Kathryn Beheshti Objectives Understand the referral process for potential organ donors Identify potential donors Understand the process of Donation after Circulatory Death DCD Recognize your role in the donation process ID: 1037555
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1. Two Pathways to DonationKathryn Beheshti
2. ObjectivesUnderstand the referral process for potential organ donorsIdentify potential donorsUnderstand the process of Donation after Circulatory Death (DCD) Recognize your role in the donation processDiscuss patient managementExplore surgical recovery of organsUnderstand the importance of transitional language and teamwork Discuss registry status
3. The Critical ShortageNationally, more than 123,158 people are waiting for a life-saving organ transplantMore than 11,000 waiting in Texas21 people die each day while waiting for a transplant in this countryA new name is added to the waiting list every 10 minutesIn reality only 2% of the population can be a brain dead organ donorSource: www.unos.org February 2015
4. Why only 2%?
5. Two PathwaysDonation after Circulatory Death (DCD)Brain Death Donation
6. Recognizing a Potential DonorNeuro insultTraumaHypoxic InjuryDrowningCardiac / Respiratory ArrestDisease ProcessesInfectionsParasitesCancer2. GCS of 5 or less (three or more absent brainstem reflexes)3. Intubated and Ventilated
7. Referral ProcessNurse calls the Donor Referral Line when patient meets referral criteriaOn-call coordinator calls back and gathers informationCoordinator goes onsite, reviews chart, and sets plan with staffCoordinator follows by phone
8. Other Times to Call the DRLWhen the patient’s condition changesPrior to code status discussionIf family mentions donationAt Cardiac Time of Death REMEMBER:Do not mention donation to the family!
9. Code Status Discussion Maintain the patient and preserve the family’s opportunity for donationRegistry statusCode status options
10. If Family Mentions Donation…“Someone will be here later to share information about the possibility of organ and tissue donation.”“One of the end-of-life decisions to be made concerns the possibility of organ and tissue donation, and later, someone will talk with you about it.”Call the Donor Referral Line
11. The Brain Death Pathway
12. Scenario2-year-old male SIDS caseLast seen breathing by parents 1 hour prior to being foundCPR given for 30 minsPatient is areflexic and hemodynamically unstable upon arrivalLNOK mother and fatherWhat happens next?
13. Pathophysiology of Brain DeathHerniationCushing’s Triad- “sympathetic storm” – brief periodVasoconstriction↑contractility + ↑SVR = ↓ CO (LVF)Followed by spinal shock - prolonged periodMassive vasodilation = ↓ preload, ↓afterload & ↓ contractility
14. Pathophysiology of Brain DeathThyroid dysfunctionT3 and T4 levels are lowdue to hypothalamus and pituitary no longer working, TSH does not rise in responseDiabetes insipidusADH, ACTH and cortisol dramatically decline post brain deathThis depletion further worsens hypovolemiaHyperglycemiaPeripheral insulin resistance
15. Pathophysiology of Brain DeathDisseminated intravascular coagulationLarge amounts of thromboplastin released following “sympathetic storm” caused by brain herniationHypothermia caused by the massive vasodilation and loss of temperature control
16. Prior to Brain Death TestingConsider placing central line and arterial linePrerequisitesEnsure core body temp > 35CMaintain acceptable BP with vasopressorsCorrect acidosis and replace electrolytesGive blood products and reverse coagulopathies if neededReverse sedatives/analgesics
17. Consider Starting T-4 InfusionTSH is no longer secreted after brain deathT4 converts to T3 and replaces TSHT4 decreases cardiac sensitivity to catecholamines released during herniationT4 enables weaning of inotropes
18. Brain Death ExamTwo different physicians will perform two different clinical exams separated by a period of timeIf post cardiac arrest/other severe acute brain injury, first exam should be deferred for 24 to 48hrsTime period may be shortened if massive, clinically obvious central nervous system destruction existsSame physician can perform apnea test
19. Interim Between Two Exams37 weeks gestational age to 30 days old 24 hours between exams31 days to 18 years 12 hours between examsInterim period may be shortened if ancillary study is done but second exam is still required
20. Clinical ExamCheck for brainstem responses:Pupillary responseCorneal reflexGag reflexCough reflexOculocephalic reflex (Doll’s Eyes)Oculovestibular reflex (Cold Calorics)
21. Clinical ExamFlaccid tone and absence of spontaneous or induced movements, excluding spinal cord events such as reflex withdrawal or spinal myoclonusThe patient’s extremities should be examined to evaluate tone by passive range of motion Observe patient for any spontaneous or induced movementsIf abnormal movements are present, clinical assessment should be done to determine whether or not these are spinal cord reflexes
