 % and hematology
(thrombocytopenia) 25.6% (table 3.11). The average SOFA score of
the period T0 is 8.64 ± 2.27; the following stages corresponds to 9.30
± 2.48 (T1), 9.51 ± 1.71 (T2), 10.44 ± 1.83 (T3), 11.4 ± 2.07 (T4)
respectively, 9.38 ± 1.72 (Tm) and all stages having significantly
increased SOFA (p <0.05) in the later stages compared to T0 (chart
3.7), but after 36 hours the average SOFA increased> 10. Nguyen
Quoc Kinh (2012, 2013) found that the total SOFA score was
statistically significant higher (p <0.05) in patients with cardiac arrest


19
compared to non arrest patients, among non arrest patients, it is better
in group of eligible for organ donation compared to groupnon e ligible
for organ donation (both are beating heart brain-dead donors). Essien
(2017) finds that the current methods of definition organ failure or
dysfunction have not yet fully predict the success of transplantations.
4.3. Evaluate the effects of res uscitation measures on the functions
of some organ in brain-dead potential donors
4.3.1. The goals of resuscitation as guiding parameters of treatment
for brain-dead potential donors.
4.3.1.1. Traditional monitoring parameters and prognosis of tissue
hypoxia in brain dead potential donors.
The average heart rate of our patients ranged from 105.3 to

108.14 times/min at T1 and T2, but trent to increase by 120.2
times/min at T4 stage but not significant. Average of MAP in
groupremained at> 80 mmHg but increased significantly at T1 stage
(89.2 ± 15.25) and Tm (101.67 ± 18.89) (p <0.05), CVP was
maintained at 6-9 mmHg but statistically high after 24 hours was 8.51
± 3.81 (p <0.05). The above results are had due to we try to optimize
the volume of infusion (table 3.15).
4.3.1.2. The hemodynamic target of the brain-dead potential organ
donors
We have choosen the law 100* (modified) target (accept the
patient's Hb at ≥ 8 g/dl), have 78.7% of our patients were eligible to
donate organs after 12 hours and up to 86.5% of patients were eligible
for organ donation after 24 hours (table 3.21) and reached 100% of
patients when harversted organs.
We resuscitated patients with brain death according to PiCCO
guidelines and found that only 12.8% of patients met the criteria at the
time of diagnosis after 12 hours, and then at 24 hours and 36 hours
respectively. 35.1% and 12.5% of patients met the criteria for PiCCO
target (Table 3.23). In the period of organ harvesting, there are 56%
meeting a ll three PiCCo parameters.
The patients who achieved both targets (PiCCo and 100) in our
study were quite low at 2.13% after 12 hours, 24.3% after 24 hours
and 2.13% after 36 hours; while achieving both goals (PiCCo and
100*), the rate of donation standard increased to 10.6% after 12 hours,
35.1% after 24 hours and 12.5% after 36 hours (table 3.24). At the
time of donation, none of the patients achieved both PiCCo/100


20
targets and 56% achieved both PiCCo/100* targets.

4.3.1.3. The targets of infusion and blood transfusion.
The main goal of body infusion control is to optimize all liquids
to ensure circulation volume and cardiac flow suitably.
During resuscitation, we kept the average CVP at 6.30 ± 3.97 at
the beginning of resuscitation stage (T0) and the highest at 8.51 ± 3.81
at. 24 hours of resuscitation (table 3.15).
4.3.1.4. Hormone replacement therapy for brain-dead potential
donors.
- Vasopressin therapy: Plurad (2012) found that vasopressine in
brain-dead donors was affected to the increasing of post-transplanted
recovery rate. Our results showed that the incidence of diabetes
inspitus gradually decreased to 42.6% after 12 hours and 27% after 24
hours and the time of organ harvesting was 16% (Table 3.16).
- Corticosteroid therapy: we had 27.7% reduction in cortisol
when diagnosed with brain death, the remaining 42.6% were normal
and 29.8% increased cortisol immediately before resuscitation (table
3.10). Follette D (1998) and McElhinney (2001) found
methylpresnisolon to be involved in improving lung quality of donors.
We use high-dose corticosteroids (methylprednisolone 15mg/kg IV).
Results of cortisol after treatment were 15.4%, 42.3% normal and
42.3% increased (chart 3.6).
- Thyroid hormone replacement therapy: Howlett found that 81%
of patients had decreased T3, 29% of patients had decreased T4, and
23% had normal TSH. After treatment, we had decreased T3 from
91.5% to 44% (chart 3.3); decreased T4 from 40.4% to 21.3% (chart
3.4); and normal TSH from 53.2% to 72.3% (chart 3.5).
- Treatment of hyperglycemia: An average blood glucose of 8.91
mmol/l at T0 and significant reduction in T1 and T3 (7,8 and 7,63
mmol/l); At the time of organ harvesting, average blood glucose 8.17
mmol/l (<9) (table 3.18). According to Blasi-Ibanez (2009),

