C C Care of the Potential Organ Care of the Potential Organ f h - - PowerPoint PPT Presentation

C f h i l O C f h i l O Care of the Potential Organ Care of the Potential Organ Donor Donor Donor Donor

 There is a disparity between the number of

t ti l d d th t f t l potential organ donors and that of actual donors.

 In order to address the shortage, we must

recover organs that offer the greatest likelihood of successful outcomes for recipients

 Optimize care of the potential donor

i l i C i i l i l i C i i l Timely Treatment is Critical Timely Treatment is Critical

Th f t d di d t t t d

 The use of standardized treatments and

algorithms that are focused on managing th h d i t t f th d h the hemodynamic status of the donor have proved to be beneficial in maintaining the t bilit f t ti l d stability of potential donors.

 Standardization protocols takes organs that

were unsuitable and makes them more suitable

 Protocols minimize the loss of donors

during maintenance and brain death

All b fi f i l All b fi f i l All organs benefit from optimal All organs benefit from optimal hemodynamic Management hemodynamic Management hemodynamic Management hemodynamic Management

 Increase the numbers of organs procured  Improves graft function in the recipients  Improves graft function in the recipients.

Cardiovascular Effects Cardiovascular Effects

 Brain death adversely affects the

di l t cardiovascular system

 Ischemia in the medulla provokes

sympathetic surge to maintain cerebral perfusion pressure

 Brain ischemia is associated with necrosis

that is concentrated in the left ventricular sub endocardium and ischemic changes in the EKG

Goals of Management Goals of Management

 Achieve Normovolemia  Maintain blood pressure  Optimize cardiac output utilizing the least

amount of vasoactive drug support

Heart Donation Heart Donation

 Heart donors should not be excluded on the

i iti l EKG initial EKG.

 Hearts can recover left ventricular function

after herniation

i Hypotension Hypotension

 Associated with decrease in organ function  Common in hypovolemic donors  Seen with patient in Diabetes Insipidus who

are not receiving ADH (vasopressin)

 Give PRBC for Hematocrit of 30 for

G ve C o e

• c
• 30 o
• xygen delivery

 Utilize 0 45 NS for hypernatremia  Utilize 0.45 NS for hypernatremia

Hyperglycemia Hyperglycemia

 Physical stress, increase in the levels of

t l t h d t counter regulatory hormones, dextrose solutions, peripheral resistance to insulin all t ib t t h l i contribute to hyperglycemia

l i l i Hyperglycemia Hyperglycemia

 Discourage use of large amounts of

d t l ti t ti dextrose solutions – creates an osmotic diuresis and electrolyte abnormalities

 Maintain Blood Glucose levels between 80-

150 with an Insulin Infusion

l id l id Fluid Management Fluid Management

 Minimally positive fluid balance is

i t d ith hi h t f l associated with higher rates of lung procurements

 Colloid solutions are recommended to

sustain oxygenation and minimize the accumulation of pulmonary edema

Vasoactive Medications Vasoactive Medications

 When adequate volume resuscitation

ti di ti

• ccurs, vasoactive medications are

necessary if hypotension continues

 Low dose vasoactive drug support has

shown a reduction in the rates of acute rejection after renal transplant and improved rates of graft survival.

Vasopressin Vasopressin

 Arginine vasopressin is an alternative

th t b d i i t d t vasopressor that can be administered to support potential donors who have h t i hypotension

 Enhances vascular sensitivity to

catecholamines while maintaining hemodynamic stability.

Vasopressin Vasopressin

 Anti Diuretic effects  Decreases serum osmolarity  Decreases sodium levels  Maintains blood pressure  Reduces the need for vasoactive  Reduces the need for vasoactive

medications

Hormone Replacement Therapy Hormone Replacement Therapy

 Dysfunction of the hypo thalamic pituitary

d l i d i b i d th lt i th adrenal axis during brain death results in the depletion of thyroid hormone and cortisol l di t d t i ti leading to organ deterioration

 Low levels of thyroid hormone may impair

mitochondrial function and the production

• f ATP.

 .

Hormone Replacement Therapy Hormone Replacement Therapy

 Hormone replacement improves

di l l bilit d EKG cardiovascular lability, reduces EKG abnormalities, reduces the acid base di t b d i th it bilit f disturbances and improves the suitability of

• rgans for transplantation

 Hormone replacements therapy was shown

to diminish requirements for vasoactive therapy

Hormone Replacement Therapy Hormone Replacement Therapy

 There also has been a correlation between

th b t ti l b f d the substantial number of organs recovered and the use of HRT

 Utilize HRT in donors that have an EF of

less than 45% and require multiple vasopressors or high dosage of vasoactive medications.

