The scenario refers to Leah, who while celebrating her 18th birthday took one Ecstasy tablet. Over the next 3 hours, Leah seemed to enjoy herself but she complained of feeling hot and sweat a lot. She kept drinking water and 4 hours after taking the tablet she was found slumped and could not wake up, in a coma. On questioning the friends at the hospital, they said that she had probably drunk around 14 pints of water over 4 hours. The blood test’s results showed hyponatremia of less than 125 mml/L (normal 135-145 mmol/L). A C.T. scan revealed cerebral odema with evidence of brain herniation, confirmed by dilated pupils due to compression of the occulomotor nerve and respiratory arrest. To correct hyponatremia, Leah was given IV saline (3%) and put on a ventilator. Three days later, as she had no improvement, her parents decided to turn off the ventilator and agreed to donate any organ that could be used; Leah had signed up to the organ transplant register.
In the following paragraphs I will explore in detail the following:
Learning Objectives:
1. Definition of unknown terms
2. Ecstasy: Mode of Action and Legal Status
3. Fluid Balance and ion concentration
4. How does a CT scan and other medical imaging work
5. Organ Donation
6. Signs and Symptoms in the scenario
1. DEFINITION OF UNKNOWN TERMS
a) Ecstasy
b) Hyponatremia
c) Cerebral Oedema
d) Gyri and sulci
e) Brain Herniation
f) Oculomotor nerve
g) Ventricular System
h) Respiratory arrest
i) Coma
j) C.T. scan
k) IV saline (3%)
l) Ventilator
m) Organ transplant register
a) Ecstasy is an amphetamine-based recreational drug having euphoric effects, typically taken in the form of a pill and particularly associated with clubbing and dance music subcultures(Oxford University Press 2017). It is a derivative of amphetamine (Fig.1) and Its chemical name is 3,4-methylenedioxymethamphetamine (MDMA). Ecstasy has a variety of street names including, XTC, Adam, M & M, E, and essence. Unlike other drugs of abuse, often derived from plants (like cocaine, morphine, nicotine), ecstasy is synthesized in laboratories by altering the structure of the amphetamine molecule. So, its purity can vary substantially from lab to lab, and other compounds are easily combined into the same tablet (contaminants often include caffeine, ephedrine, ketamine – a mild hallucinogen and methamphetamine) (National Institute on Drug Abuse 2017).
Figure 1
b) Hyponatremia is a condition that occurs when the level of sodium in the blood is abnormally low. Sodium is an electrolyte that helps regulate the amount of water in and around the cells (Nordqvist 2016). In hyponatremia (Fig.2), one or more factors — ranging from an underlying medical condition to drinking too much water — causes the sodium in the body to become diluted. Consequently, the body’s water levels rise, and the cells begin to swell. This swelling can cause many health problems, from mild to life-threatening (Mayo Clinic Staff 2017).
Figure 2
c) Cerebral Oedema
Cerebral edema is the accumulation of excessive fluid in the substance of the brain (MedicineNet.com 2017). Brain swelling is also known as cerebral oedema. It can be caused by an accident or some medical conditions. This pressure can prevent blood from flowing to the brain, which deprives it of the oxygen it needs to function (Fig.3).
Figure 3
d) Gyri and sulci
The brain consists of many folds or ridges and indentations. A brain ridge is known as a gyrus, while an indentation or depression is a sulcus or fissure (Fig.4). Brain gyri and sulci serve two very important functions. They help to increase the surface area of the cerebral cortex. This allows more neurons to be packed into the cortex and increases the brain’s ability to process information (Bailey 2016).
Figure 4
e) A brain herniation , or cerebral herniation, occurs when brain tissue, blood, and cerebrospinal fluid (CSF) shifts from their normal position inside the skull.