hyperglycemia is related with decreased renal function.
4.3.2. Effects of functional resuscitation of kidney, liver, heart and
lung organs according to the achieved targets in brain dead
potential donors.
- Kidneys. Recommendations on selected criteria of donors are
as follows: age <85 years, MAP > 70 mmHg, dopamine dose ≤ 10
µg/kg/min, creatinine <133 (1.5 mg/dl), urine outputs> 0.5 ml/kg/h


21
(0.05 - 0.1 l/h), normal renal ultrasound. We had 8/47 (17%) after 12
hours of resuscitation, 20/37 (54%) after 24 hours of resuscitation,
8/16 (50%) after 36 hours of resuscitation and 2/5 (40%) after 48
hours resuscitation (chart 3.11) were good qualifies for kidney
donation.
- Livers. Criteria for donated livers are <80 ages; SGOT, SGPT
<80, Bilirubin total <22, pH 7.35 - 7.45, PaO2> 100, PaO2/FiO2>
200, noradrenalin or adrenalin ≤ 0.05 µg/kg/min, dopamine or
dobutamin ≤ 5 µg/kg/min, normal liver ultrasound. According to the
above criteria, the number of patients eligible for our liver donation is
7/47 (14.9%) after 12 hours of resuscitation, 13/37 (35.1%) after 24
hours of resuscitation, 6 / 16 (37.5%) after 36 hours resuscitation and
3/5 (60%) after 48 hours of resuscitation (chart 3.11). Patients with the
highest dopamine use were 17% in T1 (table 3.12). Dopamine dose <8
μg/kg/min at stage T0 and ≤ 5 μg/kg/min afterwards (table 3.14).
- Hearts. Traditional criteria for heart donation patients: age <65,
EF> 60%, troponin T ≤ 0.1 UI/l, MAP > 60 mmHg, heart rate 60-80
times/min, sinus rhythm, CI> 3 liters/min/m2, CVP<12 mmHg,
dobutamine/dopamine ≤ 5 µg/kg/min, adrenaline/noradrenaline ≤ 0.05
µg/kg/min. Our number of patients who were eligible for heart

donation was 12.8% after 12 hours of resuscitation, 48.6% after 24
hours of resuscitation, 25% after 36 hours of resuscitation and 40%
after 48 hours of resuscitation (chart 3.11). Stoica (2004) has
demonstrated that the use of norepinephrine in donors is related to 1year survival rates reducing in heart recipients. Von Ziegler (2013)
found a higher survival rate if the patient did not use dopamine and
norepinephrine, but must be used, norepinephrine better for cardiac
donation. The choice of cathecolamine in our study (noradrenaline
91.5 - 100%) (table 3.12) is also consistent with the Von Ziegler ‘s
results. We followed the recommendations of cathecolaminefor
donors (4.67 ± 0.82) and dopamine (4.07 ± 1.58) µg/kg/min, adrenalin
(0.05 µg/kg/min) but noradrenalin is still high> 0.05 (0.06 ± 0.02
µg/kg/min) to ensure blood flow to organ infusion (Table 3.14).
Echocardiography also helped us to assess cardiac functions
significantly, although the average EF of the group was 63.09 ± 6.77
(%) (Table 3.8).
- Lungs. The standard of my test is as follows: <70 years,
PaO2 /FiO2 > 250, ELWI ≤ 10, PaO 2 > 100mmHg, FiO2 <50%, MAP>


22
60 mmHg, heart rate 60-80 times/min, sinus rhythm, CI> 3
liter/min/m2, CVP<12 mmHg, dobutamine/dopamine ≤ 5 µg/kg/min,
adrenaline/noradrenaline <0.05 µg/kg/min, clear 2-sided X-ray,
smokes<20 packs/year, no chest injury, no reflux or infection, no
history of cardiopulmonary surgery, no bacteria on the gram stain, no
secretions/gastric juice during bronchoscopy, no history of chronic
lung disease. The number of patients eligible for our pulmonary
donation was 2.1% after 12 hours of resuscitation, 10.8% after 24
hours of resuscitation, 6.3% after 36 hours of resuscitation and 20%
after 48 hours of resuscitation (chart 3.11).

