Presentation is loading. Please wait.

Presentation is loading. Please wait.

Organ Retrieval Workshop, Oxford, November 2012 UK donation and transplantation, 2012.

Similar presentations


Presentation on theme: "Organ Retrieval Workshop, Oxford, November 2012 UK donation and transplantation, 2012."— Presentation transcript:

1 Organ Retrieval Workshop, Oxford, November 2012 UK donation and transplantation, 2012

2 Organ Retrieval Workshop, Oxford, November 2012 Narrowing the gap Increase deceased donor numbers Reduce end stage organ failure Promote alternative sources / solutions Increase organs utilised per donor –Donor optimisation –Graft re-conditioning Improve graft longevity Failure to maximise the gift of donation dishonours both donors and their families

3 Organ Retrieval Workshop, Oxford, November 2012 Heart transplant rates, 2010 If the vision is ‘every organ, every time’, the reality is that ‘we lose more than we use’

4 Organ Retrieval Workshop, Oxford, November 2012 Phases of graft injury

5 Organ Retrieval Workshop, Oxford, November 2012 Pre-retrieval graft injury

6 Organ Retrieval Workshop, Oxford, November 2012 Organ damage in the DBD donor Causes of organ impairment  Primary pathology  Chronic co-morbidities  Brain resuscitation therapies  Pathophysiology of brain death  Fluid and electrolyte disturbance  Haemodynamic instability  Neurogenic pulmonary oedema  Endocrine dysfunction  Systemic inflammation The brain dead organ donor has a distinct collection of acute physiological disturbances that are almost always correctable Fatty kidney from an obese hypertensive donor

7 Organ Retrieval Workshop, Oxford, November 2012 % Donor cause of death Cause of death in UK DBD donors

8 Organ Retrieval Workshop, Oxford, November 2012 Ages of deceased donors in the UK,

9 Organ Retrieval Workshop, Oxford, November 2012 BMI of deceased donors in UK,

10 Organ Retrieval Workshop, Oxford, November 2012 Effect of donor age on organ retrieval in UK

11 Organ Retrieval Workshop, Oxford, November 2012 Principles of brain resuscitation Therapies for the acutely injured brain deep sedation Intubation and controlled ventilation maintenance of brain perfusion pressure −Osmotherapy (ICP) −Vasoconstrictors (MAP) Brain-directed therapies take precedence over systemic support

12 Organ Retrieval Workshop, Oxford, November 2012 Principles of brain resuscitation ICP monitoring The real complications of ICP monitoring cardiovascular collapse respiratory failure

13 Organ Retrieval Workshop, Oxford, November 2012 Complications of ICP monitoring Cardiovascular collapse The perils of maintenance of cerebral perfusion Hypotensive sedative regimens Osmotherapy −Hypovolaemia −Electrolyte imbalance Vasoconstrictor therapies

14 Organ Retrieval Workshop, Oxford, November 2012 Complications of ICP monitoring Respiratory failure The perils of denial of respiratory cares Deep sedation and paralysis Microaspiration −Basal atelectasis −Ventilator-acquired pneumonia Mechanical ventilation −Bullae −Pneumothorax

15 Organ Retrieval Workshop, Oxford, November 2012 Systemic inflammation of brain injury from Barklin, Acta Anaes Scand (2009) 53: Human and experimental evidence for antigen-independent organ injury

16 Organ Retrieval Workshop, Oxford, November 2012 Systemic inflammation of brain death Before and after brain death Trauma Haemorrhage / massive transfusion Aspiration Hypoxia Hospital acquired infection Mechanical ventilation Trauma and rescue therapies Organ retrieval Sympathetic storm Pulmonary capillary injury Systemic vasoconstriction and organ ischaemia Brain-derived inflammatory mediators Brain death Ischaemia / reperfusion Adapted from Barklin, Acta Anaes Scand (2009) 53:

17 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death Initial observations of ‘le coma dépassé’ Haemodynamic instability Pulmonary oedema Hypothalamic failure −Diabetes insipidus −Poikilothermia Disseminated intravascular coagulopathy

18 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death

19 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death Diabetes insipidus

20 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death Poikilothermia

21 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death Poikilothermia frequently overlooked vasodilatation reduced metabolic rate cool ambient surroundings may contribute to haemodynamic and haemostatic failure will continue until SVR is restored