(Fig.5)
Figure 5
8
f) Oculomotor Nerve is the third cranial nerve (CNIII) (Fig. 6) (The Teach me Series 2017). It offers motor and parasympathetic innervation to ocular structures. There are two structures in the eye that receive parasympathetic innervation from the oculomotor nerve: Sphincter pupillae – Constricts the pupil, reducing the amount of light entering the eye and Ciliary muscles – Contracts, causes the lens to become more spherical, and thus more adapted to short range vision. Compression of the Oculomotor Nerve tends to result from serious disorders, such as herniation of the brain (Merck 2017).
Figure 6
g) Ventricular system
The ventricles of the brain are a communicating network of cavities filled with cerebrospinal fluid (CSF) and located within the brain parenchyma. The ventricular system is composed of 2 lateral ventricles, the third ventricle, the cerebral aqueduct, and the fourth ventricle (Medscape 2017) (Fig. 7).
Figure 7
• Respiratory arrest is a condition when a patient stops breathing or is ineffectively breathing. It often occurs at the same time as cardiac arrest, but not always. Respiratory arrest is a state in which a patient stops breathing but maintains a pulse (ACLS MEDICAL TRAINING 2017). Respiratory arrest (MSD 2017) can be caused by airway obstruction, decreased respiratory effort, respiratory muscle weakness, drug effect.
Figure 8
h) A coma is a state of prolonged unconsciousness that can be caused by a variety of problems — traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, diabetes or an infection (Mayo Clinic Staff 2017). A coma seldom lasts longer than several weeks. People who are unconscious for a longer period of time may transition to a persistent vegetative state. Depending on the cause of a coma, people who are in a persistent vegetative state for more than one year are extremely unlikely to awaken (Fig.9).The Glasgow Coma Scale (Institute of Neurological Sciences 2017) provides a practical method for assessment of impairment of conscious level in response to defined stimuli. The Scale was described in 1974 by Teasdale and Jennett as a way to communicate about the level of consciousness of patients with an acute brain injury .
Figure 9
i) C.T. Scan
Medical imaging is the technique and process of creating visual representations of the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology) (Radiological Society of North America 2016). There are many imaging exams, such as plain radiography, ultrasound, computed axial tomography (CAT or CT) and MRI. (Members of the Ontario PET Steering Committee 2008). CT, or CAT scans, are special X-ray tests that produce cross-sectional images of
the body using X-rays and a computer.
Figure 10
j) IV saline (3%)
3% Sodium Chloride Injection is a
sterile, nonpyrogenic, hypertonic solution for fluid and electrolyte replenishment for intravenous administration. The pH may have been adjusted with hydrochloric acid (RXLIST 2017). Normal saline is a sterile mixture of salt and water. It is called normal because its salt concentration is similar to tears, blood, and other body fluids (0.9% saline). It is also called isotonic solution). IV saline 3% is hypertonic and is usually reserved for severe hyponatremia (sodium < 115 meq/L).
Figure 11
k) Ventilator
A ventilator is a machine that supports breathing. It gets oxygen into the lungs and removes carbon dioxide from the body, used for life support. A ventilator uses pressure to blow air or a mixture of gases into the lungs. This pressure is known as positive pressure. A ventilator can be set to “breathe” a set number of times a minute (U.S.Department of Health and Human Services 2017).
Figure 12
l) Organ transplant register
Organ donation (NHS Blood and Transplant 2017) is giving an organ to help someone who needs a transplant. On average, around 3 people die every day waiting for a suitable organ. Most organs are donated by deceased donors but some organs, like the kidney and liver, can be donated by living donors.
Figure 13
2. Ecstasy- mode of action
• Legal status
Ecstasy is the more common street name for 3,4-methylenedioxymethamphetamine—also known as MDMA . This is a synthetic chemical, with complex effects that mimic both stimulants and hallucinogens . In the 1970s, the drug became more commonly used in parties (Fig. 15) to enhance the pleasurable experiences. Ecstasy came under scrutiny in 1985 when the U.S. Drug Enforcement Administration banned its use due to its potential as an agent of brain damage (Fig. 16). Today, it remains on the list of drugs prohibited from sale or use (Patterson 2017).
