Presentation on theme: "University of Wisconsin Organ Procurement Organization"— Presentation transcript:
1University of Wisconsin Organ Procurement Organization Brain Death & Organ Donor Management William Snyder, RN, BSN, CPTC Organ Procurement CoordinatorUniversity of WisconsinOrgan Procurement Organization1-866-UWHC OPO( )
2Effective Donor Management Stabilize the donor – Facilitate brain death exam or DCD Tool.Manage the donor – To optimize the function and viability of all transplantable organs.“
3Effective Donor Management Requires clinical expertise, vigilance, flexibility, and the ability to address multiple complex clinical issues simultaneously and effectively.Requires collaboration among the OPO, donor hospital critical care staff and consultants, and transplant program staff.
4Effective Donor Management Donor care is not usually assumed until after consent for donation has been obtained.It is appropriate to collaborate prior to brain death, consent, etc, to prevent death and keep the option of organ donation open.
5Effective Donor Management Revision of existing orders or placement of new medical orders is intended to:D/C medications no longer needed or appropriate (e.g., anticonvulsants, mannitol, sedatives, antipyretics)Continue needed medications, or therapy (e.g., vasoactive drug infusions, IV fluids and vent settings)Create “call orders” that inform bedside personnel of the goals for physiologic parameters and alert OPC of changes in donor status.
7Uniform Determination of Death Act An individual who has sustained either:irreversible cessation of circulatory and respiratory functionor(2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.JAMA Nov 13, 1981 – Vol 246, No. 19
8Diagnosis of Brain Death Brain death is a clinical diagnosis. It can be made without confirmatory testing if you are able to establish the etiology, eliminate reversible causes of coma, complete fully the neurologic examination and apnea testing.The diagnosis requires demonstration of the absence of both cortical and brain stem activity, and demonstration of the irreversibility of this state.R. Erff, D.O., Walter Reed Army Medical Center
9Etiology of Brain Death Severe head traumaAneurismal subarachnoid hemorrhageCerebrovascular injuryHypoxic-ischemic encephalopathyFulminant hepatic necrosisProlonged cardiac resuscitation or asphyxiaTumorsR. Erff, D.O., Walter Reed Army Medical Center
10Prerequisites to the Diagnosis Evidence of acute CNS catastrophecompatible with brain death:Clinical or NeuroimagingExclusion of reversible medical conditions that can confuse the clinical assessment:Severe electrolyte, acid base and endocrine disturbanceAbsence of drug intoxication and poisoningAbsence of sedation and neuromuscular blockadeHypotension (suppresses EEG activity and CBF)Absence of severe hypothermia (core temp < 35 C)
11Brain Stem Reflexes Cranial nerve examination: No pupillary response to light. Pupils midline and dilated 4-6mm.No oculocephalic reflex (Doll’s eyes) – contraindicated in C- spine injury.No oculovestibular reflex (tonic deviation of eyes toward cold stimulus) – contraindicated in ear trauma.Absence of corneal reflexesAbsence of gag reflex and cough to tracheal suction.
12Apnea TestingOnce coma and absence of brain stem reflexes have been confirmed Apnea testing.Verifies loss of most rostral brain stem functionConfirmed by PaCO2 > 60mmHg or PaCO2 > 20mmHg over baseline value.Testing can cause hypotension, severe cardiac arrhythmias and elevated ICP.Therefore, apnea testing is performed last in the clinical assessment of brain death.Consider confirmatory tests if apnea test inconclusive.
13Apnea TestingFollowing conditions must be met before apnea test can be performed:Core temp > 35.0 CSystolic blood pressure > 90mmHg.EuvolemiaCorrected diabetes insipitusNormal PaCO2 ( PaCO mmHg).Preoxygenation (PaO2 > 200mmHg).
