Presenters Lydia Lam MD LAC USC Medical Center Keith Markillie RN OneLegacy Breakout Session C Preserving the Opportunity Before and After Consent Preserving the Opportunity ID: 935565
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Slide1
Moderator:Adam Teller, OneLegacyPresenters:Lydia Lam, MD, LAC + USC Medical CenterKeith Markillie, RN, OneLegacy
Breakout Session
C:
Preserving the Opportunity –
Before and After Consent
Slide2Preserving the Opportunity:Before and After ConsentModerator:
Adam Teller, Procurement Transplant Coordinator
OneLegacy
Slide3“How To Be”Being in Action!The Answers Are In the Room“Report out” on Questions to Run-on: Scribe Spokesperson
All Teach / All Learn
Slide4Question to Run-OnHow do your standards of care preserve the opportunity for the gift of life?
Slide5ObjectivesBy the end of this presentation, the attendee will be able to:Understand the impact of a DNR and donationRecognize pathophysiology of traumatic brain injuryAnticipate common interventions for optimal donor management
Slide6Preserving the Opportunity:Before and After ConsentLydia Lam, MD
Division of Acute Care Surgery and Surgical Critical Care
Los Angeles County + USC Medical Center
Los Angeles, CA
Slide7DNR DecisionWhat does the DNR decision mean to the family?No Chest Compressions?No Shock?
No Medications?
No Labs?
No Fluids?
No Diagnostic Tests?
Allow natural death?
“Do not harm?” or “Do not treat?”
Slide8DNR DecisionWhat does the DNR decision mean to the healthcare team?Routine decision in the Critical Care UnitStop all treatment immediately or no aggressive treatment after cardiac arrest?DNR decision has its own “culture of understanding” that varies by hospital, unit, physician and nurse
“Do not harm?” or “Do not treat?”
Slide9Donation DecisionUnderstanding the donation option clinically:Maintaining blood pressureNormalizing electrolytesManaging oxygenation and organ perfusion
Balancing Intake and Output
Assessing brain death accurately
How can a family give the gift of life when the organs are not preserved for transplantation?
Slide10Balancing DNR and DonationTraumatic Brain Injury (TBI) Overall Clinical Deterioration+ DNR Decision by Next-of-Kin + Fatal Diagnosis (Brain Death?)
How is this interpreted in your ICU?
What can be expected from your team?
How can we be proactive for this family?
Slide11Pathophysiology of Traumatic Brain InjuryPhysiologic collapse frequently accompanies TBI: Hypotension Endocrine Dysfunction
Pulmonary Dysfunction
Hematologic Dysfunction
Slide12Pathophysiology of Traumatic Brain InjuryHypotension:“Autonomic storms”Smooth muscle ATP depleted = vasomotor hypotension
Anticipate BP spike followed by BP drop
Titrate Vasopressors
Diuretics
Consider Fluid Resuscitation
Closely monitor Intake and Output – DI?
Slide13Pathophysiology of Traumatic Brain InjuryEndocrine Dysfunction:Hypothalamic injury -> pituitary dysfunctionThyroid dysfunction = T4 Infusion
Reduction of Antidiuretic Hormone / DI
ADH = Vasopressin Infusion
Glycemic control disrupted
Insulin infusion
Relative deficiency of corticosteroids
Solumedrol
Infusion
Slide14Pathophysiology of Traumatic Brain InjuryPulmonary Dysfunction:Neurogenic pulmonary edemaSystemic hypertension + LV dysfunction
Primary
pneumatocyte
dysfunction
Iatrogenic injury due to aggressive resuscitation
Exacerbated by intubation, aspiration &atelectasis
Concurrent blunt lung injury common
Parenchymal injury problematic in immunosuppressed recipients
Slide15Pathophysiology of Traumatic Brain InjuryHematologic Dysfunction:ThrombocytopeniaPlatelets as needed
Coagulopathy/DIC
FFP /
Cryo
as needed
Hypothermia
Keep them warm!
