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Professional Development Programme for Organ Donation Dr Dermot McKeown Dr Paul McAndrew Andrew Broderick 15th June 2010 Donor Management Master Class.

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Presentation on theme: "Professional Development Programme for Organ Donation Dr Dermot McKeown Dr Paul McAndrew Andrew Broderick 15th June 2010 Donor Management Master Class."— Presentation transcript:

1 Professional Development Programme for Organ Donation Dr Dermot McKeown Dr Paul McAndrew Andrew Broderick 15th June 2010 Donor Management Master Class Driving improved organ donation within your hospital

2 Professional Development Programme for Organ Donation UK Heartbeating Donors KidneyLiverPancreasThoracic (95%) 559 (91%) 308 (50%) 233 (38%)

3 Professional Development Programme for Organ Donation UK Heartbeating Donors

4 Professional Development Programme for Organ Donation Unit Experience 4

5 Professional Development Programme for Organ Donation What Does This Mean? 5 65% of units have 2 or fewer donors per year 23% of donors are from ICU with 1-2 donors per year 4% of units have 10 or more donors per year, 28% of total donor population Need to increase thoracic donation

6 Professional Development Programme for Organ Donation Masterclass Objectives 6 To empower clinical leads to raise awareness of the importance of donor management in maximising the gift of donation and to put into place or facilitate effective measures that will increase the number and quality of organs retrieved from heartbeating brainstem dead donors To nurture a wider understanding of the principles of donor assessment To reduce the number of patients who are not tested for brainstem death on the grounds of cardio-respiratory instability

7 Professional Development Programme for Organ Donation Agenda 1Brainstem Death and Management of the Organ Donor09.30 – Cardiovascular Management and Cardiac Donation10.00 – Respiratory Management and Lung Donation10.25 – Break10.50 – Group Discussion11.05 – Donor Assessment and Process – Critical Care support to Donor Operation – Case Studies – Summary & Close –

8 Professional Development Programme for Organ Donation Plan for Session 8 Review of physiology of typical donor Detailed review Cardiovascular management and cardiac donation Respiratory management, fluids and lung donation Practicalities of donor management Organisation and co-ordination Theatre management Case discussions

9 Brainstem Death and management of the organ donor Dermot McKeown

10 Professional Development Programme for Organ Donation 10

11 Professional Development Programme for Organ Donation 11

12 Professional Development Programme for Organ Donation 12

13 Professional Development Programme for Organ Donation Progression to Brainstem Death (BSD) 13 1.Increased ICP 2.Bradycardia 3.Hypertension Sympathetic Storm

14 Professional Development Programme for Organ Donation Level of Care 14 Full ICU care facilitates appropriate BSD testing After BSD testing, continued care maintains potential for donation Discussion with relatives Donor Management

15 Professional Development Programme for Organ Donation Changes following Brainstem Death (BSD) 15 Cardiovascular Hypothermia Diabetes Insipidus Disseminated Intravascular Coagulation Pulmonary Inflammation

16 Professional Development Programme for Organ Donation Incidence of Changes 16 Hypotension81% Diabetes Insipidus65% DIC28% Cardiac arrhythmias25% Pulmonary oedema18% Metabolic acidosis11% Physiologic changes During Brain Stem Death – Lessons for Management of the Organ Donor. The Journal of Heart & Lung Transplantation Sept 2004 (suppl) J Heart Lung Transplantation 2004 (suppl)

17 Professional Development Programme for Organ Donation Donor Management 17 Shift of Goals, but still Intensive Care Increase numbers of donors Increase number of organs per donor Improve function of transplantable organs

18 Professional Development Programme for Organ Donation Evidence for Donor Management 18 Totsuka Transplant Proc. 2000; 32; High sodium in liver donor doubles graft loss Rosendale Transplantation (4): Protocol increased organs per donor 3.1 to 3.8. Increased probability of transplant. Snell J Heart Lung Transplant 2008;27: % of Australian lung donations used for transplant vs. 13% in UK

19 Professional Development Programme for Organ Donation Donor Management 19 All donors are potential multiorgan donors Aim to make all organs transplantable Maintain or improve function

