1. Donor Management: From Organ Referral to Organ Recovery Matt Harvey RN, BSN, CCRN, CPTC, CTBS Donation Coordinator, LifeSource Kate Kishish Advanced Practice Donation Coordinator, LifeSource

2. Objectives The organ referral process The new organ referral call template Catastrophic brain injury guidelines Family connections and approach Organ donor management Preparation for the OR

3. Gift of Life LifeSource Mission and Vision Mission: We save lives and offer hope and healing through excellence in organ and tissue donation. Vision: Everyone shares the gift of life.

4. Gift of Life ND SD MN WI Douglas County St. Croix County Pierce County LifeSource Donation Service Area

5. Gift of Life Alexa’s Story

6. Gift of Life Organ and Tissue Donation Statistics More than 122,180 Americans are waiting for a life- saving organ transplant. –< 1 year 93 –1-5 years 583 –6-10 years 399 –11-17 years 851 –18-35 years 10,511 –35 years + 109, 738 (~45% 50-64 years) A new name is added to the list every 10 minutes. On Average 22 people die each day – every 65 minutes - waiting for a second chance at life. –89 pediatric deaths in 2010 One in 20 Americans will need some type of medical tissue transplant in their lifetime.

7. Gift of Life The Referral Process When to call 1-800-24-SHARE: –If the family mentions or has questions about donation. –Refer all patients within one hour who meet the following: Ventilated Severe neurological injury Loss of 2 or more brain stem reflexes or a GCS < 5 –After initial referral, if decision is made to withdraw life support. –As soon as possible on all patients after asystole for tissue or eye donation.

8. Gift of Life Brain Stem Reflexes: Pupils Cough/gag Corneal Pain response Doll’s eyes Respiratory drive

9. Gift of Life Would you refer?? 3-month old male. Found down at home. Diagnosis-SIDS. Pupils react, breaths over vent, no cough or gag when suctioned, no response to pain stimulation.

10. Gift of Life Would you refer?? 10-year old female. Drowning. Prognosis is grave. Not breathing over the vent. Mom asks: “If things deteriorate further, does she have the opportunity to be an organ donor?”

11. Gift of Life Regulations All deaths must be referred - 20 weeks gestation and older CMS requires that patients meeting the triggers be referred. Please do not mention donation to the family. –CMS regulations – and your O/T/E donation policy - require donation to be discussed with the family by someone from the OPO/LifeSource. –The Donation Coordinator will collaborate with the health care team to create a communication plan when donation becomes an opportunity.

12. Gift of Life Standardized Huddle Process Donation Assessment Huddle –Onsite or telephone response, after an evaluation Family Support Huddle –Prior to family discussion Family Outcome Huddle –After family discussion

13. Gift of Life Brain Death Complete and irreversible cessation of all brain function including the brain stem. Sanford Policy: NUMBER: B-075 –13 years to Adult: One unequivocal exam consisting of a clinical and apnea test all that is required. Brain death checklist available on units. Legal time of death. Sanford Policy: NUMBER: B-075 –4.2.2.1 Time of death will be recorded as the time brain death is confirmed.

14. Gift of Life Normal cerebral blood flow

15. Gift of Life Brain death

16. Gift of Life After Brain Death: Huddle to assess family dynamics Collaborative approach Discussion of donation Authorization

17. Gift of Life Donor Management Collaborate with staff Medical Examiner conversation “It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings..” Tissue typing and serology testing

18. Gift of Life Catastrophic Brain Injury Guidelines (CBIGs) Purpose: To avoid the instability of potential donors prior to and during brain death To preserve the opportunity for successful organ transplants

19. Gift of Life Catastrophic Brain Injury Guidelines (CBIGs) Blood Pressure –Goal: Maintain SBP>90 MAP >60 Urine Output –Goal: >0.5ml/kg/hr and <300ml/hr Vent Settings –Goal Maintain PO2>100, pH7.35 – 7.45

20. Gift of Life Catastrophic Brain Injury Guidelines (CBIGs) Lab Studies –Goals to Maintain Sodium 134 – 145 mmo/L Potassium 3.5-5.0 mmo/L Magnesium 1.8-2.4 meq/L Phosphorus 2.0-4.5 mg/dl Ionized Calcium 1.12 -1.30 mmo/L Glucose 60 -180 Hemoglobin > 10.0 g/dL and HCT > 30% –Protime, <18.0 –Fibrinogen > 120 –Platelets > 80 Temperature 36.5 – 37.5°

21. Gift of Life Two ways to donate: Donation after Brain Death Donation after Cardiac Death (DCD) Important for new staff to know the difference

22. Gift of Life Donor Management Goals include: –CVP <12 –Core temperature 100.5F –Urine output >0.5ml/kg/hour or <3ml/kg/hour –SaO2 <96% –Normal BP and HR for age Organ Evaluation

23. Gift of Life Brain Death Organ Donor Management LifeSource colaborates with staff on management Evaluates organ function Allocates organs to recipients Works with OR staff and surgeons to plan recovery time Case time approximately 24-36 hours

24. Gift of Life Donor Management CVP <12 SBP age appropriate EF ≥ 50% PaO2 >300 on FiO2 100% pH 7.35-7.50 Glucose ≤ 180 Clear CXR bilaterally ≤ one vasopressor Na ≤ 155 U.O. at least 0.5ml/kg/hr

25. Gift of Life How do we reach these goals? Aggressive donor management!!! YOU!!

26. Gift of Life Donor Management Pathway Utilized by Donation Coordinators Standardize care Best Practices Meet donor management goals (Dmgs) Optimizes organs transplanted per donor

27. Gift of Life Blood Pressure Choice of vasopressor: Dopamine, Levophed or Neosynephrine (if tachycardia present) Rationale: less vasoconstriction to minimize hypo-perfusion of abdominal organs

28. Gift of Life Levothyroxine (T4) Brain death is linked to metabolic, endocrine, and hemodynamic disturbances. Decrease in levels of T4 can lead to hemodynamic instability. T4 protocol is an important component of hemodynamic management. Goal of Levothyroxine: –decrease vasopressor needs –create better hemodynamic stability.

