Presentation on theme: "How to perform a BD exam and improve donor management"— Presentation transcript:
1How to perform a BD exam and improve donor management Panayiotis N. Varelas, MD, PhDDirector Neuro-ICUSenior Staff Neurology / NeurosurgeryHenry Ford HospitalAssociate Professor of NeurologyWayne State UniversityDetroit, MI
2Topics for discussion Management before BD is declared How BD exam is performedHow to approach the familyManagement after BD is declaredI have received speaker honoraria and hold stock options from The Medicines Company, which has sponsored my research. I also receive royalties from the publication of the book Seizures in the ICU, I am an editorial board member of Neurocritical Care and serving in the advisory board of Gift of Life of Michigan.Potential conflicts:I have received speaker honoraria and holds stock options from The Medicines Company. The same company has sponsored research for which he served as primary investigator. He also receives royalties from the publication of the book Seizures in the ICU, is an editorial board member of Neurocritical Care and is serving in the advisory board of Gift of Life of Michigan.
3HFH Management Recommendations BEFORE BD Declaration
4HFH Management Recommendations BEFORE BD Declaration These recommendations are to be discussed, agreed upon and ordered by the ICU Primary Team (Senior Staff) and collaboratively implemented by the ICU Primary team, Gift of Life representative, and ICU nursing.These recommendations are not orders and should not be used as such. If a decision is made to utilize one or more of these recommendations, an order must be written by the physician.Methods for attaining goals are just recommendations – they should not be used if they are contraindicated to the patient’s condition or contrary to patient’s /family’s advance directives
5HFH Management Recommendations BEFORE Brain Death Declaration MAP maintained ≥ 60 mmHg – Prevent HypotensionKeep CPP > 70, if an ICP monitor is in placeMaintenance IV Fluid: 0.9% NS with 20 mEq ml/hr. (Saline may need to be adjusted for Na+ greater than 160, see below.)For hypovolemia: Bolus with 500mL 0.9% NS until MAP sustains ≥60 mmHg.Start Dopamine and titrate to maintain MAP ≥ 60 mmHg (max 20 mcg/kg/min). Always notify the physician when starting pressors or inotropes or transfusing blood products.If Dopamine is at 20 mcg/kg/min, CVP greater than 10, and MAP/CPP remains less than 60 mmHg, consider norepinephrine infusion. Titrate to clinical effect (max 20 mcg/min)If Hct ≤ 25%, recommend 1 unit of PRBC’s over 1 hour, repeat as necessary to maintain HCT ≥ 25% or hemoglobin > 7.0.
6HFH Management Recommendations BEFORE Brain Death Declaration HypertensionUse IV Hydralazine prn. Avoid beta-blockers.HypothermiaWarming blanket to maintain core body temp between 36.5° – 37.2° C, except for pts with induced-hypothermia.Diabetes Insipidus (DI)For urinary output greater than 4 mL/kg/hr X 2 hrs AND Na+ > 155 and rising, recommend Vasopressin drip or replace urine output mL/mL:If Na+ > 160, use Half NS (0.45%) for replacementIf Na+ ≤ 160, use NS 0.9% for replacementAlways notify the physician if pt hypotensive (CPP < 70, MAP < 60) or tachycardic (HR > 90)
7HFH Management Recommendations BEFORE Brain Death Declaration HypoxemiaTitrate FiO2 to maintain SaO2 greater than 98% or PaO2 > 300 on FiO2 1.00Tidal Volume at 6 mL/kgAdd PEEP of 5-8 cmH2oRate adjusted to maintain normal pH ( )Suction and turn patient q 1-2 hrsInitiate Chest Percussion and Vibration q 1-2 hrsAlbuterol Nebulizers: 2.5mg q 4 hrs.