In the UK, among young people (16-24 year olds) ecstasy is the second most popular drug after cannabis. It is the third most popular drug, after cannabis and cocaine, for 16-59 year olds (Lader 2016).
Figure 14
You don’t have to suffer from addiction another day. Learn about treatment MDMA.
Figure 15
Figure 16
(EMCDDA 2016)
“ECSTASY” (MDMA) is readily absorbed from the intestinal tract and reaches its peak concentration in the plasma about 2 hours after oral administration (Kalant 2001). The chemical structure of ecstasy allows it to reach the brain quickly after ingestion. Once ecstasy molecules are absorbed from the stomach, they get into the bloodstream, but most of the ecstasy molecules move from the stomach into the small intestine (Fig. 17). MDMA crosses the barrier into the brain very easily. It will take about 15 minutes for ecstasy to reach the brain if taken on an empty stomach.
Ecstasy has short-term and long-term effects on the brain. The short-term effects of ecstasy include changes in brain chemistry and behavior. The long-term effects include changes in brain structure (based mainly on animal studies) and behavior.
The drug is broken down metabolically, mainly in the liver. Elimination of the drug from the body is moderately slow. MDMA acts by increasing the release of the neurotransmitters (serotonin, noradrenaline and, to a smaller extent, dopamine). MDMA does not act by directly releasing serotonin but, rather, by binding to, and thus blocking, the transporter involved in its reuptake (Shulgin 1986). The reported effects of MDMA vary according to the dose, the frequency and duration of use. Physically, it produces a marked increase in wakefulness, endurance and sense of energy, sexual arousal, and postponement of fatigue and sleepiness. The accompanying psychological effects are described as a sense of euphoria, well-being, sharpened sensory perception, greater sociability (Sherlock et al. 1999)
The increased muscle activity, together with a direct action of the drug on the thermoregulatory system in the brain (Cohen 1995) leads to an increase in body temperature. One of the consequences of the use of “ecstasy” at raves is profuse sweating as a result of both the vigorous physical activity and increase in body temperature. Large amounts of sodium can be lost in sweat, and if the dancers drink large amounts of water in order to avoid overheating, the result is frequently hemodilution and resulting hyponatremia.
An additional mechanism that can contribute to the same result is inappropriate secretion of the pituitary antidiuretic hormone, leading to retention of water by the kidneys (Holden & Jackson 1996). This leads to passage of water from the blood into the tissues, including the brain with 2 serious consequences: initiation of epilepsy-like seizures and compression of the brain stem and cerebellum downward toward the foramen magnum, which can lead to fatal disruption of respiration or circulation. Literature indicates that ecstasy (MDMA) and related drugs are potentially dangerous, even in the doses typically used by participants at raves. Both the acute and the chronic effects can lead to serious and even fatal toxicity. The variety of different adverse effects, including psychiatric, neurological, cardiovascular, hepatic, renal, thermoregulatory and even dental problems, indicates that patients with ecstasy-related difficulties may present in any part of the health care system and not only to emergency services. Because the main users are adolescents and young adults following the dictates of current drug fashion, physicians may need to be especially alert to such problems in an otherwise healthy population group.
Figure 17
Vasopressin (Klabunde 2016) (antidiuretic hormone, ADH) is a peptide hormone formed in the hypothalamus, then transported via axons to the posterior pituitary, which releases it into the blood.
ADH has two principle sites of action: the kidney and blood vessels.
1. The primary function of ADH in the body is to regulate extracellular fluid volume by regulating renal handling of water, although it is also a vasoconstrictor. It acts on renal collecting ducts to increase water permeability which leads to decreased urine formation.
2. A secondary function of ADH is vasoconstriction. Studies have shown, nevertheless, that in severe hypovolemic shock (as occurs during hemorrhage and dehydration), its release is very high.