22. Apnea TestAdjust pressors for SBP ≥100 mm HgPreoxygenate for 10 min (FiO2 100%)PaO2 >200 mm HgReduce ventilator rate to establish eucapniaPerhaps to reverse hyperventilation in neuro ptsPEEP 5 cm H2ODesaturation may suggest difficulty w/ testingBaseline ABG if pulse ox >95%
23. Apnea TestPatient temperature is normalized > 35 CDisconnect from ventilatorProvide passive oxygenPlace catheter through ETT to carina Oxygen @ 6 L/minMonitor for 8-10 minutesAbd or chest excursions (including brief gasps)If PCO2 rises 20mmHg from normal baseline and ≥ 60mmHg
24. Ancillary StudyWhen to use:apnea test cannot be performedthere is uncertainty about results of clinical exammedication effect may be present
25. Notifying Family- DecouplingHospital’s role: Attending physician informs family of brain deathTOSA’s role: Discusses donation opportunity Why?Family may perceive conflict of interestPatient may not be eligible to donateTiming may not be appropriate
26. Approaching the FamilyWhen family is emotionally ready, TOSA staff will offer the opportunity to donatePrivate roomSupport for family (minister, priest, rabbi, others)Written authorization is obtained
27. Initial Steps Upon AuthorizationBlood for HLA / Virology testing drawn and sent to San AntonioResults take 8 hours Account changed to TOSAPrevious orders discontinuedTOSA assumes care of patientAverage case time 18-36 hrs
28. Management – Key Issues
29. Fluid StatusOrgan OutcomeDehydratedOver-hydratedGoodPoor
30. Management - PulmonaryCXRABGsBronchoscopyRecruitmentBEFOREAFTER
31. Management - CardiacEchocardiogramStructural/ functional integrity of walls, valves, and chambersPump qualityECGPost brain death to evaluate damage due to cytokine and catecholamine releaseSerial Cardiac EnzymesPossible Heart Catheterization
32. Organ AllocationA donor is registered with the United Network for Organ Sharing (UNOS) using the following:ABO Height and weight AgeGenderRace
33. Allocation ProcessSickest, Closestfirst
34. OR - CardiectomyHeart at back tableFirst organ to be recoveredMust be implanted within 4 hours of cross clamp
35. OR - PneumonectomyLung(s) at back tableSecond organ recoveredTransported fully inflatedMust be implanted within 4 hours of cross clamp
36. OR - HepatectomyLiver at back tableMost vascular organ transplantedCan remain outside body for up to 12 hours after cross clamp
37. OR - Small BowelThe small bowel is sometimes recovered attached to the liver and pancreas to provide a multi-visceral transplant to one recipient
38. OR - NephrectomyKidneys at back tableMost versatile organCan remain on ice for 48 hoursOn pump for 72 hours
39. OR - Pancreaectomy Pancreas at back table Most delicate organ Can be kept on ice for 12 hours
40. Donation After Circulatory Death
41. Scenario16 year old Self inflicted GSW to headEvacuation done with bone flapGCS 3 for 7 days with no improvement, no sedationFamily had discussion with physician regarding trach and peg vs. withdraw of supportFamily has elected to withdraw supportTOSA has been following patient since arrivalWhat happens next?
42. DCD processStaff notifies TOSA of family wishesTOSA coordinator goes onsite and does a DCD evaluationIf patient meets DCD criteria (predicted to expire within 1hr following withdraw of support) TOSA will approach family
43. DCD Management ProcessAccount number remains the sameOrders are flagged for billingPrimary MD will manage patient with assistance from TOSA staff
44. DCD AllocationLiver and kidneys are evaluated for transplantPancreas is evaluated for research
45. DCD in ORMD/RN will administer comfort care medicationMD/RN administers Heparin approximately 5 minutes prior to extubationMD will pronounce CTOD in ORFive minutes after CTOD, transplant surgeons begin recovery process
46. Family in the ORFamily may be with loved one until CTODAll staff prepped prior to family being escorted to ORTOSA staff member will remain with family throughout the OR processImmediately following CTOD, family is escorted out
47. What if the patient does NOT expire?Room is pre-arranged with house supervisor, OR and ICU charge nursesPatient is moved to a designated room and comfort care is continued
48. Case Follow-UpPost-donor surveyLetters to staff and family Post-donor conferenceDonor family ceremoniesDonor tributes
49. Melisa and Adele“We know Carson would have wanted to help others…He saved 4 lives through his organ donation. We feel like it is important to publicly share our story and raise awareness on the importance of organ donation. It has touched our family in so many ways, and we are grateful that we chose to Donate Life” - Melisa Cummings.
50. Donatelifetexas.org