Donor Case Studies Optimal Management PowerPoint Presentation, PPT - DocSlides

Donor Case Studies Optimal Management PowerPoint Presentation, PPT - DocSlides

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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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Slide1

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

Slide2

What is OPTIMAL donor management?

= GOOD CRITICAL CARE

Slide3

OPTIMAL 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.

Slide4

If 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

Slide5

Case #1

63yo male found lying against a wallPossible fall vs. assaultLarge laceration to occipital areaGCS 1-4-1Pupils sluggish

Slide6

Case #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 32, sluggish Blood from left ear

Slide7

Case #1

Intubated in the ED for airway protectionTaken for CT scan for suspected severe traumatic brain injury

Slide8

Multiple intra-

parenchymal hemorrhages

Large left

subdural

hematoma

(w/ midline shift)

Slide9

Case #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

Slide10

Case #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?

Slide11

Case #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

Slide12

Brain Herniation

Often accompanied by catecholamine stormHypertensionTachycardiaAvoid anti-hypertensives

Slide13

Management 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

Slide14

What should happen next??

Begin testing for brain deathOne Legacy notification (actually should have already been notified!!!)Clinical optimization

Slide15

When to notify One Legacy…

Slide16

Case #1: What did happen….

Next morning… 1200 noon One Legacy notifiedPhysician to hold family conference to discuss poor prognosisNo new orders written…

Slide17

No 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?

Slide18

Diabetes 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

Slide19

What 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

Slide20

Management 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

Slide21

Meanwhile…

POD #3Time

0000

0600

1200

1800

2400

Glucose

219

160

406

465

398

Management?

Insulin drip finally started next morning at 0900

Slide22

Management 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

Slide23

As 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?

Slide24

Management 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

Slide25

Case #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

Slide26

Case #1: Outcome

HD deterioration to near-codePoor organ functionCrashed donor to OR because of instabilityKidneys recovered Kidney biopsy results poorNo organs suitable for transplant

Slide27

Case #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

Slide28

Case #2

Slide29

Case #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

Slide30

Case #2

Early treatment of DIDDAVPFree water replacementNa 150-154Tight glycemic control with insulin dripLoss of brainstem functionsFirst BD note < 12 hours after arrival

Slide31

Case #2

Outcome - 7 organs transplanted at local centers:Right lungLeft lungHeartLiverRight kidneyLeft kidneyPancreas

Slide32

Case #3: Steven

17yo male S/P skateboarding accidentGCS 1-1-1Severe DAI, small SDH on CT scanDevastating brain injury

Slide33

Case #3: Steven

Slide34

Donor 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

Slide35

Donor 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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