Figure 18
The nerve pathway predominantly affected by ecstasy is called the serotonin pathway. Serotonin is a neurotransmitter that is synthesized, stored, and released by specific neurons. It is involved in the regulation of several processes within the brain, including mood, emotions, aggression, sleep, appetite, anxiety, memory, and perceptions. Serotonin (Fig. 19) is stored in small vesicles within the nerve terminal of a neuron. Electrical impulses traveling down the axon toward the terminal cause the release of serotonin from small vesicles into the synaptic space. When in the synaptic space, the serotonin binds to special proteins, called receptors, on the membrane of a neighboring neuron and then it binds to serotonin receptors and causes a change in the electrical properties of the receiving neuron. When ecstasy binds to the serotonin transporters (Fig. 20-21), more serotonin ends up in the synaptic space. This occurs for two reasons. First, ecstasy can prevent the transporters from carrying serotoni
n back into the terminal. Second, ecstasy can cause the transporters to work in reverse mode- they actually brin
g serotonin from the terminal into the synaptic space. So, more serotonin is present in the synaptic space and more serotonin receptors become activated (National Institute on Drug Abuse 2017).
Figure 19 Figure 20 Figure 21
• Legal status
Ecstasy is controlled as a Class A drug under the Misuse of Drugs Act. This act is intended to prevent the non-medical use of certain drugs. For this reason it controls not just medicinal drugs (which will also be in the Medicines Act) but also drugs with no current medical use. Drugs subject to this Act are known as ‘controlled’ drugs. The law defines a series of offences including: unlawful supply; intent to supply, import or export and unlawful production. It is illegal to be in possession of the drug or supply it. Ecstasy cannot be prescribed by doctors. The maximum penalties for possession of ecstasy is 7 years imprisonment plus a fine and for supply is life imprisonment plus a fine (The Advisory Council on the Misuse of Drugs 1971).
The laws controlling drug use are complicated but there are three main statutes regulating the availability of drugs in the UK: The Misuse of Drugs Act (1971), The Medicines Act (1968) and The Psychoactive Substances Act (2016).
The Misuse of Drugs Act (MDA) divides drugs into three classes as follows:
Class A: cocaine and crack, ecstasy, heroin, LSD, methadone, methamphetamine (crystal meth), fresh and prepared magic mushrooms.
Class B: amphetamine (not methamphetamine), barbiturates, codeine, ketamine, synthetic cannabinoids such as Spice and cannabis. All cathinone derivatives, including mephedrone, methylone, methedrone and MDPV were brought under control as Class B substances in 2010.
Class C: anabolic steroids, minor tranquillisers or benzodiazepines.
Class A drugs are treated by the law as the most dangerous.
In this scenario
Leah while celebrating her 18th birthday took one Ecstasy tablet. Over the next 3 hours, Leah seemed to enjoy herself but she complained of feeling hot and sweat a lot. As mentioned above, Ecstasy reaches its peak concentration in the plasma about 2 hours after oral administration. Physically, it produces a marked increase in wakefulness, endurance and sense of energy. Leah was feeling hot because of the increased muscle activity, together with a direct action of the drug on the thermoregulatory system in the brain that lead to an increase in body temperature. She sweat a lot as a result of both the vigorous physical activity and the pharmacological action of the drug on the thermoregulatory mechanism. Large amounts of sodium can be lost in sweat, and if the dancers drink large amounts of water in order to avoid overheating, the result is frequently hemodilution and resulting hyponatremia.
