C C Care of the Potential Organ Care of the Potential Organ f h - PowerPoint PPT Presentation

C C Care of the Potential Organ Care of the Potential Organ f h f h i l O i l O Donor Donor Donor Donor  There is a disparity between the number of potential organ donors and that of actual t ti l d d th t f t l donors.  In order to address the shortage, we must recover organs that offer the greatest likelihood of successful outcomes for recipients  Optimize care of the potential donor

Timely Treatment is Critical Timely Treatment is Critical i i l l i C i i i C i i l l  The use of standardized treatments and Th f t d di d t t t d algorithms that are focused on managing the hemodynamic status of the donor have th h d i t t f th d h proved to be beneficial in maintaining the stability of potential donors. t bilit f t ti l d  Standardization protocols takes organs that were unsuitable and makes them more suitable  Protocols minimize the loss of donors during maintenance and brain death

All All organs benefit from optimal All organs benefit from optimal All b b fi f fi f i i l l hemodynamic Management hemodynamic Management hemodynamic Management hemodynamic Management  Increase the numbers of organs procured  Improves graft function in the recipients  Improves graft function in the recipients.

Cardiovascular Effects Cardiovascular Effects  Brain death adversely affects the cardiovascular system di l t  Ischemia in the medulla provokes sympathetic surge to maintain cerebral perfusion pressure  Brain ischemia is associated with necrosis that is concentrated in the left ventricular sub endocardium and ischemic changes in the EKG

Goals of Management Goals of Management  Achieve Normovolemia  Maintain blood pressure  Optimize cardiac output utilizing the least amount of vasoactive drug support

Heart Donation Heart Donation  Heart donors should not be excluded on the i iti l EKG initial EKG.  Hearts can recover left ventricular function after herniation

Hypotension Hypotension i  Associated with decrease in organ function  Common in hypovolemic donors  Seen with patient in Diabetes Insipidus who are not receiving ADH (vasopressin)  Give PRBC for Hematocrit of 30 for G ve C o e oc o 30 o oxygen delivery  Utilize 0 45 NS for hypernatremia  Utilize 0.45 NS for hypernatremia

Hyperglycemia Hyperglycemia  Physical stress, increase in the levels of counter regulatory hormones, dextrose t l t h d t solutions, peripheral resistance to insulin all contribute to hyperglycemia t ib t t h l i

Hyperglycemia Hyperglycemia l l i i  Discourage use of large amounts of d dextrose solutions – creates an osmotic t l ti t ti diuresis and electrolyte abnormalities  Maintain Blood Glucose levels between 80- 150 with an Insulin Infusion

Fluid Management Fluid Management l id l id  Minimally positive fluid balance is associated with higher rates of lung i t d ith hi h t f l procurements  Colloid solutions are recommended to sustain oxygenation and minimize the accumulation of pulmonary edema

Vasoactive Medications Vasoactive Medications  When adequate volume resuscitation occurs, vasoactive medications are ti di ti necessary if hypotension continues  Low dose vasoactive drug support has shown a reduction in the rates of acute rejection after renal transplant and improved rates of graft survival.

Vasopressin Vasopressin  Arginine vasopressin is an alternative vasopressor that can be administered to th t b d i i t d t support potential donors who have h hypotension t i  Enhances vascular sensitivity to catecholamines while maintaining hemodynamic stability.

Vasopressin Vasopressin  Anti Diuretic effects  Decreases serum osmolarity  Decreases sodium levels  Maintains blood pressure  Reduces the need for vasoactive  Reduces the need for vasoactive medications

Hormone Replacement Therapy Hormone Replacement Therapy  Dysfunction of the hypo thalamic pituitary adrenal axis during brain death results in the d l i d i b i d th lt i th depletion of thyroid hormone and cortisol l leading to organ deterioration di t d t i ti  Low levels of thyroid hormone may impair mitochondrial function and the production of ATP.  .

Hormone Replacement Therapy Hormone Replacement Therapy  Hormone replacement improves cardiovascular lability, reduces EKG di l l bilit d EKG abnormalities, reduces the acid base disturbances and improves the suitability of di t b d i th it bilit f organs for transplantation  Hormone replacements therapy was shown to diminish requirements for vasoactive therapy

Hormone Replacement Therapy Hormone Replacement Therapy  There also has been a correlation between th the substantial number of organs recovered b t ti l b f d and the use of HRT  Utilize HRT in donors that have an EF of less than 45% and require multiple vasopressors or high dosage of vasoactive medications.