14Brain Death in Children Clinical exam is same as in adults.Testing criteria depends on age of child.- Neonate < 7 days Brain death testing is not valid.- 7 days – 2 months- Two clinical exams and two EEG 48 hrs apart.- 2 months – 1 year- Two clinical exams and two EEG 24 hrs apart.- or two clinical exams, EEG and blood flow study.- Age > 1 year to 18 years- Two clinical exams 12 hrs apart, confirmatory study Optional
15Confirmatory TestingPurely optional when the clinical criteria are met unambiguously.A confirmatory test is needed for patients in whom specific components of clinical testing cannot be reliably evaluated- Incomplete brain stem reflex testing- Incomplete apnea testing- Toxic drug levels- Children younger than 1 year old.- Required by institutional policyR. Erff, D.O., Walter Reed Army Medical Center
16Confirmatory Tests for Brain Death Cerebral Blood Flow (CBF) StudiesCerebral AngiographyNuclear Flow StudyEEG (when brain scan is not utilized)
19Elements of brain death declaration DateTimeDetailed documentation of Clinical Exam including specifics of Apnea TestingPhysician signatureBrain death is usually associated with some type of trauma, whether it be a motor vehicle accident or a fall on a patch of ice. As the population ages, however, there are an increasing number of people who have strokes and heart attacks which may also lead to brain death. Most often the patient is an otherwise healthy individual and the process is sudden. Only about 2% of all deaths every year occur in someone who is brain dead.
21PathophysiologyLoss of brain stem function results in systemic physiologic instability:Loss of vasomotor control leads to a hyperdynamic state.Cardiac arrhythmiasLoss of respiratory functionLoss of temperature regulation HypothermiaHormonal imbalance DI, hypothyroidism
22Perioperative Management Following the diagnosis of Brain DeathTherapy shifts in emphasis from cerebral resuscitation to optimizing organ fxn for subsequent transplantation.The normal sequelae of brain death results in cardiovascular instability & poor organ perfusion.Medical staff must focus on:- Providing hemodynamic stabilization.- Support of body homeostasis.- Maintenance of adequate cellular oxygenation and donor organ perfusion.Without appropriate intervention brain death is followed by severe injury to most other organ systems. Circulatory collapse will usually occur within 48hrs.
23Autonomic/Sympathetic Storm Release of catecholamines from adrenals (Epinephrine and Norepinephrine) results in a hyper-dynamic state:TachycardiaElevated C.O.VasoconstrictionHypertension
24Failure of the Hypothalamus results in: Impaired temperature regulation - hypothermia or hyperthermiaLeads to vasodilation without the ability to vasoconstrict or shiver (loss of vasomotor tone)Leads to problems with the pituitary ...
25Normal Pituitary Gland Controlled by the hypothalamusReleases ADH to conserve waterStimulates the release of thyroid hormone
26Pituitary Failure results in: ADH ceases to be produced = Diabetes InsipidusCan lead to hypovolemia and electrolyte imbalancesLeads to problems with the thyroid gland
27Normal Thyroid GlandProduces hormones that increase the metabolic rate and sensitivity of the cardiovascular systemLevothyroxine (T4)Triiodothyronine (T3)
29Cardiovascular System Intensive care management“Rules of 100’s”- Maintain SBP > 100mmHG- HR < 100 BPM- UOP > 100ml/hr- PaO2 > 100mmHgAggressive fluid resuscitative therapy directed at restoring and maintaining intravascular volume. SBP > 90mmHg (MAP > 60mmHg) or CVP ~ 10 mmHg.
30Neurogenic Pulmonary Edema Brain death is associated with numerous pulmonary problemsThe lungs are highly susceptible to injury resulting from the rapid changes that occur during the catecholamine stormLeft-sided heart pressures exceed pulmonary pressure, temporarily halting pulmonary blood flowThe exposed lung tissue is severely injured, resulting in interstitial edema and alveolar hemorrhage, a state commonly referred to as neurogenic pulmonary edema
31Release of Plasminogen Activator DIC Results from the passage of necrotic brain tissue into the circulationLeads to coagulopathy and sometimes progresses further to DICDIC may persist despite factor replacement requiring early organ recovery(Also affected by hypothermia, release of catecholamines & hemodilution as a result of fluid resuscitation)
32Organ Donor Management (in a nutshell) Hypertension HypotensionExcessive Urinary OutputImpaired Gas ExchangeElectrolyte ImbalancesHypothermia
33Hypotension Management Fluid Bolus – NS or LR (Followed by MIVF NS or .45 NS)Consider colloids (seriously)DopamineNeosynephrineVasopressinThyroxine (T4 protocol)
34T4 Protocol BackgroundBrain death leads to sudden reduction in circulating pituitary hormonesMay be responsible for impairment in myocardial cell metabolism and contractility which leads to myocardial dysfunctionSevere dysfunction may lead to extreme hypotension and loss of organs for transplant
35T4 Protocol Bolus: 15 mg/kg Methylpred Infusion: 20 mcg T4 (Levothyroxine)20 units of Regular Insulin1 amp D50WInfusion:200 mcg T4 in 500 cc NSRun at 25 cc/hr (10 mcg/hr)Titrate to keep SBP >100Monitor Potassium levels closely!
