Tuesday, January 3, 2012

Organ donation .... Cheating death with generosity

Brain stem or brain death is a state following severe brain injury due to injury or stroke where critical functions of the brain mainly the ability to initiate spontaneous respiration, maintain consciousness and coordinate body functions are irreparably damaged. In this state circulation to organs is maintained, the heart is beating but meaningful life has already ceased . Eventually due to loss of coordination all systems including the heart will shut down in a matter of days. Brain death can be reliably diagnosed based on simple bedside tests once the cause of brain injury is known. Inability to elicit spontaneous respiration after withdrawal of ventilator indicates a positive apnoea test. Other tests include the caloric test and doll's eye that indicate loss of brain stem reflexes. These tests performed by a panel of clinicians or brain specialists are sufficient to declare brain death. However to remove any doubt the tests are repeated on two occasions separated by at least 6 hours before declaration. Additional tests like EEG or cranial Doppler are merely supportive and not necessary to diagnose brain death from a medical or legal standpoint. Once brain death is declared all systems can be supported using artificial devices to keep blood supply into organs intact for some time.During this period, these organs can be extracted and transplanted into patients whose organs have failed.the liver, kidneys, intestines, pancreas, heart, lungs and other tissues can all be used to save several lives when they are no longer of use to the brain dead individual. These organs will live in the recipients long after the donor has passed. Can there be a better way to cheat death?

Living donation ... A kiss of life

Patients with advanced liver disease who need early transplantation are often lost due to complications while they are waiting for a donor liver. In such circumstances a living donation from a near and dear one can serve as a kiss of life. Several terminally ill patients have been salvaged by this precious gift from their loving family

Monday, January 2, 2012

Clotting disorders in liver disease

Blood clotting is one of the main mechanisms by which bleeding is spontaneously controlled. This involves mainly three components : platelets, clotting factors and fibrinolytic factors. A stable effective clot is formed when platelets are adequate in number and function, clotting factors are available in adequate quantity and fibrinolytic mechanisms are downregulated. In liver disease particularly cirrhosis any or all of these mechanisms may be deranged. Bleeding may be a result of low platelet count or function, reduced synthesis of clotting factors ( mainly II, VII,IX and X) as well as excessive production of fibrinolytic factors( protein C,S and tissue plasminogen activator). Elevated pressure in splanchnic vessels resulting from portal hypertension makes them more liable to rupture under minimal stress or spontaneously. Curiously in some cases coagulation may be hyperactive leading to thrombosis due to overproduction of procoagulants or deficiency of fibrinolytic factors. Monitoring and maintenance of coagulation is critical in patients with severe liver disease particularly during surgery or liver transplantation. Massive blood transfusion is associated with a poor prognosis in the short and long term and hence irrational blood and component therapy has fallen into disrepute. Germane and need based timely blood or component therapy can salvage difficult situations while avoiding the effects of massive transfusions. Most centres now apply real-time point-of-care coagulation monitoring to guide their component therapy as opposed to lab report based correction. While reproducibility between different systems is lacking the clinical correlation has been encouraging. In fact one of the major successes in liver transplantation surgery has been the reduction of blood loss which has played a significant role in improving the safety and success of the procedure.

Review article written by me for Indian Journal of Surgery

Liver transplantation for hepatocellular carcinoma is a controversial and oft debated issue. The debate revolves around utility i.e. expected gain to the recipient of the liver graft in terms of survival after transplantation as opposed to the same graft being offered to someone without a tumor and equipoise i.e. whether the risk of transplant and its aftermath is lower than the risk of other therapies. In Asian countries and India since a living donor graft is the most common liver graft used, there is a double equipoise to be satisfied. Not only does the patient require to have a good expectation of survival but the advantage to the patients has to be significant enough to justify the risk albeit minimal to the living donor. How to select such patients before transplant remains an area of great interest and investigation. This and other issues have been addressed in my article based on my experience and the current published literature on the subject.

Is the world about to end? Mayans and other doomsday diatribes

Written history is replete with doomsday predictions relating to the end of the world as we know it. Everyone waits for the current one regarding 2012 to fizzle out. However if you ask me humanity has died long ago. It died the moment the human race started taking pride in developing weapons to annihilate themselves several times over. There is no other example of such sheer lunacy in the living world, where the self-preservation is the primary goal of any species. And we call ourselves intelligent!We might as well be cannibals.
Somebody is obviously goofing on the job or else the reset button would have been pressed long ago.