Organ Donation Ali Salim, MD Associate Professor of Surgery
2012 Clinical Congress 2012 Clinical Congress Presenter Disclosure Slide Presenter Disclosure Slide American College of Surgeons ♦ Division of Education Ali Salim, MD Nothing To Disclose
Why should surgical intensivists know about donation??
The Problem 140,000 120,000 100,000 80,000 Waiting list 17 60,000 deaths/day 40,000 7000/year 20,000 Transplants 0 2 4 6 8 0 2 4 6 7 8 1 9 9 9 9 0 0 0 0 0 0 1 9 9 9 9 0 0 0 0 0 0 0 1 1 1 1 2 2 2 2 2 2 2
Did you know?? Centers for Medicare/Medicaid Services & ACS Notification process Declaration of brain death Organ procurement organization (OPO) relationship Performance Improvement (PI) program Patient/family opportunity to donate
Cause of Death of Donors 4% 21% 35% 40%
Trauma Surgeons and Intensivists
Intensivist No intensivist OTPD 4.05 3.30 OTPD-SCD 4.36 3.71 OTPD-ECD 2.43 1.50 Hearts tx’d 47% 49% Lungs tx’d 43% 14% ATN rate 12% 24% Moncure, Organ Donation and transplant alliance, San Francisco November 2006
Outline Outline Types of Donors Declaration of Brain Death Critical Care Management
Types of Donors Living Donors Living Donors Deceased Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death Donors after Circulatory Determination of Death
Types of Donors Living donors 26% Deceased donors 74%
Types of Donors Types of Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
Question All of the following are required to make the diagnosis of neurologic death except Irreversible cause of brain injury must be 1. present Absent brainstem reflexes 2. Positive apnea test 3. Patient temperature of 37 C 4. Nuclear imaging for confirmation 5.
Declaring Brain Death Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
Declaring Brain Death Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
Pre-requisites Known proximal cause & irreversibility Absence of confounders Electrolyte, metabolic, endocrine, acid- base disturbances Intoxication/drug effects
Pre-requisites Known proximal cause & irreversibility Absence of confounders Electrolyte, metabolic, endocrine, acid- base disturbances Intoxication/drug effects Hypothermia > 36 C (from 32) Systolic Blood Pressure > 100 mm Hg (from 90)
Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
Clinical Exam: COMA Adapted from: Wijdicks. NEJM. 2001
Clinical Exam: BRAINSTEM REFLEXES Adapted from: Wijdicks. NEJM. 2001
Clinical Exam: BRAINSTEM REFLEXES Pupillary Light Reflex Corneal Reflex Gag Reflex Oculocephalic Reflex (Dolls Eyes) Oculovestibular Reflex (Cold Calorics)
Clinical Exam: APNEA Clinical Exam: APNEA Absence of a breathing drive Tested by CO2 challenge Prerequisites Normotension Normothermia Euvolemia Eucapnia (35-45) Absence of hypoxia
Clinical Exam: APNEA Apneic oxygenation- diffusion technique Repeat ABG: 8 min Arterial PCO2 • > 60 mm Hg OR • 20 mm Hg increase over baseline Adapted from: Wijdicks. NEJM. 2001
Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
Ancillary Tests Only if clinical exam incomplete, unreliable or unsafe Brain perfusion scan 1. 2. EEG 3. Transcranial doppler 4. Conventional angiography
Declaring Brain Death 1. Pre-requisites 2. Clinical Examination 3. Ancillary Testing 4. Documentation & Organ Donation
Documentation & Donation Time of death: pCO 2 reached target value Ancillary test interpretation
Documentation & Donation Documentation & Donation Organ donation: Federal & State law requires contact with organ procurement association OPO to approach family
Controversies Second exam 6 h repeat (1995) No evidence-based interval California – two physicians, two exams
Controversies Second exam 6 h repeat (1995) No evidence-based interval California – two physicians, two exams Newer Ancillary Tests Insufficient Evidence • MRI/MRA • CTA • Bispectral index monitoring (BIS)
