Presentation on theme: "Moderator: Adam Teller, OneLegacy Presenters:"— Presentation transcript:
1 Breakout Session C: Preserving the Opportunity – Before and After Consent Moderator:Adam Teller, OneLegacyPresenters:Lydia Lam, MD, LAC + USC Medical CenterKeith Markillie, RN, OneLegacy
2 Preserving the Opportunity: Before and After Consent Moderator:Adam Teller, Procurement Transplant CoordinatorOneLegacy
3 “How To Be” Being in Action! The Answers Are In the Room “Report out” on Questions to Run-on:ScribeSpokespersonAll Teach / All LearnAdd this slide as Slide #2, after the Title Slide and before the Question to Run-on Slide.
4 Question to Run-OnHow do your standards of care preserve the opportunity for the gift of life?
5 ObjectivesBy the end of this presentation, the attendee will be able to:Understand the impact of a DNR and donationRecognize pathophysiology of traumatic brain injuryAnticipate common interventions for optimal donor management
6 Preserving the Opportunity: Before and After Consent Lydia Lam, MDDivision of Acute Care Surgery and Surgical Critical CareLos Angeles County + USC Medical CenterLos Angeles, CA
7 “Do not harm?” or “Do not treat?” DNR DecisionWhat does the DNR decision mean to the family?No Chest Compressions?No Shock?No Medications?No Labs?No Fluids?No Diagnostic Tests?Allow natural death?“Do not harm?” or “Do not treat?”
8 “Do not harm?” or “Do not treat?” DNR DecisionWhat does the DNR decision mean to the healthcare team?Routine decision in the Critical Care UnitStop all treatment immediately or no aggressive treatment after cardiac arrest?DNR decision has its own “culture of understanding” that varies by hospital, unit, physician and nurse“Do not harm?” or “Do not treat?”
9 Donation Decision Understanding the donation option clinically: Maintaining blood pressureNormalizing electrolytesManaging oxygenation and organ perfusionBalancing Intake and OutputAssessing brain death accuratelyHow can a family give the gift of life when the organs are not preserved for transplantation?
10 Balancing DNR and Donation Traumatic Brain Injury (TBI)Overall Clinical Deterioration+ DNR Decision by Next-of-Kin+ Fatal Diagnosis (Brain Death?)How is this interpreted in your ICU?What can be expected from your team?How can we be proactive for this family?Fly each line in individually to build clinical “equation”.
12 Pathophysiology of Traumatic Brain Injury Hypotension:“Autonomic storms”Smooth muscle ATP depleted = vasomotor hypotensionAnticipate BP spike followed by BP dropTitrate VasopressorsDiureticsConsider Fluid ResuscitationClosely monitor Intake and Output – DI?
13 Pathophysiology of Traumatic Brain Injury Endocrine Dysfunction:Hypothalamic injury -> pituitary dysfunctionThyroid dysfunction = T4 InfusionReduction of Antidiuretic Hormone / DIADH = Vasopressin InfusionGlycemic control disruptedInsulin infusionRelative deficiency of corticosteroidsSolumedrol Infusion
14 Pathophysiology of Traumatic Brain Injury Pulmonary Dysfunction:Neurogenic pulmonary edemaSystemic hypertension + LV dysfunctionPrimary pneumatocyte dysfunctionIatrogenic injury due to aggressive resuscitationExacerbated by intubation, aspiration &atelectasisConcurrent blunt lung injury commonParenchymal injury problematic in immunosuppressed recipients
15 Pathophysiology of Traumatic Brain Injury Hematologic Dysfunction:ThrombocytopeniaPlatelets as neededCoagulopathy/DICFFP / Cryo as neededHypothermiaKeep them warm!
16 What are Traumatic Brain Injury Guidelines? Hospital approved guidelines for treating patients with Traumatic Brain Injury
17 What are Traumatic Brain Injury Guidelines? Prevent secondary injury, even with grave prognosisSecondary injury includes other organs, as well as the brainMaintain Organ PerfusionVolume LoadMaintain adequate CVP & MAPOxygenationCorrect electrolyte abnormalities
18 Why Implement Traumatic Brain Injury Guidelines? Ensure consistent management of the critically ill patientMaintain homeostasis for accurate brain death assessmentPrevent “secondary injury” to organs, even with grave prognosisProvide a clinical bridge between determination of brain death and family’s decision on donation
19 LAC + USC Standardized organ donor management protocol Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: )LAC + USC Standardized organ donor management protocolBefore-after study (January 1998) of ADM institutionJanuary 1995-December 2002
20 Vasopressors if MAP <70 Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: )Vasopressors if MAP <70DopamineLevophedVasopressinHormones for maximal vasopressors.InsulinSolumedrolT4
21 # patients referred increased 57% # of potential donors increased 19% Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: )878 patients referred, 460 (53.4%) patients potential organ donors and 161 (34.3%) actual donors.# patients referred increased 57%# of potential donors increased 19%# of actual donors increased 82%# of patients lost to cardiovascular collapse decreased 87%# of organs recovered increased 71%
22 How to Implement TBI Guidelines in your Hospital? Clinical EducatorCritical Practice CommitteeCritical Care LeadershipCritical Care Physicians or Medical DirectorSample Guidelines available at:
23 “Do not harm?” or “Do not treat?” DNR DecisionWhat does the DNR decision mean to the family?No Chest Compressions?No Shock?No Medications?No Labs?No Fluids?No Diagnostic Tests?Allow natural death?“Do not harm?” or “Do not treat?”