29. Gift of Life Maintain Urine Output > 0.5ml/kg/hr or < 3/ml/hr Diabetes Insipidus Treatment of Choice: Vasopressin IV drip-0.5-3 milli- units/kg/hour Crystalloids Rationale: Negative fluid balance leads to hypotension

30. Gift of Life Monitor and treat electrolytes maintaining the following: Sodium 134-145mmol/L Potassium 3.5-5.0mmol/L Magnesium 1.8-2.4meq/L Phosphorous 2.0-4.5 mg/dl ICA 1.12-1.3 mmol/L Rationale: Maintaining electrolyte balance maintains hemodynamic stability and promotes organ function and graft survival.

31. Gift of Life Maintain PO2 > 100 & pH 7.35-7.45 Adequate ventilation and normal acid/base balance Use of link vest and nebs Rationale: Promotes hemodynamic stability and overall organ function. Aggressive respiratory hygiene and respiratory treatments to prevent bronchospasm.

32. Gift of Life Goals for the potential Lung Donor PaO2 >400 on FiO2 100% and PEEP 5 CVP <12 Clear CXR bilaterally Gram stain/culture

33. Gift of Life Lung Recruitment Increase PEEP 8-10 Early bronch! Recruitment maneuvers Decrease PEEP to 5 for O2 challenges Utilize LINK VEST Q2hours Collaborate with medical staff, RT, and YOU!

34. Gift of Life O’Connor, 2006 “Critical care personnel play an essential role in optimizing management of organ donors and maximizing the supply of organs for transplantation.”

35. Gift of Life Organ Allocation Complex Process Over 122,000 people waiting National list

36. Gift of Life Organ Allocation Donor Information Recipient Information United Network for Organ Sharing (UNOS) United Network for Organ Sharing (UNOS)

37. Gift of Life Organ List

38. Gift of Life When are we going to the OR??

39. Gift of Life Procurement Surgery Recovery takes place at donor hospital: –Surgeons from transplant centers –LifeSource Surgical Recovery Coordinator –LifeSource Organ Donation Coordinator

40. Gift of Life Organ Transport Tolerated Cold Times: Heart 4 hours Lungs4-6 hours Liver12-24 hours Pancreas 24 hours Kidney24-48 hours

41. Gift of Life Donor Family Services

42. Gift of Life Case Study Our Story of Pediatric Donation and Transplantation

43. Gift of Life Donor 15 year old male admitted following a motor vehicle accident on 01/03/2013; mom driving Head trauma Air-lifted to local trauma center 01/03 @ 1826 Next of kin maternal grandparents Referral made 01/04 @ 0022 Brain death declared on 01/08/2013 @ 1522

44. Gift of Life Lung Evaluation Admission chest ct: bilateral opacities and consolidation Chest x-ray: left lung clear, right with infiltrates and pleural effusion Baseline ABG; PO2 338 1 st bronchoscopy completed on 01/08/2013 @ 1100 by Dr. Baisch Pediatric Intensivist –collapsed right lung with large amount of mucous. ABG results; PO2 361

45. Gift of Life COLLABORATION Donor MDRTPharmDRNDCChaplainFSCHUC

46. Gift of Life Donation Champion Dr. Steve Baisch Pediatric Intensivist Children’s Hospitals and Clinics of Minnesota A true champion will fight through anything… ~Floyd Mayweather, Jr

47. Gift of Life Lung Management Every 2 hour cpt/nebs/suction/turning Every 4 hour chest x-ray and ABGs Every 4 hour lung recruitment measures Repeat bronchoscopy (Dr. Baisch’s recommendation) 01/09 @ 0700 –Left lung looks beautiful. –Right lung suctioned mucous.

48. Gift of Life Continued Evaluation Post bronch ABG; PO2 353 PEEP 5 FIO2 100 Continued Recruitment Continued aggressive lung management Lung allocation initiated @ 1150 CXR 01/09 1650- continued decrease in right lung infiltrate

49. Gift of Life Final Evaluation Final blood gas prior to OR; PO2 405 Chest x-ray: left lung clear, right lung with continued decrease of infiltrate Bronch in OR by recovering surgeon: “Lungs are clear and look good!” Repeat ABG PO2 497 Time from 1 st bronch to OR was 40 hours!

50. Gift of Life Moment of Silence The Family would like you to know that Bryce was a boxer. He loved to snowboard. He was a funny unique person. He had a large family of people who loved him.

51. Gift of Life Organ Disposition Bilateral Lungs Heart Liver- split to 2 recipients Kidneys Pancreas

52. Gift of Life Questions?