SLIDE 1
Faith Borunda, MSN-RN, CCRN, CPTC Senior Director of Regional Operations Southwest Transplant Alliance
114,401
in the U.S. wait for a lifesaving transplant…
The Never-Ending Need
* United Network for Organ Sharing (UNOS)
Faith Borunda, MSN-RN, CCRN, CPTC Senior Director of Regional - - PowerPoint PPT Presentation
Faith Borunda, MSN-RN, CCRN, CPTC Senior Director of Regional - - PowerPoint PPT Presentation
Faith Borunda, MSN-RN, CCRN, CPTC Senior Director of Regional Operations Southwest Transplant Alliance The Never-Ending Need 114,401 in the U.S. wait for a lifesaving transplant * United Network for Organ Sharing (UNOS) The Never-Ending
SLIDE 2
SLIDE 3
11,840
Texans need a lifesaving transplant…
The Never-Ending Need
* United Network for Organ Sharing (UNOS)
SLIDE 4
The Never-Ending Need
* United Network for Organ Sharing (UNOS)
Another person is added to the transplant wait list
SLIDE 5
22 people die everyday waiting for the organ that never comes
The Never-Ending Need
* United Network for Organ Sharing (UNOS)
SLIDE 6
Problem Statement
* United Network for Organ Sharing (UNOS)
- -Transplantation has become the standard treatment for
many patients with organ failure, however, lack of viable
- rgans for transplantation in the United States results in an
increased number of deaths among potential donor recipients each year (UNOS, 2017).
SLIDE 7
Pathophysiology of Brain Death
SLIDE 8
Optimization of the function and viability of all transplantable organs
Stabilization of the potential donor to allow for brain death testing or DCD efforts
Implementation of a collaborative process between the OPO and hospital staff to increase the chances of life-saving transplantation
What is pre-donor management?
SLIDE 9
Management of a potential donor
Support homeostasis
Stabilize hemodynamics
Optimize donor organ perfusion
SLIDE 10
How can you optimize the process?
Make sure necessary orders exist and are available for ideal patient care Critical Care treatment to support the patient through the brain death process
Continue to follow your Catastrophic Brain Injury Guidelines (CBIGS) or Traumatic Brain Injury Protocol (TBI) Ex: dopamine and vasopressin
SLIDE 11
Autonomic/Sympathetic Storm
Catecholamine release Tachycardia Elevated cardiac output Vasoconstriction Hypertension
SLIDE 12
Leads to vasodilation without the ability to vasoconstrict or shiver (loss of vasomotor tone)
Impaired temperature regulation leading to most likely hypothermia
Which then leads to problems with the pituitary gland…
Results of Hypothalamus failure
SLIDE 13
Pituitary failure
Resultant hypovolemia and electrolyte imbalances
Diabetes insipidus with loss of ADH production
SLIDE 14
Thyroid failure
Hemodynamic instability
Cardiac instability
Coagulopathy
SLIDE 15
Intensive Care Management
Rule of 100s SBP > 100 mm Hg HR < 100 UOP > 100 mL/hr PaO2 > 100 mm Hg
Aggressive resuscitative therapy to restore and maintain intravascular volume SBP > 90 mm Hg (MAP > 60 mm Hg) CVP ~ 10 mm Hg
SLIDE 16
Intensive Care Management
Neurogenic pulmonary edema Catecholamine storm Left-sided heart pressures exceed pulmonary pressure Interstitial edema/alveolar hemorrhage
SLIDE 17
Intensive Care Management
Release of tissue plasminogen activator Coagulopathy and possibly DIC
SLIDE 18
Intensive Care Management
Hypotension Crystalloids vs. colloids Dopamine/Neosynephrine Vasopressin Thyroxine (T4)
SLIDE 19
Intensive Care Management
T4 protocol Bolus: 2 grams Methylprednisone 20 mcg T4 (Levothyroxine) IVP 20 units of Regular Insulin 1 amp D50W Infusion: 400 mcg T4 in 500 cc NS Run at 25 cc/hr (20 mcg/hr) Titrate to keep SBP >100
Monitor Potassium levels closely!
SLIDE 20
Intensive Care Management
Inotropic Preference Dopamine and Neosynephrine
Vasopressin Protocol May initiate with a 4 Unit Bolus 1-4 Units/hour – titrate to keep SBP >100 or MAP >60 Replace Urine 1:1 for Diabetes Insipidus
SLIDE 21
Intensive Care Management
Impaired gas exchange Maintain PaO2 >100 and an oxygen saturation >95% PEEP 5cm, increase PRN HOB >30 degrees Increase ET cuff pressure Aggressive pulmonary toilet Avoid over-hydration Lung protective strategies Avoid oxygen toxicity CT and bronchoscopy sometimes necessary
SLIDE 22
Intensive Care Management
Electrolyte management Hypokalemia Hypernatremia Hypocalcemia Hypomagnesemia Hypophosphatemia
SLIDE 23
Intensive Care Management
Hypothermia Continuous temperature monitoring and correction
SLIDE 24
Intensive Care Management
Anemia Prefer an H/H >10 & 30% Transfuse and reassess Identify source of blood loss and treat
SLIDE 25
The Heart of A Champion Stabilization is Key to saving Lives Normal Fluid Balance and Electrolytes to facilitate Brain Death Testing Pronouncement of Brian Death removes the burden from the family Organ Donation helps families through their grieving process
SLIDE 26
The Heart of A Champion STA’s Common Goal is to Save Lives! Let’s work together, as a TEAM to maximize the viability of donor organs for transplant
SLIDE 27
References
- Determining Optimal Threshold for Glucose Control in Organ Donors after Neurologic Determination of Death:
A United Network for Organ Sharing Region 5 Donor Management Goals Workgroup Prospective Analysis – Article – Sally MB, Ewing T, Crutchfield M, et al. (2014), J Trauma Acute Care Surg, 76(1): 62-68, 69. doi: 10.1097/TA.0b013e3182ab0d9b.
- ICU Management of the Potential Organ Donor: State of the Art – Article (subscription) – Maciel, C. and Greer,
- D. (2016). Current Neurology and Neuroscience Reports, 16(9). https://doi.org/10.1007/s11910-016-0682-1
- Management of the Heartbeating Brain-Dead Organ Donor – Article – McKeown, D., Bonser, R. and Kellum, J.
(2012). British Journal of Anaesthesia, 108, pp.i96-i107. https://doi.org/10.1093/bja/aer351
- Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine / American College of
Chest Physicians / Association of Organ Procurement Organizations Consensus Statement – Article – Kotloff RM, Blosser S, Fulda GJ, et al. (2015), Crit Care Med, 43(6): 1291-1325. doi: 10.1097/CCM.0000000000000958.
- Organ Donation in Adults: A Critical Care Perspective – Article (subscription) – Citerio, G., Cypel, M., Dobb, G.,
Dominguez-Gil, B., Frontera, J., Greer, D., Manara, A., Shemie, S., Smith, M., Valenza, F. and Wijdicks, E. (2016). Intensive Care Medicine, 42(3), pp.305-315. https://doi.org/10.1007/s00134-015-4191-5
- The Impact of Meeting Donor Management Goals on the Development of Delayed Graft Function in Kidney
Transplant Recipients – Article – Malinoski DJ, Patel MS, Ahmed O, et al. (2013), Am J Transplant, 13(4): 993-1000. doi: 10.1111/ajt.12090. Epub 2013 Feb 13.
SLIDE 28