3. Fluid Balance and ion concentration- hyponatremia
Body fluid volume and electrolyte concentration are normally maintained within very narrow limits despite wide variations in dietary intake, metabolic activity, and environmental stresses (Lewis 2016). Homeostasis of body fluids is preserved primarily by the kidneys. Water and sodium balance are closely interdependent. Total body water (TBW) is about 60% of body weight in men (Fig. 22) and 50% in women. Almost two thirds of TBW is in the intracellular compartment (intracellular fluid, or ICF; the other one third is extracellular (extracellular fluid, or ECF). Normally, about 25% of the ECF is in the intravascular compartment; the other 75% is interstitial fluid. Total body water = 70 kg× 0.60 = 42 L.
Figure 22
The major intracellular cation is potassium. The major extracellular cation is sodium. The concentration of combined solutes in water is osmolarity (amount of solute per L of solution), which, in body fluids, is similar to osmolality (amount of solute per kg of solution). Osmolality of body fluids is normally between 275 and 290 mOsm/kg. Sodium is the major determinant of plasma osmolality. Water crosses cell membranes freely from areas of low solute concentration to areas of high solute concentration. Thus, osmolality tends to equalize across the various body fluid compartments, resulting primarily from movement of water. Sodium and potassium, have the greatest osmotic activity. The average daily fluid intake is about 2.5 L. The amount needed to replace losses from the urine and other sources is about 1 to 1.5 L/day in healthy adults. However, on a short-term basis, an average young adult with normal kidney function may ingest as little as 200 mL of water each day to excrete the nitrogenous and other wastes generated by cellular metabolism. Other water losses are mostly losses from the lungs and skin, averaging about 0.4 to 0.5 mL/kg/h or about 650 to 850 mL/day in a 70-kg adult. With fever, another 50 to 75 mL/day may be lost for each degree C of temperature elevation above normal. Gastrointestinal losses are negligible, except when marked vomiting or diarrhea. Sweat losses can be significant during environmental heat exposure or excessive exercise. Water intake is regulated by thirst. Thirst is triggered by receptors in the anterolateral hypothalamus that respond to increased plasma osmolality (as little as 2%) or decreased body fluid volume. Water excretion by the kidneys is regulated primarily by vasopressin (ADH). Water intake decreases plasma osmolality.
Low sodium levels (hyponatremia)
Hyponatremia may result from not eating enough foods containing sodium, too much sweating and urinating, or being over-hydrated. When sodium levels are low, an antidiuretic hormone is produced telling kidneys to retain urine. Symptoms of hyponatremia –may be confusion, headache, irritability, loss of appetite, muscle weakness, nausea, vomiting, fatigue, decreased consciousness, hallucinations, and even coma.
Severe cases of symptomatic hyponatremia (Fig.23) after ecstasy consumption are described in the literature with partially fatal clinical outcomes. Thus, physicians should be aware of early and consequent control of the sodium and choose an interdisciplinary treatment decision (Baumann et al. 2016). The role of sodium in autoregulation of cellular function, the different fluid compartments in the human body and the pathology of cerebral oedema are crucial for the effective management of hyponatremia (Keane 2014). Dilutional hyponatraemia, mainly caused by direct stimulation of antidiuretic hormone (ADH) secretion by ecstasy (van Dijken et al. 2013) is among the many side effects of the drug. The mortality of this complication is high. Water passes from the blood into the tissues, including the brain. This has 2 serious consequences: initiation of epilepsy-like seizures and compression of the brain stem and cerebellum downward toward the foramen magnum, which can lead to fatal disruption of respiration or circulation.
Figure 23
Osmolarity vs. Osmolality
These terms have always been confusing (Erstad 2003). Osmolarity and Osmolality are both units of measurements and calculate is the osmotic activity. Osmolarity is the number of milliosmoles/liter (mOsm/L) of solution. It is the concentration of an osmotic solution. Osmolality is the number of milliosmoles/ kg (mOsm/kg ) of solvent. It is the concentration of the particles that is dissolved in a fluid. This is the clinical laboratory measurement using an osmometer.
The difference between the calculated osmolarity and measured osmolality is called the “osmolar gap” and is often used as part of differential diagnostic evaluation of patients. If the concentration of solutes in the given fluid is very low, then osmolarity and osmolality are considered to be equivalent.