Types of Donors Deceased Donors Donors after Neurologic Determination of Death Donors after Circulatory Determination of Death
Timeline of DCDD
Maastricht Classification : Controlled vs. UnControlled Abt PL et al. JACS 2006;203:208-225
Who are the Candidates? Patients with severe neurological injury Intracranial hemorrhage, stroke, anoxia, trauma Patients without neurological injury Degenerative neuromuscular diseases End-stage cardiopulmonary diseases
Who are the Candidates? Do not meet the criteria for brain death No chance for survival off the ventilator Family and physician elect to withdraw support
Where Will Withdrawal of Support Occur? Operating Room Family in attendance Family not in attendance Intensive Care Unit
What Happens if the Patient Does Not Expire? Occurs in up to 20% of cases Pre-donation discussion with family, physicians and nurses Patient transferred to pre-determined unit Treating team remains responsible for patient care
Which Organs? Presently; kidney, liver, pancreas Lungs and on rare occasions heart described Abt PL et al. JACS 2006;203:208-225
Outline Outline Types of Donors Declaration of Brain Death Critical Care Management
Catecholamine surge ↑ HR, ↑ BP, ↑ CO, ↑ SVR
arrhythmias hypotension DI DIC acidosis hypothermia pulmonary edema
Complications of Brain Death 80% 70% 60% 50% 40% 30% 20% 10% 0% PLTs DIC pressor DI card acid renal NPE isch failure Salim et al. Am Surg 2006;72:377-381.
arrhythmias hypotension DI DIC acidosis hypothermia pulmonary edema
Wood et al NEJM 2004;351:2730-2739
Hemodynamic Instability Organ Loss up to 25% Cardiovascular Collapse
Why? Hemodynamic instability Autonomic dysfunction Hypovolemia Aerobic to anaerobic metabolism Release of vasoactive inflammatory mediators Low levels of T 3 , T 4 , cortisol, insulin Reversal with replacement of T 3
Cardiovascular Collapse?? A fluid problem……. A hormonal problem…… An attention problem…… Donor management is key to preventing collapse
New Terminology Catastrophic Brain Injury Guidelines (CBIG’s) Goal – to maintain hemodynamic stability in patients with devastating brain injury
What are CBIG’s? Hemodynamic Management Invasive monitoring with endpoints
Hemodynamic Management Target criteria MAP > 60 PCWP 8-12 CVP 4-12 CI > 2.4 SVR 800-1200 Dopamine < 10
What are CBIG’s? Hemodynamic Management Invasive monitoring with endpoints Hormonal therapy T3 or T4 Methylprednisolone Vasopressin
Hormone Therapy Rapid IV bolus of: 1 amp 50% dextrose 20 units insulin 2 g Solumedrol 20 mcg T 4 Continuous T 4 infusion at 10 mcg/h T 4 only used in hemodynamically unstable donors (combined vasopresssor dose > 10mcg/kg/min)
Actions of T 3
What are CBIG’s? Ventilator Management Appropriate tidal volumes (10 cc/kg) Prevent atelectasis Recruitment maneuvers Fluid restriction (diuretics) Bronchoscopy (frequent suctioning) Prevent aspiration (elevate HOB)
What are CBIG’s? Management of complications Anemia Coagulopathy DI Electrolyte imbalances Arrhythmia's
Salim A. J Int Care Med. 2008
Critical Care Endpoint DMG 1. Mean Arterial Pressure (MAP) 60 – 100 mmHg 2. Central Venous Pressure (CVP) 4 – 10 mmHg 3. Ejection Fraction (EF) > 50% 1 and low dose 4. Vasopressor use 5. Arterial Blood Gas pH 7.3 – 7.45 6. PaO2:FiO2 (P:F) > 300 on PEEP = 5 7. Serum Na 135 – 160 mEq/ L 8. Blood Glucose < 150 mg/ dL 9. Hemoglobin (Hb) > 10 mg/ dL 10. Urine Output (averaged over 4 hours) 1-3 cc/ kg/ hr
Organ Donor Timeline OPO Management 2 nd Brain Death Family consent 1 st Brain death CVC Injury Organ Retrieval CBIG
Organ Donation Know the types of donors Know how to declare brain death Know who to call after brain death Know how to manage catastrophic brain injuries
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