Slide16What are Traumatic Brain Injury Guidelines?Hospital approved guidelines for treating patients with Traumatic Brain Injury
Slide17What are Traumatic Brain Injury Guidelines?Prevent secondary injury, even with grave prognosisSecondary injury includes other organs, as well as the brainMaintain Organ PerfusionVolume LoadMaintain adequate CVP & MAP
Oxygenation
Correct electrolyte abnormalities
Slide18Why Implement Traumatic Brain Injury Guidelines?Ensure consistent management of the critically ill patientMaintain homeostasis for accurate brain death assessmentPrevent “secondary injury” to organs, even with grave prognosis
Provide a clinical bridge between determination of brain death and family’s decision on donation
Slide19Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation
(
Salim
et al.
J Trauma
2005; 58: 991-994)
LAC + USC Standardized organ donor management protocol
Before-after study (January 1998) of ADM institution
January 1995-December 2002
Slide20Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation
(
Salim
et al.
J Trauma
2005; 58: 991-994)
Vasopressors if MAP <70
Dopamine
Levophed
Vasopressin
Hormones for maximal vasopressors.
Insulin
Solumedrol
T4
Slide21Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation
(
Salim
et al.
J Trauma
2005; 58: 991-994)
878 patients referred, 460 (53.4%) patients potential organ donors and 161 (34.3%) actual donors.
# patients referred increased 57%
# of potential donors increased 19%
# of actual donors increased 82%
# of patients lost to cardiovascular collapse decreased 87%
# of organs recovered increased 71%
Slide22How to Implement TBI Guidelines in your Hospital?Clinical EducatorCritical Practice CommitteeCritical Care LeadershipCritical Care Physicians or Medical Director
Sample Guidelines available at:
www.onelegacy.org
Slide23DNR DecisionWhat does the DNR decision mean to the family?No Chest Compressions?No Shock?
No Medications?
No Labs?
No Fluids?
No Diagnostic Tests?
Allow natural death?
“Do not harm?” or “Do not treat?”
Slide24SummaryCritical care teams can honor the DNR decision while preserving the option of donation.Pathophysiology of Traumatic Brain Injury can be anticipated and treated.TBI Guidelines can be implemented to prevent “step down” in clinical management and preserve the family’s donation option.
Slide25The Care and Management of Consented Brain Dead Organ DonorsKeith Markillie PTC, RN, BSNOneLegacy
Slide26Best Practices Approach to Saving Lives&Preserving the Opportunity for Organ Donation
Slide27Organ Donor ManagementSimilar to Traumatic Brain Injury Guidelines: “What’s good for the patient is good for the donor”Treatment of Brain DeathStandardizes donor management within OneLegacyMaximize the organs recovered per donor
Slide28Organ Donor ManagementMAP 60 – 110 mmHg CVP 4 - 12mmHgEF > 50% </= 1 pressor used AND: Dopamine </= 10 mcg/kg/min
Neosynephrine
</= 100 mcg/min
Norepinephrine </= 10 mcg/min
Vasopressin </= 2.4 units/hour (0.04 units/min)
ABG pH
7.3-7.5
PaO2:FiO2 ratio >300 on PEEP = 5
Serum Sodium <155
Urine output 1-3 mL/kg/hour
Glucose < 150
Hemoglobin >
10
Track hormone replacement usage
Slide29Hormonal ReplacementPost brain death endocrine changesThere is a sharp decrease in T3 and T4 to 50% of normal within one hour of brain death & down to Zero after 16 hoursCortisol levels decrease to 50% after one hour and continue to decreaseAntidiuretic Hormone decrease significantly and completely disappear after 6 hours Insulin decreased to 20% of baseline by 13 hours>>Transplantation, Vol 83, pp 1396-1402, no 11, December 15, 2006
