Harbor-UCLA Critical Care – Organ Donation Symposium. April 12, 2010. Brant Putnam, MD FACS. Trauma / Acute Care Surgery / Surgical Critical Care. Harbor-UCLA Medical Center. What is OPTIMAL donor management?. ID: 721769
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Donor Case StudiesOptimal Management
Harbor-UCLA Critical Care – Organ Donation SymposiumApril 12, 2010Brant Putnam, MD FACSTrauma / Acute Care Surgery / Surgical Critical CareHarbor-UCLA Medical Center
Slide2What is OPTIMAL donor management?
= GOOD CRITICAL CARE
Slide3OPTIMAL donor management begins
PRIOR to proclamation of brain death.The ICU nurses and physicians are jointly responsible for optimal donor management, not just the OPO.
Slide4If the patient has not been formally pronounced brain dead, then the patient is alive.
Who is not willing to provide good critical care to a live patient?NO ONE
Slide5Case #1
63yo male found lying against a wallPossible fall vs. assaultLarge laceration to occipital areaGCS 1-4-1Pupils sluggish
Slide6Case #1
Called as a “Tier II” (high acuity) traumaA - Patent, but not protectedB - Spontaneous, clear bilaterallyC - P = 86 BP – 150D - Unresponsive GCS = 1-4-1 Pupils 32, sluggish Blood from left ear
Slide7Case #1
Intubated in the ED for airway protectionTaken for CT scan for suspected severe traumatic brain injury
Slide8Multiple intra-
parenchymal hemorrhages
Large left
subdural
hematoma
(w/ midline shift)
Slide9Case #1
Neurosurgery consultation To OR immediately for bilateral craniectomy + evacuation ICH and SDHGCS 1-1-1Coagulopathic and HD unstable intra-opPrognosis deemed poor leaving the OR
Slide10Case #1
Patient transported to ICUTime
0400
2200
2300
0000
0100
BP
140/70
140/70
160/80
80/60
100/70
P
90
85
110
60
100
Labetalol given
Levophed started
What do you think happened here?
Slide11Case #1: So to review…
Time
2200
2300
0000
0100
BP
140/70
160/80
80/60
100/70
P
85
110
60
100
Pupils
4, sluggish
4
mm,NR
6 mm, NR
6 mm, NR
Motor
Flexor pos
Flexor pos
No movement
No movement
Cough
+
+
-
-
Herniation
Slide12Brain Herniation
Often accompanied by catecholamine stormHypertensionTachycardiaAvoid anti-hypertensives
Slide13Management Goal #1
Appropriate hemodynamic resuscitation to maintain perfusion to potential organs for donationMaintain MAP 65-100 mmHgPlace central venous line; fluid resuscitation to CVP 4-10 cm H20Use of < 1 vasopressorDopamine < 10 mcg/kg/minLevophed < 10 mcg/minNeosynephrine
<
60 mcg/min
Consider hormonal resuscitation with
T4 protocol
Slide14What should happen next??
Begin testing for brain deathOne Legacy notification (actually should have already been notified!!!)Clinical optimization
Slide15When to notify One Legacy…
Slide16Case #1: What did happen….
Next morning… 1200 noon One Legacy notifiedPhysician to hold family conference to discuss poor prognosisNo new orders written…
Slide17No new orders written…
Time
0800
1200
1800
2400
UOP
300
250
300
100
Na
153
158
164
165
24 hr total
- 1000 cc
165
What do you think is going on here? Management?
Slide18Diabetes Insipidus
Excretion of large amounts of severely dilute urine“Central” – no ADH release from brainKidney can not concentrate urineTherapyDDAVP (desmopressin acetate)Synthetic analogue of ADH Free water replacementFrequent monitoring of serum Na
Slide19What was done…
DDAVP given at 1900Free water replacement started next morning (POD #2)…M.D. “brain death evaluation when electrolytes correct”Time
0800
1200
1800
2400
UOP
300
250
300
100
Na
153
158
164
165
Slide20Management Goal #2
Maintain perfusion to all organsGoal urine output 1-3 cc/kg/hrSuspect DI if U/O > 200 cc/hr x 2 hrsTreat with DDAVP and fluid (free H2O)Keep serum Na 135-155
Slide21Meanwhile…
POD #3Time
0000
0600
1200
1800
2400
Glucose
219
160
406
465
398
Management?
Insulin drip finally started next morning at 0900
Slide22Management Goal #3
Potential donors are critically ill patientsTight glucose control appliesIncrease frequency of Accu-checksIncrease sliding scaleInsulin drip as neededGoal is to keep serum glucose < 150
Slide23As time passes . . .
Multiple ventilator alarmsPIPs 45-50Low exhaled tidal volumesO2 sats 85%Increase TVs to 1 L to maintain sats 88-90%Is this the best ventilator management?
Slide24Management Goal #4
Maintain good oxygenationPaO2/FiO2 ratio > 300Reduce FiO2 to reduce oxygen toxicityAvoid high PEEP effects on hemodynamicsMaintain adequate ventilationABG pH 7.30-7.45Avoid barotrauma to lungsPIPs < 32 cm H20
Slide25Case #1: POD #4
0300 1st Brain Death Note written(Note: 75 hours after herniation event)1000 2nd Brain Death Note written1455 One Legacy obtains consent for all organs and tissue
Slide26Case #1: Outcome
HD deterioration to near-codePoor organ functionCrashed donor to OR because of instabilityKidneys recovered Kidney biopsy results poorNo organs suitable for transplant
Slide27Case #2 – Getting it right . . .
22yo male S/P pedestrian struck by auto x 2GCS 1-1-1Lost pulses on arrival; CPR x 12 minDevastating brain injuryOne Legacy notified within 4 hours of arrival
Slide28Case #2
Slide29Case #2
Ongoing resuscitationIV fluid to CVP 8Blood products to keep Hb near 10Correction of coagulopathyUse of Levophed to maintain MAP > 65Addition of T4 within 4 hoursAdequate oxygenation / ventilationABG 7.39 / 40 / 118 / 24 / -2 / 99%PaO2 / FiO2 = 350PIPs 22-24
Slide30Case #2
Early treatment of DIDDAVPFree water replacementNa 150-154Tight glycemic control with insulin dripLoss of brainstem functionsFirst BD note < 12 hours after arrival
Slide31Case #2
Outcome - 7 organs transplanted at local centers:Right lungLeft lungHeartLiverRight kidneyLeft kidneyPancreas
Slide32Case #3: Steven
17yo male S/P skateboarding accidentGCS 1-1-1Severe DAI, small SDH on CT scanDevastating brain injury
Slide33Case #3: Steven
Slide34Donor Management Goals
Appropriate hemodynamic resuscitationMAP 65-100CVP 4-10EF 50-70%Use of < 1 vasopressorHormonal resuscitation with T4 protocol
ALL organs
Lungs, ALL
Heart, ALL
Heart, ALL
ALL
Slide35Donor Management Goals
Good oxygenation / ventilationPaO2/FiO2 ratioABG pH 7.30-7.45PIPs < 32 cm H20 Urine output 1-3 cc/kg/hrSerum Na 135-155Glucose < 150
Lungs
Lungs, ALL
Lungs
Kidney
Liver
Pancreas
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