Luckraz and Reyes did not see any difference for recipients with
PaO2 /FiO2 < 300 compared to PaO2/FiO2> 300. The PaO2 /FiO2 ratio
of our study decreased gradually in the later stages, especially 36
hours (T3) with a statistica lly significant reduction (still satisfactory ≥
300) (table 3.18). In addition, the ELWI <10 played an important role
in determining the lung quality assessment, in the changes of ELWI,
from T0 to T2 and Tm, the ELWI is relatively stable <10, but from T3
on wards ELWI increased > 10 and was significant at 36 hours (T3)
(Table 3.22).
Mascia (2010) and Neto (2012) found that low Vt would increase
the number of transplanted eligible lung organs from brain-dead
potential donors. Our patients were resuscitated according to the "lung
protection strategy", quite stable resuscitation stages for blood pH,
PaCO2 , PO2 , which were not significantly different between periods,
except after 24 hours. PO2 reduced significantly but average is still
228.09 ± 65.89 (table 3.17).
4.3.3. The patient's outcome after organ’s brain-dead resuscitation.
The results of our study have 25/47 real donors, 22/47 were non
donating. Mortality rate is 100% (chart 3.2). The proportion of
patients achieving treatment goals at T2 and T3 is the largest,
including donation or non-donation groups, stage T2, T3 are the best
results in terms of resuscitation, especially T2 with p = 0.014 (table
3.25).
4.3.4. Post-transplant results of organ receivers.
- Kidneys: The total number of kidney transplants from 25 donors is
47/50 (94%) (chart 3.13) and the proportion of 47 brain-dead potential
donors is 50% (1 donor has 2 kidneys) (chart 3.12). 1 patient died, 46
patients survived, 1 case of post – transplanted ureteruria, 45 cases

23
remained stably.
- Livers: The total number of liver transplants from 25 donors is 22
(88%) (chart 3.13) and the proportion of 47 brain-dead potential
donors is 46.8% (chart 3.12). 1 dead (28 days) postoperative due to
acute hepatic failure, 4 deaths after surgery due to recurrent HCC. The
remaining 17 cases stably.
- Hearts: The total number of heart transplants from 25 donors was 11
(44%) (chart 3.13) and 23.4% (from 47 brain-dead potential donors is)
(chart 3.12). There were 5 patients died, 6 survived> 3 years, stably.
CONCLUSION
Through the research of organ donated-targets resuscitation for 47
brain-dead potential patients with severe brain trauma who diagnosed
with brain death according to Vietnamese standards and laws from
January 2010 to December 2015 in Vietduc Univers ity Hospital. We
propose the following conclusions:
1. In brain-dead potential patientsare affected by the
consequences of brain death, causing clinical and laboratory
disorders.
- Hypotension must be used cathecolamine (95.7%), in which must be
used high dose cathecolamine (91.5%).
- Acute lung injury (33%) in which ARDS accounts for 12.8%
(PaO2/FiO2 <200).
- Diabetes insipidus (70.2%) and hemodialysis pressure 337.05 ±
20.07 mosmol/kg was higher than the group without diabetes insipidus
300.78 ± 24.99 mosmol /kg (p <0.001)
- Cardiac Index CI <3 (48.9%), ELWI > 10 (21.3%).
- Renal dysfunction (17.1%), creatinine increased > 170 G/L (4.3%).
- Hepatic dysfunction (17.1%), bilirubin increased > 33 µmol/l
(4.3%).

- Thrombocytopenia <150 G / L (50.1%), severe reduction <50 G / L
is 4.3%.
- Hypernatremiawas 42.6% (> 155 mmol/l) and hypopotassemia was
46.8% (<3.5 mmol/l).
- T3 thyroid hormone has a serious deficiency (91.5%).
2. Effects of res uscitation measures on the functions of some organ
in brain-dead potential donors.
- Achieved hemodynamic treatment according to PiCCo guidelines
(CI ≥ 3 ml/min/m2, GEDI ≥ 680 ml/m2, ELWI ≤ 10%) highest