Slide30Hormonal ImbalancesResearch findings suggest that after brain death aerobic metabolism changes to anaerobic cellular metabolismATP and creatinine phosphate deplete & lactate increases which leads to decreased cardiac function After T4 infusion, lactate decreases, glucose utilization increases and the mitochondria resume aerobic energy generation>>Transplantation, Vol 83, pp 1396-1402, no 11, December 15, 2006
Slide31T-4 ProtocolGive IV boluses of the following: 20 mcg T-4 IV push20 units regular insulin50 mL dextrose 50%30 mg/kg Solumedrol (2 grams max)After initial bolus start T-4 drip 200 mcg in 500mL NS at 25mL/hour initially (10 mcg/hour)Titrate as needed to maintain BP Continue drip to procurement
Slide32SolumedrolUsed in conjunction with T-4 Corticosteroid replacement for lowered cortisol levels in brain dead patientsUsed routinely throughout care of the donor
Slide33Vasopressin/PitressinUsed as hormone replacement of ADH from posterior pituitary gland in brain dead patientVery effective in treating DI related hypotensionMay or may not give 1 unit IV bolus of vasopressin before starting dripDrip rate is 0.5 – 2.4 units/ hourClosely observe Urine Output—don’t make the donor anuric
Slide34InsulinMonitor glucose every 2 hoursTreat with insulin drip rather than SQKeep 80-150Utilize hospital or OneLegacy protocol
Slide35Treatment beyond HormonesOrgan PerfusionBalance electrolytesCorrect coagulopathyCorrect metabolic acidosisOptimize oxygenation and ventilationAntibiotic usage
Slide36Organ PerfusionMaintain MAP 60 – 110mmHg1. Consider invasive hemodynamic monitoringAdequate hydration to maintain euvolemiaCrystalloids, colloids, blood productsFree waterVasopressor supportDopamineVasopressinNeosynephrineLevophed
2D Echo to evaluate function once resuscitated & pressors low dose
Slide37Balance ElectrolytesMonitor and treat electrolytes maintaining: Sodium: 134 – 145 mMol/L Potassium: 3.5 – 5.0 mMol/LMagnesium: 1.8 – 2.4 mEq/LPhosphorus: 2.0 – 4.5 mg/dLIonized Calcium: 1.12 – 1.3 mmol/L
Slide38Correct CoagulopathyMaintain normothermia 36 – 37.5 degrees Celsius (96.8 – 99.5 degrees Fahrenheit)Maintain hemoglobin > 10.0 g/dL & hematocrit > 30%If PT > 2.0, consider transfusion of FFPIf Fibrinogen is 70 - 100, consider FFP. If < 70, consider cryoprecipitateIf platelets < 50, consider platelet transfusion
Slide39Metabolic AcidosisAdequate perfusionVolume resuscitationSodium BicarbonateUse judiciously with high sodiumFind other reasons for acidosis (respiratory, kidney failure, electrolytes)Use potassium and sodium acetate to supplement electrolytes
Slide40Oxygenation/VentilationEarly bronchoscopy to clear secretionsRoutine use of SolumedrolGood pulmonary toiletingBreathing treatments/MDINarcan earlyLung recruitmentPEEP maneuversI:E ratio manipulation
Slide41Antibiotic UsageALL patients get antibiotics! Dosages can be adjusted to size and kidney clearanceLess than 5 days = ZosynGreater than 5 days = Vancomycin + LevaquinMay need other coverage, depending on pre-donor conditionID consult? Never a bad idea with “strange circumstances”
Slide42Organ Donor ManagementMAP 60 – 110 mmHg CVP 4 - 12mmHgEF > 50% </= 1 pressor used AND: Dopamine </= 10 mcg/kg/min
Neosynephrine
</= 100 mcg/min
Norepinephrine </= 10 mcg/min
Vasopressin </= 2.4 units/hour (0.04 units/min)
ABG pH
7.3-7.5
PaO2:FiO2 ratio >300 on PEEP = 5
Serum Sodium <155
Urine output 1-3 mL/kg/hour
Glucose < 150
Hemoglobin >
10
Track hormone replacement usage
Slide43Final Thoughts“Everyone of us can help make this difference …Because that truly is the Right Thing to Do.”Dr. Kenneth Moritsugu, MDUS Deputy Surgeon General
Slide44Question to Run-OnHow do your standards of care preserve the opportunity for the gift of life?