9Current BD criteria in the US Responsibility left to individual institutions: Each hospital has to develop its own criteria, based onState laws criteria based on “accepted medical standards”, based onPresident’s Commission (1981), Uniform Determination of Death Act (UDDA, 1993), AAN (2010) or other Societies recommendations, which are “advisory” and carrying the weight of “guidelines” rather than standards
10HFH: determination of brain death Determination of “death by brain criteria” in accordance with MI lawTwo different physicians, licensed in MI: 1) The primary senior staff physician2) Senior staff from Neurology or NSor designated physician under direct supervision, i.e resident, fellow
11Determination of brain death - Process GCS ≤ GOL notified within 1 hourIf All prerequisites are metClinical evaluation:Cerebral unresponsiveness: deep, irreversible comaAbsence of brainstem reflexesAbsence of respiration (Apnea test)± Confirmatory testing
12Determination of brain death - Prerequisites Established & sufficient cause of irreversible comaAge 7 daysExclusion of any complicating condition confounding clinical assessment:Absence of deep sedation or peripheral nerve or muscle dysfunction, i.e., (+) TOF, if NM blockadeToxScreen: ETOH < 80mg%, < 10g/ml, drugs?Temp-core 32.2oC (90oF)SBP 90 mmHg or MAP > 60 mm Hg or age-specific normotensive range in childrenSevere electrolyte, acid-base or endocrine disturbances
13Suspicion of drugs – toxins? Administer antidotesNarcotics naloxoneBenzodiazepines flumazenilCarbon monoxide oxygenCarbon disulfide, cyanide, hydrogen sulfide amyl nitriteDeclare brain death if traces of drug are found below therapeutic levelUnable to quantify drug/poison observe for x 5 half livesUnknown, but high suspicion 48 hrs observation, if no confirmatory studyWijdicks Brain Death 2001
14Pitfall: Effect of hypothermia on sedative metabolism Figure A shows the time course changes in concentration of Midazolam in brain-injured patients undergoing hypothermic therapy As shown in (A) concentration of the agent increased linearly until Body Temp reached 35 °C, after which the levels decrease profoundly when Body Temp rose to 36 °C, even during continuous administration of Midazolam.(B) Depicts the time course changes in concentration of Midazolam in brain-injured patients with normothermic therapy. In the figure, the concentration of the agent increased at 24 h after administration, then plateaued from 72 h, lasting until 216 h, during continuous infusion.Fukuoka et al, Resuscitation 2004
15Clinical Examination - Coma Lack of responsiveness to supraorbital nerve, nail-bed or TMJ pressurePitfalls:Uncoordinated, non-integrated into posturing responses = i.e. 2o to spinal cord reflexesPartial eye opening in response to ipsilateral nipple twisting 5 sec later (sympathetic fibers to Muller’s muscle?) (Santamaria et al., 1999)
16Clinical Examination - Reflexes Mid-position (4-6 mm) or dilated pupilsPitfalls: Drugs that influence pupils:Topical application of mydriaticsAtropine in IV doses 0.03 mg/kg slight mydriasis, but (+) reaction to light (Goetting et al., 1991)Escalating doses of non-depolarizing paralytics lead from reversible to non-reversible mydriasis (Schmidt et al., 2000)
18Clinical Examination - Reflexes Corneal, blinking to threatGrimacing to pain, jaw reflexPitfall: facial myokymia/fibrillation from muscle denervation may mimic facial movementsNasal tickle (V2 - XI)Gag, coughOver-breathingAtropine test: tachycardia (↑ HR > 3%) to 2-3mg IV atropine (Huttemann et al., ICM 2000)
19Apnea test Always with the second BD exam Pre-oxygenation 100% FiO2 Pre-admission or “normal” level for the ptApnea testAlways with the second BD examPre-oxygenation 100% FiO2PaCO2 target: 60 mmHg or [baseline + 20]PaCO2 by 3-6 mm Hg/minHypothermia ( CO2 production, left shift O2 dissociation curve) normothermiaHypotension SBP goal 90 mm Hg
20Apnea test - Solutions Unable to complete the test?? repeat after correcting the problem clinical exam + confirmatory test use tricks:CO2 augmentation (1 L/min) – PaCO2 > 60 mmHg within 2 min (Lang, 1995)Bulk diffusion (set rate = 0, CPAP = 0, 100% FiO2, L/min continuous flow) - 22/24 pts completed the test (al Jumah et al., 1992)T-piece (12 L/min) with CPAP valve (10 cm H2O) – less desaturation with T-piece compared to cannula inside ETT or T-piece alone (Levesque et al., CCM 2006)ADVICE: perform apnea test even if pt on high FiO2 and draw ABGs as O2 Sat reaches 90%!
