1. Preserving the Donation Opportunity

2. Shared Goals Maintain urine output Maintain oxygenation Maintain normothermia Maintain normoglycemia Prevent/treat infection Optimize organ perfusion and medical suitability

3. What are the most common Challenges 1.Hypotension (hypovolemia, vasodilatory shock) 2.Diabetes Insipidus / Hypernatremia 3.Oliguria 4.Metabolic (acid/base, electrolytes, glucose) 5.Hypoxemia, Ventilator settings 6.Hypothermia

4. Hemodynamics Goal: Maintain Systolic BP>90; CVP of 6-8 mmHg Hypotension /hypertension Heart rate fluctuations-dysrhythmias Coagulopathy Interventions -CVP < 6 and (H &H) normal Lactated Ringers or Normal Saline fluid bolus of 500 cc over 30 minutes for SBP < 90 mmHg. -CVP < 6 and (H&H) < 8, then administer 1-2 units of PRBC’s

5. Vasoactive IV fluids/drips Vasopressors commonly used are: –Dopamine –Epinephrine –Neosynephrine –Levophed/Norepinephrine –Vasopressin (AVP) low dose

6. Goal: Maintain PO2>100mm Hg and pH7.35-7.45 Potential Problems: –Hypoxemia –Acid Balance Disturbances –Neurogenic pulmonary edema Interventions: –Tidal volume of 7-10cc’s/kg –Steriods –Suctioning; in-line treatments –Therapeutic bronchoscopy –PEEP (5) Oxygenation

7. Acid- Base and Electrolytes Goals pH -7.35-7.45 Electrolytes- Na, K, Ca, Mg, P - WNL Glucose- < 150 U/O 1-3 ml/kg/min Interventions Adjustments of Vent and/or Na Bicarbonate IV Appropriate IVF – LR, NS,.5 NS (Depending on Na, K, Gluc) Appropriate supplementation FOR K +, Ca ++, Mg ++,P +++ Insulin –bolus and/or continuous drip DDAVP or Fluids, Diuretics, Mannitol

8. Goal: Maintain Urine Output 1ml/kg/hr in the Adult or 2ml/kg/hr in the Child Potential Problems: –Diabetes insipidus –Hyperglycemia Interventions: –Volume replacement –DDAVP / vasopressin –K+ replacement Urine Output

9. Goal: Maintain Core Temperature Between 97-100 F Hypothermia Hyperthermia Interventions Heating/cooling blankets Temperature

10. Other IV fluids (drips) Dobutamine--used to treat heart failure, may be combined with dopamine. May be used as a pressor in pediatric patients Vasopressin--used to treat shock, diabetes insipidus; enhances the effectiveness of other vasoactive medications. May be used as a pressor in pediatric patients Nipride--used to treat hypertension Esmolol, Verapamil, Adenosine---used to correct irregular heartbeats

11. Infection Goal: Ensure Absence of Infection Use of Broad Spectrum Antibiotics Obtaining cultures as needed Blood Sputum Urine Monitor WBC’s

12. Temperature Goal: Maintain Core Temperature Between 97-100 F Hypothermia Hyperthermia

13. Family Preparation

14. What can You Do Check yourself Offer open honest communication Have them tell you what they understand the situation to be Offer them support by involving pastoral Care

15. Allowing families time to process the death and brain death explanation is IMPORTANT  “Decoupling” - separating the brain death explanation from the request for organ donation  Decoupling may be a valuable tool in obtaining consent for donation  Siminoff, et al concluded that the most important factor in obtaining consent was time spent with the OPO

16. Creating the Bridge  Hospital is an advocate of organ donation  Patient Care Conferences  Timely notification  Appropriate requester  Families satisfaction with quality of care  Frequent communication  Time with loved one  Understanding of brain death *Source: JAMA July 4, 2001 and Collaborative High Leverages Changes

17. Pre-request Conference A sensitive, timely and informed consent How to accomplish…. “huddle” with hospital staff to determine:  The key decision maker  Family’s understanding of the grave prognosis  Review communication plan  Determine who, when, where and how the communication will occur  Revise the plan as needed

18. Guiding principles For the family, their grief and loss are primary, not the donation— and all of our actions are guided by this awareness. We are not taking something from families. We are giving information to families about an important opportunity: To consider the opportunity of donation

19. Wouldn’t it be Nice?