When all body fluids have an osmolarity near 300 mOsm/L, the osmotic press
ure of the two fluid compartments are equal = no net water movemen
t occurs. This is called iso-osmotic or isotonic. Hypotonic solutions will move water into the cell, causing the cell to swell and potential burst. By lowering the serum osmolarity, the body fluids shift out of the blood vessels into the interstitial tissue and cells. Hypotonic solutions hydrate the cells and can deplete the circulatory system. Hypertonic solutions conversely cause the water from within a cell to move to the ECF compartment, causing the cell to shrink. These solutions are used to replace electrolytes. Hypertonic dextrose solutions when used alone, shifts ECF from interstitial to plasma.
Clinical relevance of osmolality (Henderson 2016)
As cell membranes in general are freely permeable to water, the osmolality of the extracellular fluid (ECF) is approximately equal to that of the intracellular fluid (ICF). Therefore, plasma osmolality is a guide to intracellular osmolality. In normal people, increased osmolality in the blood will stimulate secretion of antidiuretic hormone (ADH). This will result in increased water reabsorption, more concentrated urine and less concentrated blood plasma. A low serum osmolality will suppress the release of ADH, resulting in decreased water reabsorption and more concentrated plasma. An increase of only 2% to 3% in plasma osmolality will produce a strong desire to drink. Hypernatraemia may cause a decreased urine osmolality and hyponatraemia may cause an inappropriately increased urine osmolality.
Severe symptoms of Hyponatremia (e.g., coma, seizures) typically occur when the sodium level falls below 120 mEq per L, but can occur at less than 125 mEq per L. Severe symptomatic hyponatremia must be corrected promptly because it can lead to cerebral edema, irreversible neurologic damage, respiratory arrest, brainstem herniation, and death. Treatment includes the use of hypertonic 3% saline infused at a rate of 0.5 to 2 mL per kg per hour until symptoms resolve (Braun & Barstow 2015).
In this scenario
Leah was taken to the hospital in coma due to severe hyponatremia of less than 125 mml/L. A CT scan showed cerebral odema with flattened gyri and narrow sulci and compression of the ventricular system due to the accumulation of Cerebrospinal Fluid within her brain. Hyponatremia resulted in brain herniation (confirmed by the dilated pupils due to compression of the oculomotor nerve bilaterally). Compression of the Oculomotor Nerve tends to result from serious disorders, like brain herniation. This severe situation lead to respiratory arrest. She was given IV saline (3% saline solution) to correct the hyponatremia and put on a ventilator but unfortunately neurologic damage was irreversible.
4. How does a CT scan and other medical imaging work
In modern medicine, medical imaging has undergone major advancements. Μedical imaging covers the entities of tissue that can be detected which range from structure, physiology, metabolism/biochemistry, drug distribution and molecular pathways. Medical imaging is the technique and process of creating visual representations of the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (Radiological Society of North America 2016). The first non-invasive technique to get images from the human body was the radiography, invented in 1896, and it used x-rays, an invisible electromagnetic radiation. However, x-rays can show only the anatomical structures, and nothing else. Enlargement, movement and flow of substances could be observed in some selected organs (for example, the heart or the intestines) by using some liquids which are opaque to the x-rays, but not much more. Since some organs (like the brain) do not move, radiographs are of little value to study function, particularly normal function. Computed tomography (Health 2017) (CT), sometimes called “computerized tomography” or “computed axial tomography” (CAT), is a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body. Each cross-sectional image represents a “slice” of the person being imaged, like the slices in a loaf of bread. These cross-sectional images are used for a variety of diagnostic and therapeutic purposes.
How a CT system works(National Institute of Biomedical Imaging and Bioengineering 2017):
• A motorized table moves the patient through a circular opening in the CT imaging system.
