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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

What is OPTIMAL donor management?

= GOOD CRITICAL CARE

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.

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

Case #1

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

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

Case #1

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

Multiple intra-

parenchymal

hemorrhages

Large left

subdural

hematoma(w/ midline shift)

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

Case #1

Patient transported to ICU

Time04002200230000000100BP140/70140/70160/8080/60100/70P908511060100

Labetalol given

Levophed started

What do you think happened here?

Case #1: So to review…

Time2200230000000100BP140/70160/8080/60100/70P8511060100

Pupils4, sluggish4 mm,NR6 mm, NR6 mm, NRMotorFlexor posFlexor posNo movementNo movementCough++--

Herniation

Brain Herniation

Often accompanied by catecholamine stormHypertensionTachycardiaAvoid anti-hypertensives

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 protocol

What should happen next??

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

When to notify One Legacy…

Case #1: What did happen….

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

No new orders written…

Time0800120018002400UOP300250300100Na153158164165

24 hr total - 1000 cc 165

What do you think is going on here? Management?

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

What was done…

DDAVP given at 1900Free water replacement started next morning (POD #2)…M.D. “brain death evaluation when electrolytes correct”

Time0800120018002400UOP300250300100Na153158164165

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

Meanwhile…

POD #3

Time00000600120018002400Glucose219160406465398

Management?

Insulin drip finally started next morning at 0900

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

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?

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

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

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

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

Case #2

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

Case #2

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

Case #2

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

Case #3: Steven

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

Case #3: Steven

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

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