36Vasopressin (AVP, Pitressin) Low dose shown to reduce inotrope usePlays a critical role in restoring vasomotor toneVasopressin Protocol4 unit bolus1- 4 u/hour – titrate to keep SBP >100 or MAP >60
37Diabetes Insipidus Management Treatment is aimed at correcting hypovolemiaDesmopressin (DDAVP) 1 mcg IV, may repeat x 1 after 1 hour.Replace hourly U.O. on a volume per volume basis with MIVF to avoid volume depletionLeads to electrolyte depletion/instability monitor closely to avoid hypernatremia and hypokalemia
38Diabetes Insipidus Goal is UOP 1-3 ml/kg/hr Rule of thumb – 500 ml UOP per hour x 2 hours is DISevere cases – Notify OPC. Assess clinical situation.
39Impaired Gas Exchange Management Maintain PaO2 of >100 and a saturation >95%Monitor ABG’s q2h or as requested by OPOPEEP 5 cm, HOB up 30oIncrease ET cuff pressure immediately after BD declarationAggressive pulmonary toilet (Keep suctioning & turning q2h)CXR (Radiologist to provide measurements & interpretation)OPO may request bronchoscopyCT of chest requested in some cases
40Correct Impaired Gas Exchange and Maximize Oxygenation! Most organ donors are referred with:Chest traumaAspirationLong Hospitalization with bed rest resulting in atelectasis or pneumoniaImpending Neurogenic Pulmonary EdemaBrain Death contributes to and complicates all of these conditions
41Impaired Gas Exchange Goals… Goals are to maintain health of lungs for transplant while optimizing oxygen delivery to other transplantable organsAvoid over-hydrationVentilatory strategies aimed to protect the lungAvoid oxygen toxicity by limiting Fi02 to achieve a Pa02 100mmHg & PIP < 30mmHg.
42Electrolyte Imbalance Management HypokalemiaIf K+ < 3.4 – Add KCL to MIVF(anticipate low K+ with DI & T4 administration)HypernatremiaIf NA+ >155 – Change MIVF to include more free H20, Free H20 boluses down NG tube (this is often the result of dehydration, NA+ administration, and free H20 loss 2o to diuretics or DI)Calcium, Magnesium, and PhosphorusDeficiencies here common…often related to polyuria associated with osmotic diuresis, diuretics & DI.
43Hypothermia Management Monitor temperature continuouslyNO tympanic, axillary or oral temperatures. Central only.Place patient on hypothermia blanket to maintain normal body temperatureIn severe cases (<95 degrees F) consider:warming lightscovering patient’s head with blanketshot packs in the axillawarmed IV fluidswarm inspired gas
44Anemia Hematocrit < 30% must be treated Transfuse 2 units PRBC’s immediatelyReassess 1o after completion of 2nd unit and repeat infusion of 2 units if HCT remains below 30%Assess for source of blood loss and treat accordingly
45Incidence of pathophysiologic changes following Brain Death: - Hypotension 81%- Diabetes Insipidus 65%- DIC %- Cardiac arrhythmias 25%- Pulmonary edema 18%- Metabolic acidosis 11%Physiologic changes During Brain Stem Death – Lessons for Management of the Organ Donor.The Journal of Heart & Lung Transplantation Sept 2004 (suppl)
46Organ Donation Process Evaluate organ functionLabs (& UA) within 6 hours of surgeryType and ScreenConsent signedSerology testingMedical Social HistoryLocate potential recipientsManage hemodynamicsArrange operating room
47The Teams... Your Hospital Abdominal Transplant Team - Anesthesia- Primary Care Physician or Intensivist (For DCD)Surgical Technician/Scrub NurseCirculating NurseAbdominal Transplant Team- Surgeon- Physician Assistant- Surgical Recovery CoordinatorCardiothoracic Team- Surgical Fellow