transplant.bc.ca DCD PANBC October 29, 2011 Greg Grant

2 Disclosures BC Transplant St Paul’s Hospital Mt. St. Jospeh’s Hospital Vancouver General Hospital BC Women’s Hospital BC Ambulance

3 OBJECTIVES -Understand the Types of Organ Donation -Understand the Differences between Brain Death and DCD

4 Types of Donation LivingKidneyLiver Brain Death Lung, Heart, Liver, Pancreas, Kidney Deceased Donation Cornea, Skin, Bone Kidney, Liver, Pancreas Islet Cells

Case History 49 year old man 49 year old man Witnessed collapse at 10:25 Witnessed collapse at 10:25 Struck Head and small abrasion Struck Head and small abrasion ALS arrived 1034 – PEA ALS arrived 1034 – PEA ROSC 10:55 - Down time 30 minutes ROSC 10:55 - Down time 30 minutes SPH – No criteria for angio – Inf/Lat ST Dep SPH – No criteria for angio – Inf/Lat ST Dep CT no acute bleed CT no acute bleed GCS 3 – Cooling Protocol GCS 3 – Cooling Protocol

History Exertional chest pain x 6 months Exertional chest pain x 6 months Increasing pain over last week Increasing pain over last week Elevated LDL, Hypertension, Mild Asthma, Elevated LDL, Hypertension, Mild Asthma, Fluticasone, Fluticasone, Alcohol 12 drinks per week Alcohol 12 drinks per week

Initial Labs Initial Bloods Initial Bloods –Troponin 0.09 –Lactate hours later 12 hours later –Troponin 22.5 –Lactate 1.4 –CK 1091

Course in ICU – Day 2 Cooling protocol stopped after 24 hours: Cooling protocol stopped after 24 hours: CT Head and Spinal protocol CT Head and Spinal protocol 24 hours : Very abnormal c/w diffuse ischemic injury 24 hours : Very abnormal c/w diffuse ischemic injury Neurology Consult Neurology Consult –Intact brain stem reflexes, no response to painful stimulation, arm movements with cough, - just coming off cooling

Course in ICU – Day 3 Diffuse myoclonus, needed suppression for ventilation Diffuse myoclonus, needed suppression for ventilation Treated with Midazolam and then transitioned to Propofol Treated with Midazolam and then transitioned to Propofol

Course in ICU – Day 4 Continued myoclonus Continued myoclonus EEG EEG –Off sedation for 8 hours –Burst suppression pattern noted without seizure activity CT Scan CT Scan –Progression with loss of grey-white differentiation, particularly in basal ganglia, –Further effacement of Sulci

Course in ICU – Day 5 Neurology Consult Neurology Consult –Myoclonus still present on face with occasional whole body movements. –Pupils brisk, dolls eyes intact, corneal intact, gag present. –Diffuse spasticity of arms and legs with sustained clonus in ankles and down going toes. –No withdrawl to painful stimulus. –Breathing on PS 5 peep 5, normothermic

Direction of Care Family meeting with Wife and support Family meeting with Wife and support Attending Intensivist discussed prognosis Attending Intensivist discussed prognosis Decision made to change to comfort care Decision made to change to comfort care Donation team met with family Donation team met with family Consent obtained for donation Consent obtained for donation Second Physician opinion re Comfort Care Second Physician opinion re Comfort Care

Consent Explanation of the procedure Explanation of the procedure –24 hours delay to obtain tests for donation –Extubation –Regular comfort care –When becoming unstable Heparin –If died in 90 minutes 2 physicians examine and declare –2 minutes in the ICU room –Travel to OR anti-room –Reconfirmation death – 2 physicians – –To OR

Comfort Care Family and friends present in the room during extubation Family and friends present in the room during extubation Patient died 23 minutes after extubation Patient died 23 minutes after extubation Family left shortly after declaration Family left shortly after declaration To OR for donation To OR for donation