Cardiac Arrhythmias Cardiac Arrhythmias

 Common and attributable to conduction

t i th t i d t th system necrosis that is secondary to the sympathetic surge that results from d ll i h i t b li di t b medullary ischemia, metabolic disturbances

• r electrolyte abnormalities

 Arrhythmias are resistant to antiarrthymic

treatment and occur frequently during herniation, try to correct the cause

Arrhythmias Arrhythmias

 Lidocaine/Amiodarone have shown to be

ff ti f V t i l A h th i effective for Ventricular Arrhythmias

 Supraventricular Arrhythmias respond

better to Amiodarone

 Brady Arrhythmias are the result of vagus

nerve disruption and do not respond to atropine, must use isuprel or epinephrine.

Respiratory Effects Respiratory Effects

 Optimal Management of donors respiratory

f ti ill h th lit f ll function will enhance the quality of all

• rgans to be donated

 Low arterial CO2 and high minute

ventilation used to treat head injuries should be normalized in the donor.

 Normalization limits the potential for

ventilation induced injury to the lungs

Respiratory Management Respiratory Management

 End Inspiratory Plateau pressure should be  End Inspiratory Plateau pressure should be

limited to less than 30 cm of water. A l i d E i Fl id

 Atelectatasis and Excessive Fluid

Resuscitation are two correctable causes of h i h f l d h f hypoxemia that often preclude the use of lungs for transplant.

 Bronchoscopy, suctioning, and judicious

fluid resuscitation are all interventions to improve lung outcomes – Maintain CVP 6- 8 mm Hg. with diuretic therapy.

Respiratory Management Respiratory Management

 Albuterol has been show to augment the

l f l d d f l i clearance of pulmonary edema and useful in conjunction with diuretics

 Corticosteroids (15 mg/kg) may also

stabilize lung function.

Goals of Mechanical Ventilation Goals of Mechanical Ventilation

 Fraction of inspired oxygen – 0 40  Fraction of inspired oxygen 0.40  Partial pressure of arterial O2 - >100 mm Hg

i l f CO2 34 40 G

 Partial pressure of CO2 34-40 mm HG  Arterial pH 7.35-7.45  Tidal volume 8-10 ml/kg  PEEP 5 cm H2O  PEEP 5 cm H2O  Static airway pressure - <30 cm H2O

Goals of Bronchoscopy Goals of Bronchoscopy

 Evaluate anatomy  Assess for foreign body and remove  Define and locate aspirated materials,

secretions, or infection

 Clear secretions

C e sec e o s

Goals of Pulmonary Hygiene Goals of Pulmonary Hygiene

 Prevent atelectasis with the use of suction,

i d l i t h i percussion and lung expansion techniques

Prevent Hypernatremia Prevent Hypernatremia

 Hypernatremia in the donor can adversely

ff t th f ti f th t l t i th affect the function of the transplant in the recipient

 DI results from the absence of vasopressin

after the destruction of the posterior pituitary gland.

Diabetes Insipidus Diabetes Insipidus

 Contributes to hyperosmolarity,

h d i i t bilit l t l t hemodynamic instability, electrolyte abnormalities as a consequence of excessive l f f t loss of free water

 Treat with Arginine Vasopressin to produce

vasoconstrictive and antidiuretic effect – administer as a continuous infusion

Hypothalamic Thermoregulation Hypothalamic Thermoregulation

 Adverse effects of hypothermia include

di d f ti h th i cardiac dysfunction, arrhythmias, coagulopathy, cold induced diuresis.

 Maintain core temperature at higher than 35

degress or 95 F.

 Use warming fluids, blankets.

Key Management Parameters Key Management Parameters

CVP 5 10

• CVP

5-10

• Urine output 0.5-3.0 ml/kg/hr
• SBP

> 100 & MAP > 65

• Sodium

< 155 Sodium 155

• Glucose

< 140 H 7 35 7 45

• pH 7.35 - 7.45
• O2 Sats > 95 %

Care of the Donor is Care of the Donor is Si l C f l i l Si l C f l i l Simultaneous Care of Multiple Simultaneous Care of Multiple Recipients Recipients Recipients. Recipients.

 Vigilant medical management ensures that

th t t b f b the greatest number of organs can be recovered in the best possible condition to id ti l t f th i i t provide optimal outcomes for the recipients.

 Current therapies enhance successful organ

procurement