Taking the IF Out of Gift: Best Practices for Organ and Tissue - PDF document

10/14/2015 Taking the “IF” Out of Gift: Best Practices for Organ and Tissue Donation Karl Serrao, MD, FAAP, FCCM The Challenge 118,000 120,000 # of pts. waiting # of transplants 99,180 100,000 92,000 82,819 85,723 80,000 74,093 60,712 60,000 50,130 37,684 40,000 19,043 20,215 21,992 22,827 25,455 26,984 28,932 27,957 28,052 20,000 0 1994 1998 2002 2006 2012 Statistics  In 2014, over 29,534 lives were saved and improved by organ transplant (OPTN Data)  Over 7,065 people died in 2014 while waiting for an organ transplant (OPTN Data)  20 deaths each day on the waiting list (OPTN Data) 1

10/14/2015 Cowboys Stadium 105,121 (opening day 9-20-09; vs Giants) 2

10/14/2015 Waiting List 122,489 (National) 13,200 (Texas) 1 (Texan will die today waiting for a transplant) (Based on OPTN data as of October 12, 2015) Texas Patients on Waiting List (as of October 12, 2015) Kidney 10,635 Liver 1,800 Heart 432 Lung 163 Kidney/Pancreas 109 Pancreas 54 Heart/Lung 4 Intestine 1 TOTAL 13,200 In 2014, the generosity of Texas donors led to 2,627 life-saving organ transplants (OPTN Data) Statistics for Children (0-17 Years) OPTN Data National Texas • Waiting list (Oct 2015) 2120 212 • Died waiting for 136 15 transplant (2014) • Lives saved (2014) 1795 181 Approximately every 3 Days a child will die waiting for a transplant 3

10/14/2015 Questions To Run On…  What is my professional obligation in regards to organ donation?  How can I best work with organ procurement organization (OPO) to increase the number of transplantable organs in my hospital?  Can I provide optimal patient care to the brain- injured individual that preserves the option of donation and best possible outcome for the recipient?  Is organ transplantation and efforts to obtain more transplantable organs…'really worth my time and effort…?’ Know Your Organ Procurement Organization (OPO) How Does the Donor Process Work in Your Hospital? 1. Referral 6. Surgical Recovery 2. Donor Evaluation 3. Brain Death 5. Donor Management 4. Family Approach/Consent 4

10/14/2015 “An Effective Request Process” Case Study Upon Admission:  12 year old female;  AMS, vomiting, non-verbal, nods to questions  Intubated in ER; admitted to ICU  CT shows ruptured cerebral aneurysm PMH: Non-contributory Case Study Day 2 • Craniotomy • Clinical Triggers met • RN called referral to OPO Centers for Medicare and Medicaid Services (CMS) requires hospitals to notify OPO within one hour of any patient meeting “clinical triggers” for donation . Clinical Triggers • Ventilator • Neurological insult • Missing 2 or more reflexes Age, medical condition, or Medical Examiner involvement does not preclude organ donation 5

10/14/2015 Case Study Day 2 (cont’d) OPO Coordinator arrived on site to evaluate • patient’s donation potential and establish plan with patient’s care team • Huddle to discuss brain death declaration process physicians, coordinator, nurses, social workers and • chaplains • Patient over-breathing the ventilator; fentanyl and midazolam for sedation On-site Evaluation Case Study Day 3 • Patient deteriorates • OPO notified of plan to start brain death exam; OPO Coordinator dispatched • Patient declared brain dead per clinical exam, including apnea test 6

10/14/2015 The Approach Process Attending physician was very caring with the family:  Moved to a private, quiet setting.  Explained brain death from a medical standpoint.  Spent time and listened to the family.  Answered the family’s questions; “What is the next step?” The Approach Process Best introduction of the OPO Coordinator: “Your family has some important decisions to make at this difficult time. This is Laura, and she will help support your family and answer any questions you might have regarding end-of-life decisions for your daughter.” Collaborative Approach  According to CMS Guidelines , only a trained, designated requestor can mention donation to the family. For a physician, or other healthcare provider currently caring for the potential donor, to mention donation can be perceived by the family as a conflict of interest. 7

