Case study 5: All Or None (Case discussed at brain death symposium held by MOHAN Foundation at CMC Hospital, Vellore in year 2001)

16 year old boy brought to the emergency in unconscious state. Bitten by a snake when playing in the garden.  On arrival BP 60/40 had an arrest in emergency. CPR instituted, revived after 7 minutes hemodynamic stability maintained for 3 days. However no signs of brain stem reflex. GCS 3/15. Antivenin serum instituted, but no response. Normal blood programmers expect for increased alkaline phosphate and SGPT. On day 4, request for organ donation made to father who agrees

Dilemmas

1. Will you proceed with retrieval surgery?
2. Which organ should be taken?
3. Will you tell recipient of the cause of death of the donor? 

Discussions

            To retrieve or not to retrieve is an often repeated question in the organ donation scenario and never more relevant than in this particular scenario where the potential donor is a snake bite victim. One group of doctors categorically refused to entertain the idea of organ retrieval from any case of poisoning. However, most of the other doctors felt that organ retrieval could definitely proceed in this case of cobra snake bite. Cobra venom being neurotoxin, it could be surmised that patient not die of the venom directly, but of respiratory arrest [not attended] the toxin itself would be fixed to the patient’s brain and nerves and, therefore, not pose a problem to organ retrieval.

The heart could definitely be retrieved. One of the hospitals, which was actually confronted with this particular scenario, this being one of their first cases, found themselves in a very difficult worrisome situation. There was no documentation of organ retrieval from a snake- bite victim, except for a case from Saudi Arabia reported in Dialysis Nephrology and Transplantation where the recipient did very badly. At any rate, the hospital team went ahead and retrieved both the Kidneys and the liver. The kidneys were transplants and worked well. The liver was retrieved, even though it looked slightly necrotic, and the alkaline phosphatise and SGPT were both raised. Unfortunately, if couldn’t be used. It was felt that this being a post –anoxic event [there was respiratory arrest], there was a likelihood of every organ being affected by the process. As to whether the recipient should be informed of the cause of death of the donor, it was felt that the information need not be passed on. In most cases, the recipients to not ask for information about the donors, it is actually the other way, round sometimes with the donor family wanting information about the recipient.