Download - Optimising the brain-stem dead donor
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Dr Gerlinde Mandersloot20th April 2012
Optimising the brain-stem dead
donorDr Gerlinde Mandersloot
National Clinical Lead - Donor Optimisation
Organ Donation Past, Present and Future 1
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Challenges
4Organ Donation Past, Present and Future
• Physiological consequences of BSD
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‘Collateral damage’
• Hormonal • Diabetes insipidus
• Hypovolaemia• Hypernatraemia
• T3 / T4 reduces• ACTH• Blood glucose
• Hypothermia
Organ Donation Past, Present and Future 5
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Incidence of organ involvement
• Hypotension 81%
• Diabetes insipidus 65%
• DIC 28%
• Cardiac dysrhythmias 25%
• Pulmonary oedema 18%
• Metabolic acidosis 11%
J Heart Lung Transplantation 2004 (suppl)
Organ Donation Past, Present and Future 6
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Challenges
7Organ Donation Past, Present and Future
• Physiological consequences of BSD• Stabilisation and brainstem death testing
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Stabilisation of a patient to facilitate neurological examination
• Difficulties in defining futility, especially in survivors• Replace by concept of ‘Best Interests’
• Not only medical factors taken into account
• Stabilisation of patient prior to BSD testing• Brainstem death testing is part of a neurological examination of the patient
• Clinical in the majority of cases• Ancillary tests where required
• Active management may be necessary in order to examine accurately
• Continued care after BSD to explore possibility of donation
• Integral part of every End of Life Care Plan
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Challenges
9Organ Donation Past, Present and Future
• Physiological consequences of BSD• Stabilisation and brainstem death testing• Consistent donor optimisation
• 65% of units have 2 or fewer donor per year• 23% of donors are from these units• Only 4% units have 10 or more donor per year, 28% of the total donor
population
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Give me a CVP of 6-10
Too much-less than 6
I’d like 10-12
Just get on with it!! Make sure they aren’t hypovolaemic, please
Fluid overload is a problem for us-if we get goals withless that’s good
Lots of fluid please-better function
earlier
Decent perfusion, good gases and BP, it can only
get worse
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Evidence
• Totsuka Transplant Proc. 2000; 32;322-326
• High sodium in liver donor doubles graft loss
• Rosendale Transplantation 2003. 75 (4): 482-487
• Protocol increased organs per donor 3.1 to 3.8. Increased probability of
transplant
• Snell J Heart Lung Transplant 2008;27:662-7
• 54% of Australian lung donations used for transplant vs. 13% in UK
Organ Donation Past, Present and Future 11
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12Organ Donation Past, Present and Future
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Organ Donation Past, Present and Future 13
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Unifying practice across the UK• Optimisation tool
• Non-controversial (or not too controversial)• Not too complicated• One side of an A4 ?• Buy-in from retrieval / transplant community• Easy to audit
• Extended Care Bundle with two components• Prescription: medical staff • Implementation
• Critical care nurses• SN-ODs• ‘Scouts’
• Monitoring implementation
14Organ Donation Past, Present and Future
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15Organ Donation Past, Present and Future
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16Organ Donation Past, Present and Future
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Priorities, if not already addressed
17Organ Donation Past, Present and Future
• Assess fluid status and correct hypovolaemia with fluid boluses as required
• Perform lung recruitment manoeuvre(s) as at risk of atelectasis following apnoea tests
• Identify, arrest and reverse effects of Diabetes insipidus
• Introduce vasopressin infusion: reduces Norepinephrine requirements and treats DI
• Methylprednisolone, 15 mg/kg to max of 1g, as soon as possible
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Hormonal treatment• Vasopressin
• Reduction in other vaso-active drugs• Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time)
• Liothyronine (T3)• No clear evidence for use• May add haemodynamic stability in very unstable donor• Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team
• Methylprednisolone in all cases• Dose: 15 mg/kg up to 1g
• Insulin• At least 1 unit/h (occasionally may need to add glucose infusion)• ‘Tight’ glycaemic control (4 - 10 mmol/l)
Organ Donation Past, Present and Future 18
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19Organ Donation Past, Present and Future
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Monitoring optimisation
20Organ Donation Past, Present and Future
• Implementation: use of care bundle• Adherence easy to monitor• Audit first 5 priorities
• Results of optimisation evaluated• Number of organs retrieved• Increase in cardiothoracic organs retrieved
• Quality of organs: graft function in recipients• Delayed graft function• Quality: biomarkers• Duration of graft function: long term project
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