Optimal Management. 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: 529141
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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 CenterSlide2
What is OPTIMAL donor management?
= GOOD CRITICAL CARESlide3
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?
63yo male found lying against a wallPossible fall vs. assaultLarge laceration to occipital areaGCS 1-4-1Pupils sluggishSlide6
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 earSlide7
Intubated in the ED for airway protectionTaken for CT scan for suspected severe traumatic brain injurySlide8
hematoma(w/ midline shift)Slide9
Neurosurgery consultation To OR immediately for bilateral craniectomy + evacuation ICH and SDHGCS 1-1-1Coagulopathic and HD unstable intra-opPrognosis deemed poor leaving the ORSlide10
Patient transported to ICU
What do you think happened here?Slide11
Case #1: So to review…
Pupils4, sluggish4 mm,NR6 mm, NR6 mm, NRMotorFlexor posFlexor posNo movementNo movementCough++--
Often accompanied by catecholamine stormHypertensionTachycardiaAvoid anti-hypertensivesSlide13
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/minConsider hormonal resuscitation with T4 protocolSlide14
What should happen next??
Begin testing for brain deathOne Legacy notification (actually should have already been notified!!!)Clinical optimizationSlide15
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…
24 hr total - 1000 cc 165
What do you think is going on here? Management?Slide18
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 NaSlide19
What was done…
DDAVP given at 1900Free water replacement started next morning (POD #2)…M.D. “brain death evaluation when electrolytes correct”
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 135-155Slide21
Insulin drip finally started next morning at 0900Slide22
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 < 150Slide23
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 H20Slide25
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 tissueSlide26
Case #1: Outcome
HD deterioration to near-codePoor organ functionCrashed donor to OR because of instabilityKidneys recovered Kidney biopsy results poorNo organs suitable for transplantSlide27
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 arrivalSlide28
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 22-24Slide30
Early treatment of DIDDAVPFree water replacementNa 150-154Tight glycemic control with insulin dripLoss of brainstem functionsFirst BD note < 12 hours after arrivalSlide31
Outcome - 7 organs transplanted at local centers:Right lungLeft lungHeartLiverRight kidneyLeft kidneyPancreasSlide32
Case #3: Steven
17yo male S/P skateboarding accidentGCS 1-1-1Severe DAI, small SDH on CT scanDevastating brain injurySlide33
Case #3: StevenSlide34
Donor Management Goals
Appropriate hemodynamic resuscitationMAP 65-100CVP 4-10EF 50-70%Use of < 1 vasopressorHormonal resuscitation with T4 protocol
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