22HFH: determination of brain death - Observation period between 2 clinical exams (continue) Children 1 year – 18 years: 2 Clinical exams 12 hours + apnea ( optional ConfTest)Children 2 months – 1 year: 2 Clinical exams 24 hours + apnea + ConfTestNeonates 7 days – 2 months: 2 Clinical exams 48 hours + apnea + ConfTest (2 EEGs 48 hours apart or CBF study, if equivocal)Pregnant women: no BD exam or test, until confirmation of viability of fetus
23Confirmatory tests may be required Confirmatory Tests “are recommended”:Normal or inconclusive CTOH/MRICOPD or sleep apnea- ? chronic PaCO2Inconclusive or indeterminable apnea testChildrenInability to perform full clinical examSevere facial trauma (ex. Racoon eyes)
25Confirmatory tests may be required (continue) 7. Preexistent abnormal/surgical pupilSevere cranial neuropathiesToxic/therapeutic level of CNS depressants, neuromuscular blocking agents, aminoglycosides, anticholinergics(?) complex/integrated motor activityInjury as a result of crime (not at HF!)If only one brain death exam is requiredHenry Ford!!)
31Clinical QuestionsAre there patients who fulfill the clinical criteria of brain death who recover brain function?What is an adequate observation period to ensure that cessation of neurologic function is permanent?Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death?What is the comparative safety of techniques for determining apnea?Are there new ancillary tests that accurately identify patients with brain death?
32Approaching the family BRAIN DEATHApproaching the familyAND NOT DISCUSSING ABOUT DONATION!!!
33Consent rates Average national consent rate 45-50% Early referral when BD is imminentSuitability for donation relies on OPO(Franz et al., 1997, DeJong et al., 1998)
34Consent rates Factors improving donation rates: Discussion in a quite environmentTrained requester (i.e., OPO)Decoupling = family understands & accepts BD before any donation mentioned (Gortmaker et al., 1998)Within 30 min after BD notification (because if simultaneous donation rate by 20-40% !)(Niles & Mattice, 1996)
35Donation was not discussed prior to brain death NICU Brain Death and Organ Donation Request Policy (Helms et al. Neurology 2004)Donation was not discussed prior to brain death Brain death declared according to hospital and AAN policiesFamily informed and brain death process explained by treating attending physicianPhysician does not bring up donation to family and leaves the roomProcurement coordinator (OPO) makes the request
36Organ and tissue donation consent rates 21 months before and 21 months after the institution of policy change (Helms et al. Neurology 2004)Before %After %Odds ratio, 95% CIp valueNICUEye220.127.116.11,0.5Bone & Tissue10.437.35.1,0.002*Solid organs45.652.61.3,0.7Total18.104.22.168,0.01*Other units16.514.20.8,22.214.171.124,0.845.061.51.9,0.419.722.41.2,0.3
37Approaching the family Let family know that the 1st BD is done and a 2nd will be performed at X time.No mention about donation !If family asks about it, refer them to GOLAfter the 2nd exam (or after the only BD exam), discuss again with family and explain the results and that the pt is irreversibly and legally dead.Allow time for them to absorb the info, introduce GOL to them and then leave the room
38Approaching the family If the family decides for donation and consent is signed GOL takes overHelp GOL with tests, proceduresIf the family decides against donation pt is disconnected from vent within 1 hour