22 Organ Retrieval Workshop, Oxford, November 2012 Pituitary failure in brain death Diabetes insipidus ≈ 70% incidence in BSD Failure of neurohypophysis Diuresis of up to 1000 ml / hr Results in −hypovolaemia −hypokalaemia −hypernatraemia May confound diagnosis of death and assessment of perfusion Frequently undertreated

23 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death Pupillary mydriasis

24 Organ Retrieval Workshop, Oxford, November 2012 Pathophysiology of brain death Cushing’s reflex Harvey Cushing Neurosurgeon

25 Organ Retrieval Workshop, Oxford, November 2012 Initial observations 80-90% of brain dead donors are haemodynamically unstable Severity α rate of ICP rise −Frequently worse in children, young adults Multi-factorial in its aetiology −Sympathetic storm and myocardial ischaemia −Spinal shock −Neurogenic pulmonary oedema −Diabetes insipidus Almost always reversible, given sufficient time and effort Haemodynamic instability of brain death

26 Organ Retrieval Workshop, Oxford, November 2012 Sympathetic storm

27 Organ Retrieval Workshop, Oxford, November 2012 Sympathetic storm Transient release of endogenous catecholamines in canine model From Novitzky D. Selection and management of cardiac allograft donors. Current opinion in organ transplantation 1998;3: Contraction band necrosis

28 Organ Retrieval Workshop, Oxford, November 2012 Sympathetic storm ? a form of stress (Takutsubo’s) cardiomyopathy

29 Organ Retrieval Workshop, Oxford, November 2012 Haemodynamics of brain death Regional neuraxial blockade of sympathetic storm

30 Organ Retrieval Workshop, Oxford, November 2012 Aftermath of the sympathetic storm Persistent hypotension From Herijgers et al. The effect of brain death on cardiovascular function in rats. Part I. Is the heart damaged. Cardiovascular Research 38:

31 Organ Retrieval Workshop, Oxford, November 2012 Aftermath of the sympathetic storm Preserved myocardial performance in rat model of brain death From Herijgers et al. The effect of brain death on cardiovascular function in rats. Part I. Is the heart damaged. Cardiovascular Research 38: Spinal shock vasoparalysis Hyperdynamic circulation

32 Organ Retrieval Workshop, Oxford, November 2012 Aftermath of the sympathetic storm Preserved myocardial performance in rat model of brain death From Herijgers et al. The effect of brain death on cardiovascular function in rats. Part I. Is the heart damaged. Cardiovascular Research 38:

33 Organ Retrieval Workshop, Oxford, November 2012 Brain death related hypotension

34 Organ Retrieval Workshop, Oxford, November 2012 Afterglow of one big bang Cosmic microwave background radiation

35 Organ Retrieval Workshop, Oxford, November 2012 Afterglow of autonomic storm Neurogenic pulmonary oedema Alveolar flooding common frequently −misdiagnosed −mistreated cardiogenic in origin, non- cardiogenic in behaviour can be florid precursor for systemic inflammatory response

36 Organ Retrieval Workshop, Oxford, November 2012 Afterglow of autonomic storm Neurogenic pulmonary oedema Disruption of the alveolar – capillary barrier common frequently −misdiagnosed −mistreated cardiogenic in origin, non- cardiogenic in behaviour can be florid precursor for systemic inflammatory response

37 Organ Retrieval Workshop, Oxford, November 2012 Principles of donor management Donor management requires a fundamental shift in focus – from brain to donor organ directed therapies.

38 Organ Retrieval Workshop, Oxford, November 2012

39

40

41 Hazard ratio 95% CI Nor-epinephrine Epinephrine Dopamine Dobutamine

42 Organ Retrieval Workshop, Oxford, November 2012 Catecholamines and donor therapy The case against catecholamines Catecholamines are raised during the sympathetic storm Catecholamines are implicated in contraction band necrosis Hearts from donors who have received catecholamine infusions do badly (norepinephrine)