• While the patient is inside the opening, an X-ray source and a detector assembly within the system rotate around the patient. A single rotation typically takes a second or less. During rotation the X-ray source produces a narrow, fan-shaped beam of X-rays that passes through a section of the patient’s body.
• Detectors in rows opposite the X-ray source register the X-rays that pass through the patient’s body as a snapshot in the process of creating an image. Many different “snapshots” (at many angles through the patient) are collected during one complete rotation.
• For each rotation of the X-ray source and detector assembly, the image data are sent to a computer to reconstruct all of the individual “snapshots” into one or multiple cross-sectional images (slices) of the internal organs and tissues.
CT images of internal organs, bones, soft tissue, and blood vessels provide greater clarity and more details than conventional X-ray images, such as a chest X-Ray.
Molecular imaging is a relatively new discipline that allows the biological processes taking place in the body to be viewed at a cellular and molecular level. Single Photon Emission Computer Tomography (SPECT) and Positron Emission Tomography (PET) have their significant contribution to the world of molecular imaging. Anatomical techniques such as CT and MRI through their high spatial resolution capabilities serve to identify morphological changes in small structures. When these imaging modalities are combined in one imaging session, the amount of information obtained can synergically and significantly improve the diagnostic process and its outcome when compared to a single diagnostic technique (Khalil et al. 2011). The biochemical activity of the cells changes when disease occurs and, as it progresses, this abnormal activity starts to affect the body and cause changes to bones and tissue that might not be noticed using conventional CT or MRI scans.
CT scanning of the head is typically used to detect (RadiologyInfo.org 2017):
• bleeding, brain injury and skull fractures in patients with head injuries.
• bleeding caused by a ruptured or leaking aneurysm in a patient with a sudden severe headache.
• a blood clot or bleeding within the brain shortly after a patient exhibits symptoms of a stroke.
• a stroke, especially with a new technique called Perfusion CT.
• brain tumors.
• enlarged brain cavities (ventricles) in patients with hydrocephalus.
• diseases or malformations of the skull.
In this scenario a C.T. scan revealed cerebral odema with evidence of brain herniation, confirmed by dilated pupils due to compression of the occulomotor nerve and respiratory arrest.
5. Organ donation
Organ Donor Register (ODR)(NHS Blood and Transplant 2017)
The NHS Organ Donor Register is a confidential list of people who want to donate their organs and/or tissue. Joining the register makes it easier for everyone to know one’s wishes and follow them. Joining the register provides legal consent for you to donate your organs and/or tissue after you die. When someone registers, he/she should tell family and friends about this decision. Even if the name is on the register, when someone dies, family or friends will be asked to confirm
that. One can register by filling an online form. Organ transp
lant is an operation that removes an organ or tissue from one person and places it in another. Organ donation is when you someone allows his/her organs or tissues to be removed and given to someone else. Most donated organs and tissues are from people who have died. Others get organs from living donors because of a shortage of organs. The most common transplants are:
• Kidney transplant
• Heart transplant
• Liver transplant
• Lung transplant
Other transplants include:
• Pancreas transplant
• Small bowel transplant
• Tissue such as, corneas, heart valves, skin and bone
Kidneys are the most common organ donated by a living person. About a third of all kidney transplants carried out in the UK are from living donors. A healthy person can lead a normal life with one working kidney. A living liver donor is a person who gives part of their liver to someone with liver failure who needs a transplant (the recipient). This could be a friend or family member, or someone they do not already know. Living donor liver transplantation has been successfully performed in the UK since 1995. A liver transplant operation is life saving surgery for patients with end stage liver disease. It is also performed for some patients with primary liver cancer and children with metabolic diseases. Most religious groups in the UK support organ donation and transplant . Consent is needed to use organs and tissues by:ticking in the appropriate boxes on the NHS Organ Donor Register, or telling family and friends. Family or friends should tell a healthcare professional straightway if they know that someone wanted to donate his/her organs. In case someone has no family or relatives NHS professionals will speak to his/her GP about medical and social history. The law allows other people close to someone (spouse or partner, parent or child, brother or sister, other relatives, or close friend) to decide on donating someone’s organs, if his/her wishes are not stated. There is no age limit on becoming an organ and/or tissue donor. But there are a few medical conditions that may prevent someone from donating organs. Children can join the ODR but their parents or guardians must give consent after they die. Blood for transmissible diseases and viruses will be tested including HIV and Hepatitis. If someone is HIV positive he/she may be able to donate to someone who already has HIV. Deceased donors with some cancers may be safely used. However, someone cannot be a donor if he/she has Creutzfeldt-Jakob disease or cancer that has spread in the last 12 months. A healthcare professional will decide whether organs or tissue can be transplanted based on medical history. The law in Wales has changed to bring in a soft ’opt-out’ system for consent to organ donation. People living in Wales now have three choices:
• If they want to be a donor, they can either register to be a donor (opt in) on the NHS Organ Donor Register or do nothing
• If they do nothing, they will be regarded as having no objection to donating organs. This is called deemed consent.
