Organ Donation Ali Salim, MD Associate Professor of Surgery 2012 - - PowerPoint PPT Presentation

Organ Donation

Ali Salim, MD Associate Professor of Surgery

2012 Clinical Congress 2012 Clinical Congress Presenter Disclosure Slide Presenter Disclosure Slide

Ali Salim, MD

American College of Surgeons ♦ Division of Education

Nothing To Disclose

Why should surgical intensivists know about donation??

The Problem

20,000 40,000 60,000 80,000 100,000 120,000 140,000 1 9 9 2 1 9 9 4 1 9 9 6 1 9 9 8 2 2 2 2 4 2 6 2 7 2 8 2 1 1

17 deaths/day 7000/year

Waiting list Transplants

Did you know??

 Centers for Medicare/Medicaid Services

& ACS

 Notification process  Declaration of brain death  Organ procurement organization (OPO)

relationship

 Performance Improvement (PI) program  Patient/family opportunity to donate

Cause of Death of Donors

40% 4% 35% 21%

Trauma Surgeons and Intensivists

Moncure, Organ Donation and transplant alliance, San Francisco November 2006

Intensivist No intensivist OTPD 4.05 3.30 OTPD-SCD 4.36 3.71 OTPD-ECD 2.43 1.50 Hearts tx’d 47% 49% Lungs tx’d 43% 14% ATN rate 12% 24%

Outline Outline

 Types of Donors  Declaration of Brain Death  Critical Care Management

Types of Donors

  Living Donors

Living Donors

  Deceased Donors

Deceased Donors

  Donors after Neurologic Determination of Death

Donors after Neurologic Determination of Death

  Donors after Circulatory Determination of Death

Donors after Circulatory Determination of Death

Types of Donors

Deceased donors 74% Living donors 26%

Types of Donors Types of Donors

 Deceased Donors

 Donors after Neurologic Determination of Death  Donors after Circulatory Determination of Death

Question

All of the following are required to make the diagnosis of neurologic death except

1.

Irreversible cause of brain injury must be present

2.

Absent brainstem reflexes

3.

Positive apnea test

4.

Patient temperature of 37 C

5.

Nuclear imaging for confirmation

Declaring Brain Death Declaring Brain Death

• 1. Pre-requisites
• 2. Clinical Examination
• 3. Ancillary Testing
• 4. Documentation & Organ Donation

Declaring Brain Death Declaring Brain Death

• 1. Pre-requisites
• 2. Clinical Examination
• 3. Ancillary Testing
• 4. Documentation & Organ Donation

Pre-requisites

 Known proximal cause & irreversibility  Absence of confounders

 Electrolyte, metabolic, endocrine, acid-

base disturbances

 Intoxication/drug effects

Pre-requisites

 Known proximal cause & irreversibility  Absence of confounders

 Electrolyte, metabolic, endocrine, acid-

base disturbances

 Intoxication/drug effects

Hypothermia > 36 C (from 32) Systolic Blood Pressure > 100 mm Hg (from 90)

Declaring Brain Death

• 1. Pre-requisites
• 2. Clinical Examination
• 3. Ancillary Testing
• 4. Documentation & Organ Donation

Clinical Exam: COMA

Adapted from: Wijdicks. NEJM. 2001

Clinical Exam: BRAINSTEM REFLEXES

Adapted from: Wijdicks. NEJM. 2001

Clinical Exam: BRAINSTEM REFLEXES

 Pupillary Light Reflex  Corneal Reflex  Gag Reflex  Oculocephalic Reflex (Dolls Eyes)  Oculovestibular Reflex (Cold Calorics)

Clinical Exam: APNEA Clinical Exam: APNEA

 Absence of a breathing drive

 Tested by CO2 challenge

 Prerequisites

 Normotension  Normothermia  Euvolemia  Eucapnia (35-45)  Absence of hypoxia

Clinical Exam: APNEA

Adapted from: Wijdicks. NEJM. 2001

Repeat ABG: 8 min

Arterial PCO2

• > 60 mm Hg OR
• 20 mm Hg increase over baseline

Apneic oxygenation- diffusion technique

Declaring Brain Death

• 1. Pre-requisites
• 2. Clinical Examination
• 3. Ancillary Testing
• 4. Documentation & Organ Donation

Ancillary Tests

Only if clinical exam incomplete, unreliable

• r unsafe

1.