24 SummaryCritical care teams can honor the DNR decision while preserving the option of donation.Pathophysiology of Traumatic Brain Injury can be anticipated and treated.TBI Guidelines can be implemented to prevent “step down” in clinical management and preserve the family’s donation option.
25 The Care and Management of Consented Brain Dead Organ Donors Keith Markillie PTC, RN, BSNOneLegacy
26 Best Practices Approach to Saving Lives & Preserving the Opportunity for Organ Donation
27 Organ Donor Management Similar to Traumatic Brain Injury Guidelines: “What’s good for the patient is good for the donor”Treatment of Brain DeathStandardizes donor management within OneLegacyMaximize the organs recovered per donor
28 Organ Donor Management MAP 60 – 110 mmHgCVP mmHgEF > 50%</= 1 pressor used AND:Dopamine </= 10 mcg/kg/minNeosynephrine </= 100 mcg/minNorepinephrine </= 10 mcg/minVasopressin </= 2.4 units/hour (0.04 units/min)ABG pHPaO2:FiO2 ratio >300 on PEEP = 5Serum Sodium <155Urine output 1-3 mL/kg/hourGlucose < 150Hemoglobin > 10Track hormone replacement usage
29 Hormonal Replacement Post brain death endocrine changes There is a sharp decrease in T3 and T4 to 50% of normal within one hour of brain death & down to Zero after 16 hoursCortisol levels decrease to 50% after one hour and continue to decreaseAntidiuretic Hormone decrease significantly and completely disappear after 6 hoursInsulin decreased to 20% of baseline by 13 hours>>Transplantation, Vol 83, pp , no 11, December 15, 2006
30 Hormonal ImbalancesResearch findings suggest that after brain death aerobic metabolism changes to anaerobic cellular metabolismATP and creatinine phosphate deplete & lactate increases which leads to decreased cardiac functionAfter T4 infusion, lactate decreases, glucose utilization increases and the mitochondria resume aerobic energy generation>>Transplantation, Vol 83, pp , no 11, December 15, 2006
31 T-4 Protocol Give IV boluses of the following: 20 mcg T-4 IV push20 units regular insulin50 mL dextrose 50%30 mg/kg Solumedrol (2 grams max)After initial bolus start T-4 drip200 mcg in 500mL NS at 25mL/hour initially (10 mcg/hour)Titrate as needed to maintain BPContinue drip to procurement
32 Solumedrol Used in conjunction with T-4 Corticosteroid replacement for lowered cortisol levels in brain dead patientsUsed routinely throughout care of the donor
33 Vasopressin/Pitressin Used as hormone replacement of ADH from posterior pituitary gland in brain dead patientVery effective in treating DI related hypotensionMay or may not give 1 unit IV bolus of vasopressin before starting dripDrip rate is 0.5 – 2.4 units/ hourClosely observe Urine Output—don’t make the donor anuric
34 Insulin Monitor glucose every 2 hours Treat with insulin drip rather than SQKeepUtilize hospital or OneLegacy protocol
35 Treatment beyond Hormones Organ PerfusionBalance electrolytesCorrect coagulopathyCorrect metabolic acidosisOptimize oxygenation and ventilationAntibiotic usage
36 Organ Perfusion Maintain MAP 60 – 110mmHg 1. Consider invasive hemodynamic monitoringAdequate hydration to maintain euvolemiaCrystalloids, colloids, blood productsFree waterVasopressor supportDopamineVasopressinNeosynephrineLevophed2D Echo to evaluate function once resuscitated & pressors low dose
39 Metabolic Acidosis Adequate perfusion Volume resuscitation Sodium BicarbonateUse judiciously with high sodiumFind other reasons for acidosis (respiratory, kidney failure, electrolytes)Use potassium and sodium acetate to supplement electrolytes
40 Oxygenation/Ventilation Early bronchoscopy to clear secretionsRoutine use of SolumedrolGood pulmonary toiletingBreathing treatments/MDINarcan earlyLung recruitmentPEEP maneuversI:E ratio manipulation
41 Antibiotic UsageALL patients get antibiotics! Dosages can be adjusted to size and kidney clearanceLess than 5 days = ZosynGreater than 5 days = Vancomycin + LevaquinMay need other coverage, depending on pre-donor conditionID consult? Never a bad idea with “strange circumstances”
42 Organ Donor Management MAP 60 – 110 mmHgCVP mmHgEF > 50%</= 1 pressor used AND:Dopamine </= 10 mcg/kg/minNeosynephrine </= 100 mcg/minNorepinephrine </= 10 mcg/minVasopressin </= 2.4 units/hour (0.04 units/min)ABG pHPaO2:FiO2 ratio >300 on PEEP = 5Serum Sodium <155Urine output 1-3 mL/kg/hourGlucose < 150Hemoglobin > 10Track hormone replacement usage
43 Final Thoughts“Everyone of us can help make this difference …Because that truly is the Right Thing to Do.”Dr. Kenneth Moritsugu, MDUS Deputy Surgeon General
44 Question to Run-OnHow do your standards of care preserve the opportunity for the gift of life?