43 Organ Retrieval Workshop, Oxford, November 2012 The case against catecholamines Catecholamines are raised during the sympathetic storm Catecholamines are implicated in contraction band necrosis Hearts from donors who have received catecholamine infusions do badly Therefore we must not give donors catecholamine infusions Hearts may be declined when donors are on high doses of catecholamines Catecholamines and donor therapy

44 Organ Retrieval Workshop, Oxford, November 2012 But…… outcomes in kidney transplantation Kidneys from donors who have received catecholamine infusions do well Cardiac injury of the sympathetic storm is reversible Standardised donor management protocols allow retrieval of apparent unsuitable heart grafts −Restoration of normovolaemia −Correction of vasodilatation −Titrated inotropic support Catecholamines and donor therapy

45 Organ Retrieval Workshop, Oxford, November 2012 But……. reversibility in survivors of the sympathetic storm Catecholamines and donor therapy Kidneys from donors who have received catecholamine infusions do well Cardiac injury of the sympathetic storm is reversible Standardised donor management protocols allow retrieval of apparent unsuitable heart grafts −Restoration of normovolaemia −Correction of vasodilatation −Titrated inotropic support

46 Organ Retrieval Workshop, Oxford, November 2012 Catecholamines and donor therapy Kidneys from donors who have received catecholamine infusions do well Cardiac injury of the sympathetic storm is reversible Standardised donor management protocols allow retrieval of apparent unsuitable heart grafts −Restoration of normovolaemia −Correction of vasodilatation (vasopressin > norepinephrine) −Titrated inotropic support (dopamine > epinephrine) Wheeldon et al. Transforming the unacceptable donor. J Heart Lung Transplant. 1995; 14: But…… transformation of unacceptable donors

47 Organ Retrieval Workshop, Oxford, November 2012 The case for hormone replacement Hormone replacement therapy

48 Organ Retrieval Workshop, Oxford, November 2012 Hypotension is bad for kidneys Catecholeamines may be bad for hearts…….. …….. but good for kidneys Hormone replacement may be good for hearts Invasive haemodynamic monitoring may be good for thoracic organs…………if you know how to use it Some ICU clinicians seem reluctant to deliver it Donor optimisation Early observations Critical care of the potential organ donor is not a passive process and should start as early as possible.

49 Organ Retrieval Workshop, Oxford, November 2012 Donor Care Bundle

50 Organ Retrieval Workshop, Oxford, November 2012 Donor care bundle Key initial priorities Assess fluid status and correct hypovolaemia Introduce vasopressin infusion and where required introduce flow monitoring Perform lung recruitment manoeuvres (e.g. following apnoea tests, disconnections, deterioration in oxygenation or suctioning) Identify, arrest and reverse effects of diabetes insipidus Administer methylprednisolone (all donors)

51 Organ Retrieval Workshop, Oxford, November 2012 Haemodynamic optimisation I ObjectivesInterventions Improve organ perfusion Correction of hypovolaemia Restoration of vasomotor tone Improvement of myocardial contractility Initial therapy a. early correction of hypovolaemia, diabetes insipidus and electrolyte and acid-base disturbances as directed above. b. vasopressin infusion, 1 unit followed by 1 – 4 units / hour: as initial therapy for fluid-unresponsive hypotension, or to replace / reduce existing catecholamine infusions c. Use terlipressin as alternative to vasopressin General haemodynamic goals: Heart rate 60 – 100 bpm CVP < 12 cmH 2 O Mean arterial pressure 70 mmHg Systolic blood pressure > 100 mmHg Mixed venous saturation > 60% Reduction of catecholamine infusion(s)

52 Organ Retrieval Workshop, Oxford, November 2012 Choice of colloid Hydroxyethylstarch and post-graft renal function Elohes (MW 200 kDa) Relative lack of free water Osmotic nephropathy

53 Organ Retrieval Workshop, Oxford, November 2012 Choice of colloid Hydroxyethylstarch and post-graft renal function It is important to prescribe adequate crystalloid when administering colloid solutions to avoid inducing a hyperoncotic state. Higher molecular weight hydroxyethyl starch (hetastarch and pentastarch MW ≥ 200 kDa) should be avoided in brain-dead kidney donors due to reports of osmotic-nephrosis- like lesions.

