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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Presentations text content in Donor Case Studies
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 32, 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
Pupils4, sluggish4 mm,NR6 mm, NR6 mm, NRMotorFlexor posFlexor posNo movementNo movementCough++--
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/minConsider 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…
Time0800120018002400UOP300250300100Na153158164165
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”
Time0800120018002400UOP300250300100Na153158164165
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 #3
Time00000600120018002400Glucose219160406465398
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
Download this presentation
DownloadNote - The PPT/PDF document "Donor Case Studies" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Presentations text content in Donor Case Studies
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 ICU
Time04002200230000000100BP140/70140/70160/8080/60100/70P908511060100
Labetalol given
Levophed started
What do you think happened here?
Slide11Case #1: So to review…
Time2200230000000100BP140/70160/8080/60100/70P8511060100
Pupils4, sluggish4 mm,NR6 mm, NR6 mm, NRMotorFlexor posFlexor posNo movementNo movementCough++--
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/minConsider 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…
Time0800120018002400UOP300250300100Na153158164165
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”
Time0800120018002400UOP300250300100Na153158164165
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 #3
Time00000600120018002400Glucose219160406465398
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