39Time from declaration to VF- asystole Time (hours) to asystoleStudyNo ofpatients<2424-4848-72>72Jorgensen 19736362%25%13%Mohandas and Chou 19712556%20%16%8%Hicks and Torda 197980%Narimazie 19801060%40%Jennett et al 198147636%31%11%23%Ouaknine 197540“Generally between 1 and 7 days”Kaste et al 197912“On average 24 hours”Nishimura 1984“On average six days”Goulon 198423“Up to 128 hours”Kenneth Wood, DO, University of Wisconsin, Pallis ABC of Brain Stem Death 1996
40Medical management after BD Integrative, multi-disciplinary and collaborative approach between OPO and Critical Care TeamPre-BD management, aiming at brain function preservation, may compromise other organs and contradict the post-BD/donor managementAggressive donor management may allow up to 84% of initially unsuitable donors to yield transplantable organs(Wheeldon et al., J Heart Lung Transpl 1995)
55Management of Respiratory Function in the Organ Donor Goals of mechanical ventilationFiO2: 0.40PaO2 > 100 mmHg; or PaO2 > 300 on 100% FiO2PaCO2: mmHgArterial pH,Tidal volume: ml/kg of predicted body weightPEEP: 5 cm of waterPeak airway pressure: < mm HgCVP 6-8 mm Hg or PAWP 8-12 mm HgRecruitment maneuver: prone or CPAP 40 cm H2O x 30 sec, repeated q 20 min x3Kirschbaum & Hudson, Prog Transpl 2010
56Management of Respiratory Function in the Organ Donor Goals of bronchoscopyEvaluate anatomy; Assess for foreign body and assist in removalDefine and locate aspirated material or apparent infection; Clearance of secretionsGoals of pulmonary hygienePrevent atelectasis with the use of q 2-4 hr ETT & supraglottic suction, percussion, postural drainage and lung-expansion techniques; Bronchodilators; ParalyticsUse of anti-infective & anti-inflammatory therapyUse of antibiotics based on results of Gram’s staining of aspirated secretionsMethyl-prednisolone 15 mg/kg IV plus 15 mg/kg IV q 6 hrsNaloxone 8 mg IV to minimize Neurogenic Pulmonary Edema (?)Kirschbaum & Hudson, Prog Transpl 2010
57Retrospective, all potential donors within a 5-year period 20 pts on ACV & 25 pts on APRVACV: RR breaths/min, TV 5-10ml/kg, 40%, PEEP 5APRV: 6-10 breaths/min, inspir pressure cm H2O and 40%Donated lungs:7/40 (18%) in ACV vs42/50 (84%) in APRV (p < 0.001)Partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FIO2) ratios on admission to the intensive care unit and following 100% oxygen challengeHanna, K. et al. Arch Surg 2011;146:
58Management of Liver donors Increased recipient death or re-transplantation:ABO incompatibilityHigh Na+ levels (> 155 mEq/L)Long cold ischemia timeLarge platelet transfusionsProlonged recipient PTTPloeg et al., Transplant 1993; Figueras et al., Transplant 1996; Kutsogiannis et al., Can J Anaesth 2006
59Management of Kidney donors + Immunomodulatory effects of catecholaminesLow dose dopamine (< 10 g/kg/min) or epinephrine or vasopressin (< 0.04 U/min)Colloids can be used (hydroxyethyl starch)Avoid SBP < mm HgKeep urine output > 1 ml/kg/hrAvoid nephrotoxic drugsDeman at al., Nephrol Dial Transplant 1999; Dictus et al., Clin Transplant 2009
60Intensivist-Led Management of Brain-Dead Donors Is Associated with an Increase in Organ Recovery for TransplantationIn the before period, 66 out of210 (33%) potentially available organs vs. 113 out of 258 (44%) potentiallyavailable organs in the after period, p = 0.008Singbartl et al, Am J Transpl 2011