20 Professional Development Programme for Organ Donation Goals 20 General Stability Target Values Mean Arterial Pressure mmHg CVP 4-10 mmHg Heart Rate Rhythm sinus Target Values Cardiac Index >2.1 l/min/m 2

21 Professional Development Programme for Organ Donation General Care 21 Continue ICU care Temperature control Give methylprednisolone, review drugs Donor Management Guideline

22 Professional Development Programme for Organ Donation 22 Guidelines

23 Professional Development Programme for Organ Donation 23 Guidelines

24 Professional Development Programme for Organ Donation 24

25 Professional Development Programme for Organ Donation General Care Bundle 25 Continue ICU care Temperature control Give methylprednisolone, review drugs Donor Management Guideline Consider escalation of monitoring Relatives may be at bedside

26 Professional Development Programme for Organ Donation Review Notes 26 Intravascular volume Review treatment goals Osmotic therapy and urine output Co-ordinator will review in detail

27 Professional Development Programme for Organ Donation 27

28 Professional Development Programme for Organ Donation Cardiovascular 28 Hormonal Package Increased Activity: Assess clinically Invasive monitoring Intravenous fluid Vasoactive drugs: vasopressor/inotrope ECHO Flow Monitoring

29 Professional Development Programme for Organ Donation xxx 29

30 Professional Development Programme for Organ Donation 30 Figure 1: Odds of an organ being recovered and transplanted: Hormonal Resuscitation (HR) verses Non- Hormonal Resuscitation (NHR)

31 Professional Development Programme for Organ Donation Respiratory 31 Head up positioning Lung protective ventilation PEEP and lowest possible FiO 2 Recruitment Avoid overhydration

32 Professional Development Programme for Organ Donation Diabetes Insipidus 32 Common in BSD Posterior pituitary Polyuria, electrolyte disturbance Hypovolaemia Fluids Vasopressin/DDAVP

33 Professional Development Programme for Organ Donation Other Issues 33 Electrolyte disturbances Blood and Coagulopathy Spinal reflexes

34 Professional Development Programme for Organ Donation Other Issues 34

35 Professional Development Programme for Organ Donation 35 Donor Referrals+ 57% Potential Donors+ 19% Actual donors + 82% Lost donors (CVS) 39 to 5 (-87%) Organs per donor (-6.5%) Organs recovered + 71%

36 Professional Development Programme for Organ Donation Donor Co-ordination 36 Donor assessment Donor management Offering organs Thoracic units Retrieval team Theatre time Transport

37 Professional Development Programme for Organ Donation Questions? 37

38 Professional Development Programme for Organ Donation Summary 38 Brainstem death triggers complex pathophysiology Active Donor Management can treat this, and maximise donation Guidelines assist standard management Future developments

39 Cardiovascular Management and Cardiac Donation Increasing Cardiac Donation

40 Professional Development Programme for Organ Donation UK Heartbeating Donors

41 Professional Development Programme for Organ Donation UK Heartbeating Donors

42 Professional Development Programme for Organ Donation UK Cardiothoracic Donors Age Donors

43 Professional Development Programme for Organ Donation Ideal Heart Donor 43 < 55 Female, < 50 Male, Good PMH No diabetes Non-smoking No drugs CVS stable Rhythm, normal ECG, no or minimal support Good function on ECHO, no LVH

44 Professional Development Programme for Organ Donation Expanded Criteria 44 Age < 65 No cardiac PMH that precludes transplantation ECG without definitive pathology Consider smokers, hypertension, arrest or arrythmia, drug abuse, vasopressor use Driven by recipient characteristics

45 Professional Development Programme for Organ Donation Assume all donors can be cardiac donors 45

46 Professional Development Programme for Organ Donation Targets 46 Rate , sinus MAP mmHg CVP ~ 4-10 mmHg CI > 2.1 l.min -1.m -2

47 Professional Development Programme for Organ Donation Clinical and Translational Research 47

48 Professional Development Programme for Organ Donation 48

49 Professional Development Programme for Organ Donation 49

50 Professional Development Programme for Organ Donation 50

51 Professional Development Programme for Organ Donation 51

52 Professional Development Programme for Organ Donation 52

53 Professional Development Programme for Organ Donation 53

54 Professional Development Programme for Organ Donation Adverse Factors 54 Effects of Sympathetic Storm Potentially huge rise in catecholamines Worse with rapid ICP rise Effects of vasodilation Relative hypovolaemia Afterload reduction Volume status