Cardiac Arrhythmias Cardiac Arrhythmias  Common and attributable to conduction system necrosis that is secondary to the t i th t i d t th sympathetic surge that results from medullary ischemia, metabolic disturbances d ll i h i t b li di t b or electrolyte abnormalities  Arrhythmias are resistant to antiarrthymic treatment and occur frequently during herniation, try to correct the cause

Arrhythmias Arrhythmias  Lidocaine/Amiodarone have shown to be effective for Ventricular Arrhythmias ff ti f V t i l A h th i  Supraventricular Arrhythmias respond better to Amiodarone  Brady Arrhythmias are the result of vagus nerve disruption and do not respond to atropine, must use isuprel or epinephrine.

Respiratory Effects Respiratory Effects  Optimal Management of donors respiratory function will enhance the quality of all f ti ill h th lit f ll organs to be donated  Low arterial CO2 and high minute ventilation used to treat head injuries should be normalized in the donor.  Normalization limits the potential for ventilation induced injury to the lungs

Respiratory Management Respiratory Management  End Inspiratory Plateau pressure should be  End Inspiratory Plateau pressure should be limited to less than 30 cm of water.  Atelectatasis and Excessive Fluid A l i d E i Fl id Resuscitation are two correctable causes of hypoxemia that often preclude the use of h i h f l d h f lungs for transplant.  Bronchoscopy, suctioning, and judicious fluid resuscitation are all interventions to improve lung outcomes – Maintain CVP 6- 8 mm Hg. with diuretic therapy.

Respiratory Management Respiratory Management  Albuterol has been show to augment the clearance of pulmonary edema and useful in l f l d d f l i conjunction with diuretics  Corticosteroids (15 mg/kg) may also stabilize lung function.

Goals of Mechanical Ventilation Goals of Mechanical Ventilation  Fraction of inspired oxygen – 0 40  Fraction of inspired oxygen 0.40  Partial pressure of arterial O2 - >100 mm Hg  Partial pressure of CO2 34-40 mm HG i l f CO2 34 40 G  Arterial pH 7.35-7.45  Tidal volume 8-10 ml/kg  PEEP 5 cm H2O  PEEP 5 cm H2O  Static airway pressure - <30 cm H2O

Goals of Bronchoscopy Goals of Bronchoscopy  Evaluate anatomy  Assess for foreign body and remove  Define and locate aspirated materials, secretions, or infection  Clear secretions C e sec e o s

Goals of Pulmonary Hygiene Goals of Pulmonary Hygiene  Prevent atelectasis with the use of suction, percussion and lung expansion techniques i d l i t h i

Prevent Hypernatremia Prevent Hypernatremia  Hypernatremia in the donor can adversely affect the function of the transplant in the ff t th f ti f th t l t i th recipient  DI results from the absence of vasopressin after the destruction of the posterior pituitary gland.

Diabetes Insipidus Diabetes Insipidus  Contributes to hyperosmolarity, hemodynamic instability, electrolyte h d i i t bilit l t l t abnormalities as a consequence of excessive l loss of free water f f t  Treat with Arginine Vasopressin to produce vasoconstrictive and antidiuretic effect – administer as a continuous infusion

Hypothalamic Thermoregulation Hypothalamic Thermoregulation  Adverse effects of hypothermia include cardiac dysfunction, arrhythmias, di d f ti h th i coagulopathy, cold induced diuresis.  Maintain core temperature at higher than 35 degress or 95 F.  Use warming fluids, blankets.

Key Management Parameters Key Management Parameters • CVP CVP 5 10 5-10 • Urine output 0.5-3.0 ml/kg/hr • SBP > 100 & MAP > 65 • Sodium Sodium < 155 155 • Glucose < 140 • pH 7.35 - 7.45 H 7 35 7 45 • O2 Sats > 95 %

Care of the Donor is Care of the Donor is Si Simultaneous Care of Multiple Simultaneous Care of Multiple Si l l C C f f l i l l i l Recipients Recipients Recipients. Recipients.  Vigilant medical management ensures that the greatest number of organs can be th t t b f b recovered in the best possible condition to provide optimal outcomes for the recipients. id ti l t f th i i t  Current therapies enhance successful organ procurement