Brain perfusion scan

• 2. EEG
• 3. Transcranial doppler
• 4. Conventional angiography

Declaring Brain Death

• 1. Pre-requisites
• 2. Clinical Examination
• 3. Ancillary Testing
• 4. Documentation & Organ Donation

Documentation & Donation

Time of death:

 pCO2 reached target value  Ancillary test interpretation

Documentation & Donation Documentation & Donation

Organ donation:

 Federal & State law requires contact with organ

procurement association

 OPO to approach family

Controversies

Second exam

 6 h repeat (1995)

No evidence-based interval

California – two physicians, two exams

Controversies

Second exam

 6 h repeat (1995)

No evidence-based interval

California – two physicians, two exams Newer Ancillary Tests

• MRI/MRA
• CTA
• Bispectral index monitoring (BIS)

Insufficient Evidence

Types of Donors

 Deceased Donors

 Donors after Neurologic Determination of Death  Donors after Circulatory Determination of Death

Timeline of DCDD

Maastricht Classification : Controlled vs. UnControlled

Abt PL et al. JACS 2006;203:208-225

Who are the Candidates?

 Patients with severe neurological injury

 Intracranial hemorrhage, stroke, anoxia, trauma

 Patients without neurological injury

 Degenerative neuromuscular diseases  End-stage cardiopulmonary diseases

Who are the Candidates?

 Do not meet the criteria for brain death  No chance for survival off the ventilator  Family and physician elect to withdraw

support

Where Will Withdrawal of Support Occur?

 Operating Room

 Family in attendance  Family not in attendance

 Intensive Care Unit

What Happens if the Patient Does Not Expire?

 Occurs in up to 20% of cases  Pre-donation discussion with family,

physicians and nurses

 Patient transferred to pre-determined unit  Treating team remains responsible for

patient care

Which Organs?

Presently; kidney, liver, pancreas Lungs and on rare occasions heart described

Abt PL et al. JACS 2006;203:208-225

Outline Outline

 Types of Donors  Declaration of Brain Death  Critical Care Management

Catecholamine surge ↑HR, ↑ BP, ↑ CO, ↑ SVR

DI DIC arrhythmias pulmonary edema acidosis hypothermia hypotension

Complications of Brain Death

0% 10% 20% 30% 40% 50% 60% 70% 80%

PLTs DIC pressor DI card isch acid renal failure NPE

Salim et al. Am Surg 2006;72:377-381.

DI DIC arrhythmias pulmonary edema acidosis hypothermia hypotension

Wood et al NEJM 2004;351:2730-2739

Cardiovascular Collapse Hemodynamic Instability

Organ Loss up to 25%

Why?

Hemodynamic instability

 Autonomic dysfunction  Hypovolemia  Aerobic to anaerobic metabolism  Release of vasoactive inflammatory mediators  Low levels of T3, T4, cortisol, insulin

 Reversal with replacement of T3

Cardiovascular Collapse??

 A fluid problem…….  A hormonal problem……  An attention problem……

Donor management is key to preventing collapse

New Terminology

 Catastrophic Brain Injury Guidelines (CBIG’s)

 Goal – to maintain hemodynamic stability in

patients with devastating brain injury

What are CBIG’s?

 Hemodynamic Management

 Invasive monitoring with endpoints

Hemodynamic Management

 Target criteria

 MAP > 60  PCWP 8-12  CVP 4-12  CI > 2.4  SVR 800-1200  Dopamine < 10

What are CBIG’s?

 Hemodynamic Management

 Invasive monitoring with endpoints  Hormonal therapy

 T3 or T4  Methylprednisolone  Vasopressin

Hormone Therapy

 Rapid IV bolus of:

 1 amp 50% dextrose  20 units insulin  2 g Solumedrol  20 mcg T4

 Continuous T4 infusion at 10 mcg/h

T4 only used in hemodynamically unstable donors (combined vasopresssor dose > 10mcg/kg/min)

Actions of T3

What are CBIG’s?

 Ventilator Management

 Appropriate tidal volumes (10 cc/kg)

 Prevent atelectasis

 Recruitment maneuvers  Fluid restriction (diuretics)  Bronchoscopy (frequent suctioning)  Prevent aspiration (elevate HOB)

What are CBIG’s?

 Management of complications

 Anemia  Coagulopathy  DI  Electrolyte imbalances  Arrhythmia's

Salim A. J Int Care Med. 2008

Critical Care Endpoint DMG

• 1. Mean Arterial Pressure (MAP)

60 – 100 mmHg

• 2. Central Venous Pressure (CVP)

4 – 10 mmHg

• 3. Ejection Fraction (EF)

> 50%

• 4. Vasopressor use

 1 and low dose

• 5. Arterial Blood Gas pH

7.3 – 7.45

• 6. PaO2:FiO2 (P:F)

> 300 on PEEP = 5

• 7. Serum Na

135 – 160 mEq/ L

• 8. Blood Glucose

< 150 mg/ dL

• 9. Hemoglobin (Hb)

> 10 mg/ dL

• 10. Urine Output (averaged over 4 hours)

1-3 cc/ kg/ hr

Organ Donor Timeline

Injury

1st Brain death 2nd Brain Death Family consent

Organ Retrieval OPO Management

CVC CBIG

Organ Donation

 Know the types of donors  Know how to declare brain death  Know who to call after brain death  Know how to manage catastrophic brain

injuries