55 Professional Development Programme for Organ Donation Assessing Volume Status 55 Review charts, examine patient Vital signs and postural effects Numbers

56 Give me a CVP of 6-10 Too much-less than 6 Id like Just get on with it!! Make sure they arent hypovolaemic, please Fluid overload is a problem for us-if we get goals with less thats good Lots of fluid please -better function earlier Decent perfusion, good gases and bp, it can only get worse

57 Professional Development Programme for Organ Donation Priorities 57 Volume Restore Tone Effective Circulating Volume: Myocardial perfusion Cardiac function Organ perfusion Avoid Overload Effective Circulating Volume: Myocardial perfusion Cardiac function Organ perfusion Avoid Overload Inotropes? Optimise cardiac output

58 Professional Development Programme for Organ Donation Assessing Volume Status 58 Review charts, examine patient Vital signs and postural effects Numbers Systolic pressure variation Response to therapy

59 Professional Development Programme for Organ Donation Flow Measurement 59 Clinical Waveforms LiDCO PiCCO Doppler Serial ECHO PAWPC

60 Professional Development Programme for Organ Donation Volume Therapy 60 Consider vascular tone Restore tone: Vasopressin Balanced Colloid or Crystalloid Look for significant response Flow monitoring

61 Professional Development Programme for Organ Donation Vasopressin 61 Vasoconstriction: V1 receptor Water reabsorption: V2 receptor Increased ACTH secretion: V3 receptor (Vasodilation at low concentration - Oxytocin receptors)

62 Professional Development Programme for Organ Donation Priorities (contd) 62 Intravascular Volume Vascular tone / Vasopressin Flow parameters Direct Cardiac Index Adequacy of resuscitation Appropriate catecholamines (T3, Hydrocortisone, GTN)

63 Professional Development Programme for Organ Donation 63 Venkateswaran R V et al. Eur Heart J 2009;30: Published on behalf of the European Society of Cardiology. All rights reserved. © The Author For permissions please

64 Professional Development Programme for Organ Donation 64 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author For permissions please Venkateswaran R V et al. Eur Heart J 2009;30:

65 Professional Development Programme for Organ Donation Intensive management benefits all organs 65

66 Professional Development Programme for Organ Donation Continued Review 66 CVS and adequacy of resuscitation Fluid and Electrolytes Offering system and liasion with accepting units Specialist treatments or investigations Continued ICU and theatre management

67 Professional Development Programme for Organ Donation Questions? 67

68 Professional Development Programme for Organ Donation Summary 68 Heart donors are precious Treat all donors as potential heart donors Donor management crucial Volume status, Vascular tone (Vasopressin) Role of Flow monitoring

69 Respiratory Management and Lung Donation Increasing Lung Donation

70 Professional Development Programme for Organ Donation Objectives 70 Understand the effects of the pathophysiology of brainstem death on lung function Understand the consequences of the necessary ventilatory support for lung function Understand how active donor management can improve the number of lungs offered Understand how lung management conflicts with management of other systems

71 Professional Development Programme for Organ Donation UK Heartbeating Donors

72 Professional Development Programme for Organ Donation UK Heartbeating Donors

73 Professional Development Programme for Organ Donation UK Cardiothoracic Donors Age groups Number of donors

74 Professional Development Programme for Organ Donation The Lung Donor 74 Lung donors, in common with other organ donors are often classified into : Ideal Extended criteria It has become clear that both donor pools are important and can meet with clinically successful outcomes

75 Professional Development Programme for Organ Donation The Ideal Lung Donor (1/2) 75 Age <55 years Chest X ray clear PaO 2 > 39.4 kPa (300mmHg) when FiO 2 = 1.0 & PEEP = 5cmH 2 O? Absence of chest trauma No evidence of aspiration or sepsis Absence of purulent secretions at bronchoscopy

