1. Optimising the brain-stem dead donor
Dr Gerlinde Mandersloot
National Clinical Lead - Donor Optimisation
Dr Gerlinde Mandersloot
20th April 2012
Organ Donation Past, Present and Future 1

4. Challenges Physiological consequences of BSD
Organ Donation Past, Present and Future

5. ‘Collateral damage’ Hormonal Hypothermia Diabetes insipidus
Hypovolaemia
Hypernatraemia
T3 / T4 reduces
ACTH
Blood glucose
Hypothermia
Thyroid T3, 4 down
Euthyroid Sick Syndrome?
T3 treatment reduces anaerobic metabolism
Improves myocardial function
Probably important in longterm ODM
Steroid improves CVS responsiveness
Organ Donation Past, Present and Future 5

6. Incidence of organ involvement
Hypotension 81%
Diabetes insipidus 65%
DIC 28%
Cardiac dysrhythmias 25%
Pulmonary oedema 18%
Metabolic acidosis 11%
J Heart Lung Transplantation 2004 (suppl)
Organ Donation Past, Present and Future 6

7. Challenges Physiological consequences of BSD
Stabilisation and brainstem death testing
Organ Donation Past, Present and Future

8. Stabilisation of a patient to facilitate neurological examination
Difficulties in defining futility, especially in survivors
Replace by concept of ‘Best Interests’
Not only medical factors taken into account
Stabilisation of patient prior to BSD testing
Brainstem death testing is part of a neurological examination of the patient
Clinical in the majority of cases
Ancillary tests where required
Active management may be necessary in order to examine accurately
Continued care after BSD to explore possibility of donation
Integral part of every End of Life Care Plan

9. Challenges Physiological consequences of BSD
Stabilisation and brainstem death testing
Consistent donor optimisation
65% of units have 2 or fewer donor per year
23% of donors are from these units
Only 4% units have 10 or more donor per year, 28% of the total donor population
Organ Donation Past, Present and Future

10. Decent perfusion, good gases and BP, it can only Give me a CVP of 6-10
get worse
Make sure they aren’t
hypovolaemic, please
Give me a CVP of 6-10
Just get on with it!!
Lots of fluid please
-better function
earlier
Fluid overload is a
problem for us-if
we get goals with
less that’s good
I’d like 10-12
Too much-less than 6 10

11. Evidence Rosendale Transplantation 2003. 75 (4): 482-487
Totsuka Transplant Proc. 2000; 32;
High sodium in liver donor doubles graft loss
Rosendale Transplantation (4):
Protocol increased organs per donor 3.1 to Increased probability of transplant
Snell J Heart Lung Transplant 2008;27:662-7
54% of Australian lung donations used for transplant vs. 13% in UK
Active Donor Management is a developing area. It was always known that unstable donors and ‘crash’ retrieval of organs was associated with poor function. Totsuka in Pittsburgh showed that Sodium greater than 155 was associated with double graft loss over lower sodium, including those who had previously high sodium that were actively managed.
Organ Donation Past, Present and Future 11

12. Organ Donation Past, Present and Future

13. Organ Donation Past, Present and Future13

14. Unifying practice across the UK
Optimisation tool
Non-controversial (or not too controversial)
Not too complicated
One side of an A4 ?
Buy-in from retrieval / transplant community
Easy to audit
Extended Care Bundle with two components
Prescription: medical staff
Implementation
Critical care nurses
SN-ODs
‘Scouts’
Monitoring implementation
Unsurprisingly, a warm, well perfused donor on no vasopressor support with good blood results and no evidence of poor organ perfusion is likely to provide a full complement of well functioning organs. Converting unstable donors to this condition is the Challenge.
Organ Donation Past, Present and Future

15. Organ Donation Past, Present and Future
General ICU level staffing should be maintained, and in fact extra help may be required at bedside (equipment, monitoring, blood sampling)
Temperature measurement, active warming (Bair Hugger, water blanket, HME)
Methylprednisolone should be given. 15mg/Kg (1g for adult) to reduce inflammation. Also associated with reduced lung water in lung donors. Review drugs. Introduce insulin if not already in progress (ready to manage DI, inotropic) Stop non-essentials. Maintain indicated antibiotics. Start to wean vasopressors if possible.
A guideline should be used. ICS, Canadian, various cardiac. Although confusing, ukbt are trying to clarify minor differences. Overall management principles are non-contentious
More invasive monitoring may be required. This should have been discussed with relatives.
Organ Donation Past, Present and Future

16. Organ Donation Past, Present and Future

17. Priorities, if not already addressed
Assess fluid status and correct hypovolaemia with fluid boluses as required
Perform lung recruitment manoeuvre(s) as at risk of atelectasis following apnoea tests
Identify, arrest and reverse effects of Diabetes insipidus
Introduce vasopressin infusion: reduces Norepinephrine requirements and treats DI
Methylprednisolone, 15 mg/kg to max of 1g, as soon as possible
Organ Donation Past, Present and Future

18. Hormonal treatment Vasopressin Liothyronine (T3)
Reduction in other vaso-active drugs
Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time)
Liothyronine (T3)
No clear evidence for use
May add haemodynamic stability in very unstable donor
Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team
Methylprednisolone in all cases
Dose: 15 mg/kg up to 1g
Insulin
At least 1 unit/h (occasionally may need to add glucose infusion)
‘Tight’ glycaemic control ( mmol/l)
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19. Organ Donation Past, Present and Future

20. Monitoring optimisation
Implementation: use of care bundle
Adherence easy to monitor
Audit first 5 priorities
Results of optimisation evaluated
Number of organs retrieved
Increase in cardiothoracic organs retrieved
Quality of organs: graft function in recipients
Delayed graft function
Quality: biomarkers
Duration of graft function: long term project
Organ Donation Past, Present and Future