• If they do not want to be a donor, they can register not to be a donor (opt out) on the NHS Organ Donor Register
More than 19million people are on the UK donor register but 1,000 people a year still die waiting for a transplant(Borland 2013). NHS Blood and Transplant looking at ways to increase donations considering plans to give transplant priority to registered donors. But although the number of Britons signing up to donate their organs has increased, most die in old age when their body parts are no longer healthy enough to be given to anyone else. Each year organs from only 5,000 people who have died are deemed healthy enough to be transplanted. There are 19.5million people on the register but the NHS wants to increase this to 25million.Under plans that are going out for consultation, the NHS wants to introduce a system similar to that in place in Israel and Singapore whereby patients who had previously signed up to the register would be given priority on transplant waiting lists.
There are two ways that people die (LifeCenter Northwest 2017): circulatory death and brain death. Both brain death and circulatory death are formal, legal definitions of death. Circulatory death is the irreversible loss of function of the heart and lungs. Brain death is the irreversible loss of function of the brain and brain stem. Brain death occurs when brain function ceases because the flow of blood to the brain is stopped permanently due to a severe injury to the brain. When this happens, all brain function stops, including the most primitive life-sustaining reflexes, such as the ability to breathe or respond to pain. A physician performs a series of tests to determine if brain death has occurred. The doctor also performs tests to rule out any other reason that could be causing the brain to not function, such as medical conditions, medications, or extreme cold. Once a patient has been declared brain dead, there is no chance for recovery. They no longer have any sensations and can feel no pain. They have normal color and warm skin only because of the ventilator. The chest continues to move up and down with artificial breath because of the ventilator. The legal time of death is when the doctor has written their diagnosis of brain death on the medical chart. The discontinuation of the ventilator does not cause death.
In this scenario, 3 days after Leah was on the ventilator and was no improvement in her condition was observed (brainstem death), her parents decided to turn off the ventilator, because they were aware that Leah had signed up to the organ transplant register and they agreed that if any organ could be used they should be.
Summary of the scenarios
Leah (18) took an Ecstasy at her party. She danced (due to Ecstasy effects on behavior-serotonin) but complained of feeling hot and sweat (due to Ecstasy pharmacological effects). She drunk a great amount of water that caused (in conjunction with Ecstasy effects – higher body temperature and ADH) hyponatremia that resulted in a coma. The blood test results showed hyponatremia of less than 125 mml/L. A CT scan showed cerebral odema and compression of the ventricular system. There was evidence of brain herniation and respiratory arrest. She was given IV saline (3% saline solution) to correct the hyponatremia and put on a ventilator. After 3 days of non improvement, as her damage was irreversible, her parents decided to turn off the ventilator and agreed for organ donation as Leah was had signed up to the organ transplant register.
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