76 Professional Development Programme for Organ Donation The Ideal Lung Donor (2/2) 76 Absence of organisms on sputum gram stain No history of primary pulmonary disease Tobacco history <20 pack-years ABO compatibility No prior cardiopulmonary surgery Size match

77 Professional Development Programme for Organ Donation Assume all donors can be lung donors 77

78 Professional Development Programme for Organ Donation Pathophysiology 78 1.Pre-brainstem death 2.Brainstem death 3.Post brainstem death

79 Professional Development Programme for Organ Donation Pathophysiology 79 Trauma Aspiration Infection Pre-Brainstem Death 1 Catecholamine surge Systemic inflammatory response Brainstem Death 2 Conflict Lungs v The Rest Post Brainstem Death 3

80 Professional Development Programme for Organ Donation Targets 80 Protective lung ventilation Lowest FiO 2 possible Lung recruitment Early steroids Minimise lung water

81 Professional Development Programme for Organ Donation The Conflicts 81 Fluid management and lung water The lungs versus the circulation Flow Lung damage Acute Lung Injury (ALI) Acute Respiratory Distress Syndrome (ARDS) Ventilatory strategies

82 Professional Development Programme for Organ Donation Ventilation 82 Ventilation is associated with characteristic types of damage: Barotrauma Volutrauma Infection Aspiration

83 Professional Development Programme for Organ Donation Management 83 Lung protocols: San Antonio Lung Transplant donor management protocol (SALT) Impact of a lung transplantation donor-management protocol on lung donation and recipient outcomes. Am J Respir Crit Care Med Sep 15;174(6):710-6 Ventilator care bundles: Head of the bed elevated to 30 degrees Ulcer prophylaxis DVT prophylaxis (Daily sedation hold) Pmax < 30cmH 2 O, Pplat < 25cmH 2 O Lowest FiO 2 to maintain SpO 2 > 95%

84 Professional Development Programme for Organ Donation SALT 84 The SALT protocol adopted a number of strategies: Education Active donor management Prevent aspiration Recruitment ­ Restricting fluid administration ­ Diuretics ­ Flow directed therapy

85 Professional Development Programme for Organ Donation 85

86 Professional Development Programme for Organ Donation Lung Computed Tomography during a Lung Recruitment Manoeuvre in Patients with Acute Lung Injury 86 Here we see recruitment in a number of lungs: Can have a dramatic effect on PaO2 values and PaO 2 /FiO 2 ratios, creating the ideal donor Can also reduce lung water After procedures

87 Professional Development Programme for Organ Donation Other Options 87 Hormone therapy Vasopressin & the dual role Antidiuresis Vasoconstriction T3 Cardiovascularly unstable Steroids Methylprednisolone 15mg/kg As soon as brain death confirmed

88 Professional Development Programme for Organ Donation Assessment 88 Ventilation parameters History CXR Gas exchange Bronchoscopy

89 Professional Development Programme for Organ Donation The Expanded Criteria Lung Donor 89 Age >55 years, up to 70 years CXR infiltrates are not important Purulent secretions Organisms Pack-years > 20 Unilateral lung damage PaO 2 > 30kPa (FiO 2 1.0, PEEP 5cmH 2 O) Pulmonary Venous PvO 2 >40kPa

90 Professional Development Programme for Organ Donation Maximizing the number of Lungs for LTx 90

91 Professional Development Programme for Organ Donation Maximizing the number of Lungs for LTx 91 PaO 2 231mmHg (30.8 kPa)

92 Professional Development Programme for Organ Donation Maximizing the number of Lungs for LTx 92 PaO 2 231mmHg (30.8 kPa) PV PaO 2 94 mmHg (12.4kPa)

93 Professional Development Programme for Organ Donation 93 Maximizing the number of Lungs for LTx 93 PaO 2 231mmHg (30.8 kPa) PV PaO mmHg (47 kPa) PV PaO 2 94 mmHg (12.4kPa)

94 Professional Development Programme for Organ Donation Assessment Strategies 94 Bronchoscopy Direct inspection Extra-corporeal perfusion

95 Professional Development Programme for Organ Donation Extracorporeal Perfusion 95

96 Professional Development Programme for Organ Donation Questions? 96


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