10/14/2015 Collaborative Approach OPO Coordinator offered support and explained opportunity to donate :  Reinforced physician’s explanation of brain death  Potential timeline for organ recovery  Directed Donation (opportunity to donate to someone they know on the waiting list)  Donation-related hospital costs paid by OPO  Open casket funeral remains an option Donor Registry/UAGA*  This patient was not on the Donor Registry  Patients who are registered are considered “First Person Consent”  Texas Health and Safety Code (chapter 692A) also states:  Review of medical records and examinations.  Measures to ensure suitability may not be withdrawn. *Uniform Anatomical Gift Act Lives Saved Heart: Recovered for research (countless lives saved) R Kidney: 15y F (high school cheerleader; enjoys hunting , fishing and outdoors) L Kidney: 53y M (married with two children; enjoys dominos and watching sports) Liver: 13y M (middle school, video games, baseball) Double Lung: 12y F (middle school, music, choir) Pancreas: 45 y M (pharmacy tech; married; loves gardening and spending time with family) 8

10/14/2015 What made this case so successful?  Early recognition of clinical triggers and referral to Southwest Transplant Alliance  Frequent huddles to help prepare everyone for their role in the approach process  Physician and OPO Coordinator communicated in order to best meet the needs of the family  Medical staff was transparent and honest with the family about the grave prognosis Conflict of Interest…  There is no conflict of interest. The transition from caring for a critically ill or dying patient to a potential organ donor can be a difficult process for health care providers.  Treat all patients as though they will survive.  What’s good for the patient is good for organ donation.  To avoid the perception of conflict of interest, the OPO Family Services Coordinator often takes the lead during the approach process. …in charge and responsible  Once patient is declared brain dead, the OPO Medical Director and Coordinator assume responsibility for managing that patient  The donation process often requires physicians’ support  Procedures (e.g., place central and arterial lines, bronchoscopy, echocardiography, etc.)  Medical management consultation  OPO Donation Coordinators are specially trained in donor management 9

10/14/2015 Evidence-Based Standards of Care in Donor Management Catastrophic Brain Injury Guidelines  MAP > 60 (age appropriate if pediatric) (Vasopressor support if necessary; Dopamine 1 st choice)  Urine Output > 0.5ml/kg/hr < 4 ml/kg/hr (300 ml/hr ) (Vasopressin if DI)  Electrolyte balance  Na + < 155  Hgb/Hct/Coags  pH 7.35 – 7.45  pO 2 > 100  Temp 36-37.5 These goals should be met prior to organ recovery. Brain Death vs Donation after Circulatory Death Brain Death • Irreversible cessation of all brain function including the brain stem. Brain dead donors remain on the vent and vital signs and heartbeat are maintained until organ recovery begins. 10

10/14/2015 Brain Death vs Donation after Circulatory Death Donation after Circulatory Death (DCD) Option for patients who have a non-recoverable illness or • injury that has caused neurological devastation and/or other system failure resulting in ventilator dependency; Patient’s condition is irreversible but patient does not • meet the clinical criteria for brain death; Determination is made that cardiopulmonary death will • likely occur within 60 min following withdrawal of ventilator support Family decides to decelerate treatment • Hemodynamic Sequelae of Brain Death  Sympathetic storm  Increasing catecholamine levels  Several hours after brain death, catecholamines decrease to less than 10% of normal  Hemodynamic Instability  Hypertension  Hypotension  Endocrine abnormalities  Diabetes Insipidus Other Sequelae of Brain Death  Electrolyte disturbance  Anemia and Coagulopathy  Oxygenation issues 11

10/14/2015 Role of Clinical Care Team Good Critical Care Patient Management EQUALS Good Donor Medical Management  Intensivists  Hemodynamics  Pulmonologists  Cardiologists  Ventilatory Management  Nurses  Respiratory Therapists  Echocardiography  Spiritual Support  Diagnostic Procedures Worth our time and effort? Is it worth my time to take care of these “dead” people? YES! One donor can give life to 8 people Heart Kidney Liver Lung Lung Kidney Pancreas 12

10/14/2015 Reality: With limited time, people and money, it’s important to collaborate internally to get procedures completed. So…what can we do? Clinical Management of the Organ Donor  Maintain age appropriate BP  Hypotension secondary to hypovolemia most common complication  0.45 percent saline  Albumin  Blood products Clinical Management of the Organ Donor  Use of central venous catheter  Central venous pressure (CVP) : 4-6  Once patient is adequately fluid resuscitated, can use vasopressors to maintain adequate BP  Dopamine  Vasopressin  Neosynephrine  Avoid use of norepinepherine  End-organ damage secondary to hypoperfusion 13