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Dr Gerlinde Mandersloot 20 th April 2012 Optimising the brain-stem dead donor Dr Gerlinde Mandersloot National Clinical Lead - Donor Optimisation Organ.

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Presentation on theme: "Dr Gerlinde Mandersloot 20 th April 2012 Optimising the brain-stem dead donor Dr Gerlinde Mandersloot National Clinical Lead - Donor Optimisation Organ."— Presentation transcript:

1 Dr Gerlinde Mandersloot 20 th April 2012 Optimising the brain-stem dead donor Dr Gerlinde Mandersloot National Clinical Lead - Donor Optimisation Organ Donation Past, Present and Future 1

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4 Challenges 4 Organ Donation Past, Present and Future Physiological consequences of BSD

5 ‘Collateral damage’ Hormonal Diabetes insipidus Hypovolaemia Hypernatraemia T3 / T4 reduces ACTH Blood glucose Hypothermia Organ Donation Past, Present and Future 5

6 Incidence of organ involvement Hypotension81% Diabetes insipidus65% DIC28% Cardiac dysrhythmias25% Pulmonary oedema18% Metabolic acidosis11% J Heart Lung Transplantation 2004 (suppl) Organ Donation Past, Present and Future 6

7 Challenges 7 Organ Donation Past, Present and Future Physiological consequences of BSD Stabilisation and brainstem death testing

8 Stabilisation of a patient to facilitate neurological examination Difficulties in defining futility, especially in survivors Replace by concept of ‘Best Interests’ Not only medical factors taken into account Stabilisation of patient prior to BSD testing Brainstem death testing is part of a neurological examination of the patient Clinical in the majority of cases Ancillary tests where required Active management may be necessary in order to examine accurately Continued care after BSD to explore possibility of donation Integral part of every End of Life Care Plan

9 Challenges 9 Organ Donation Past, Present and Future Physiological consequences of BSD Stabilisation and brainstem death testing Consistent donor optimisation 65% of units have 2 or fewer donor per year 23% of donors are from these units Only 4% units have 10 or more donor per year, 28% of the total donor population

10 Give me a CVP of 6-10 Too much-less than 6 I’d like Just get on with it!! Make sure they aren’t hypovolaemic, please Fluid overload is a problem for us-if we get goals with less that’s good Lots of fluid please -better function earlier Decent perfusion, good gases and BP, it can only get worse

11 Evidence 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 Organ Donation Past, Present and Future 11

12 12 Organ Donation Past, Present and Future

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14 Unifying practice across the UK Optimisation tool Non-controversial (or not too controversial) Not too complicated One side of an A4 ? Buy-in from retrieval / transplant community Easy to audit Extended Care Bundle with two components Prescription: medical staff Implementation Critical care nurses SN-ODs ‘Scouts’ Monitoring implementation 14 Organ Donation Past, Present and Future

15 15 Organ Donation Past, Present and Future

16 16 Organ Donation Past, Present and Future

17 Priorities, if not already addressed 17 Organ Donation Past, Present and Future Assess fluid status and correct hypovolaemia with fluid boluses as required Perform lung recruitment manoeuvre(s) as at risk of atelectasis following apnoea tests Identify, arrest and reverse effects of Diabetes insipidus Introduce vasopressin infusion: reduces Norepinephrine requirements and treats DI Methylprednisolone, 15 mg/kg to max of 1g, as soon as possible

18 Hormonal treatment Vasopressin Reduction in other vaso-active drugs Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time) Liothyronine (T3) No clear evidence for use May add haemodynamic stability in very unstable donor Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team Methylprednisolone in all cases Dose: 15 mg/kg up to 1g Insulin At least 1 unit/h (occasionally may need to add glucose infusion) ‘Tight’ glycaemic control ( mmol/l) Organ Donation Past, Present and Future 18

19 19 Organ Donation Past, Present and Future

20 Monitoring optimisation 20 Organ Donation Past, Present and Future Implementation: use of care bundle Adherence easy to monitor Audit first 5 priorities Results of optimisation evaluated Number of organs retrieved Increase in cardiothoracic organs retrieved Quality of organs: graft function in recipients Delayed graft function Quality: biomarkers Duration of graft function: long term project

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