54 Organ Retrieval Workshop, Oxford, November 2012 Haemodynamic optimisation II ObjectivesInterventions Improve organ perfusion Correction of hypovolaemia Restoration of vasomotor tone Improvement of myocardial contractility Additional therapies in unresponsive cases initiate cardiac output monitoring, titrating fluid, vasoconstrictors or inotropic therapy to following end points: cardiac index > 2.4 L / min / m 2 pulmonary artery occlusion pressure < 12 cmH 2 O systemic vascular resistance 800 – 1200 dynes / sec / cm 5 left ventricular stroke work index > 15 g / kg / minute Use catecholamines as sparingly as possible: dopamine / dobutamine > epinephrine / norepinephrine / phenylephrine. General haemodynamic goals: Heart rate 60 – 100 bpm CVP < 12 cmH 2 O Mean arterial pressure 70 mmHg Systolic blood pressure > 100 mmHg Mixed venous saturation > 60% Reduction of catecholamine infusion(s)

55 Organ Retrieval Workshop, Oxford, November 2012 Haemodynamic optimisation III ObjectivesInterventions Improve organ perfusion Correction of hypovolaemia Restoration of vasomotor tone Improvement of myocardial contractility Additional therapies in unresponsive cases b. in refractory cases consider parenteral empirical thyroid replacement therapy levothyroxine (tetra-iodothyronine, T 4 ), 20 μg IV bolus, followed by 10 μg / hour, or liothyronine, (tri-iodothyronine, T 3 ), 4 μg IV bolus, followed by 3 μg / hour General haemodynamic goals: Heart rate 60 – 100 bpm CVP < 12 cmH 2 O Mean arterial pressure 70 mmHg Systolic blood pressure > 100 mmHg Mixed venous saturation > 60% Reduction of catecholamine infusion(s)

56 Organ Retrieval Workshop, Oxford, November 2012 Haemodynamic optimisation III ? Role for lio-thyronine

57 Organ Retrieval Workshop, Oxford, November 2012 Respiratory optimisation ObjectivesInterventions Correct atelectasis that follows the apnoea tests Give methylprednisolone, 15 mg / kg. Reinstate routine chest physiotherapy, 2 hourly rotation to lateral position and regular endotracheal suction. 30 o head up tilt and firm inflation of endotracheal tube cuff to prevent microaspiration and bronchial soiling Intensive alveolar recruitment - e.g. periodic application of PEEP up to 15 cm H 2 O, sustained inspiration to 30 cm H 2 O for seconds and diuresis where indicated. Ventilatory targets are as follows: Tidal volume 6-8 ml/kg; PEEP 5–10 cmH 2 O; PIP<30 cmH 2 O pH , PaCO 2 4.5–6kPa, PaO 2 >11kPa, SaO 2 >95% Initiate antibiotic therapy as directed by results of sputum / lavage microscopy and culture, avoiding nephrotoxic anti- microbials. Continue / re-instate general respiratory care of intubated / ventilated patient; protect against microaspiration Identify and reverse specific pulmonary complications of critical care / brain-stem death Introduce lung- protective ventilatory therapies

58 Organ Retrieval Workshop, Oxford, November 2012 Metabolic optimisation ObjectivesInterventions Identify and correct the metabolic, biochemical and haematological derangements: hypernatraemia hypokalaemia hyperglycaemia anaemia DIC Correct diabetes insipidus and the associated hypovolaemia hypernatraemia Administer parenteral electrolyte supplements to restore serum electrolyte concentrations to normal range. Continue / commence nutrition, and maintain blood glucose 4 – 10 mmol / L with iv insulin Maintain haemoglobin at 9 – 10 g / dl Treat derangements in coagulation with appropriate clotting factors and / or platelets if there is significant on-going bleeding. Have clotting factors available for organ retrieval. Normalise markers of adequate perfusion: decreasing blood lactate, mixed venous saturation > 60% urine output of 1 – 2 ml/ kg/ hour (in absence of diabetes insipidus).

59 Organ Retrieval Workshop, Oxford, November 2012 heart liver kidney pancreas lungs small bowel Time after diagnosis of brain death (hours) Duration of support following diagnosis of brain death Inaba et al. J TRAUMA :


Download ppt "Organ Retrieval Workshop, Oxford, November 2012 UK donation and transplantation, 2012."

Similar presentations


Ads by Google