Management of the Cardiac Donor

Monica Colvin-Adams, MDUniversity of Minnesota

Heart Failure/Cardiac Transplant

What are the goals? Successful organ recovery

Timeliness in order to save patient and minimize ischemic time

Respectful organ recovery

Optimize the function of each organ

Place as many organs as possible

Keep the doctors happy?

Aim of Organ Transplant Breakthrough Aim of Organ Transplant Breakthrough Collaborative (OTBC)Collaborative (OTBC)

““Save or enhance thousands of lives a year by maximizing the number of Save or enhance thousands of lives a year by maximizing the number of organs transplanted from each and every donor…achieve an average of 3.75 organs transplanted from each and every donor…achieve an average of 3.75 organs transplanted per donor.”organs transplanted per donor.”

---- Launched October 2005---- Launched October 2005

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Data source: OPTN database as of 8/2007

Collaborative starts here

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Organ Donation / Organ Transplantation Breakthrough Collaboratives in Synergy

Organs Transplanted Per Month With 12 Month Moving Average

CollaborativeStart Date

Close “the Gap”; Reach “Capacity,” Achieve 35,000

Capacity is reached when a DSA produces 75% conversion rates

3.75 organs transplanted per donor and 10% DCD (with 2.75 OTPD)

generates sufficient resources to transplant the resulting organ supply.

Goal of the Transplant Growth and Management Collaborative (TGMC)

“Save or enhance thousands of lives a year by maximizing the number of organs transplanted from each and every donor and building the necessary capacity within the Nation’s transplant programs to transplant 35,000 organs annually.”

Launched in October 2007

Learning ObjectivesDefine hemodynamics and the meaning of the

various measurements

Describe the hemodynamic concerns that arise with managing patients experiencing brain death

Discuss the “tensions” between organ procurement groups related to varying hemodynamic targets

Identify strategies to support the donor while yielding the greatest number of viable organs for transplant

Donor Assessment and Evaluation

Donor Assessment and EvaluationDonor History and Physical

Hemodynamic evaluation

Pressor and Inotropic Requirement

Cardiac Output

Cardiac Enzyme Markers

ECG

Echocardiogram

Coronary Angiogram

And then there are the issues surrounding the patient’s death. . .Cause of death – potential for organ trauma

Potential aspiration – risk of lung injury

Brain injury – associated with myocardial suppression

Diabetes insipidus – fluid losses build quickly

Intubated, ventilated patient - risk for pneumonia

Assessment and Evaluation Demographics

ABO

Cause of brain death

Time of declaration

Viral serologies

Substance use

Donor History Thoracic trauma

Hemostability

Pressors/inotropes

Down time (duration of cardiac arrest)

CPR

Hypotension

Donor Issues that may affect the outcome of the recipient Ischemia Time

Age

Size

Cause of Death

Substance Abuse

Ischemic Time Four hours is acceptable

Prolonged ischemic time associated with mortality and possibly graft vasculopathy after heart transplant, especially when complicated by older donor, increased resource utilization-conflicting data

Longer ischemic times may be acceptable in pediatric patients

Ischemic injury and contraction band necrosis

Preventive measures: post-conditioning, warm blood cardioplegia

Increased ischemic time allows for prospective CM, LVAD patients

Age Patient specific approach

Up to age 50-55

ISHLT registry increased mortality with older donors

Relationship between donor age and CAV (?): age related endothelial dysfunction

RV failure due to stiffer hearts

Donor age > 50 is a predictor of perioperative and long-term mortality

Del Rizzo et al. JHLT 1999

Analysis of Ischemic Time and Age: UNOS analysis

Russo et al. Cardiothoracic Transplantation 2007

Russo et al. Cardiothoracic Transplantation 2007

Analysis of Ischemic Time and Age: UNOS analysis

Size Matters Donor mismatch greater than 30% is a contraindication

Undersizing Pulmonary Hypertension

Oversizing Acute MI and urgent LVAD implantation Multiple cardiac surgeries with adhesions Cachexia

Case Donor Management Goals

•SBP >90•CVP 4-8•Final PO2 >350•PH 7.35-7.45•Glucose <200•Temp 96.8-99.6•UO 1-2cc kg/hr•NA <160•Total Fluid Balance @ DM and OR

The Deceased Organ Donor

BowelBowel

PancreasPancreas

LiverLiver

KidneysKidneys

LungsLungs

HeartHeart

DeceasedDeceasedDonorDonor

Transplant Surgeons:Not All On the Same Page

BowelBowel

PancreasPancreas

LiverLiver

KidneysKidneys

LungsLungs

HeartHeart

DeceasedDeceasedDonorDonor

“Don’t wreck it!”

“CVP 2-5”

“CVP 10-12”

“Keep it perfused”

“CVP 6-10”

“The more themerrier”

What do they really mean?

BowelBowel

PancreasPancreas

LiverLiver

KidneysKidneys

LungsLungs

HeartHeart

DeceasedDeceasedDonorDonor

“Like all organs, itneeds perfusion, butis less volume sensitive”

“Hypoperfusion cancause organ damage”

“Fluid excess can causealveolar infiltration and render lungs untransplantable”

“Hypoperfusion can stimulate ATN, injuringthe kidney and complicating recovery”

“The liver is less volume sensitive exceptin severe volume depletion or shock”

“Fluid excess can stress the heart”

What’s a Donor Coordinator to Do?

CardiacSurgeon

LiverSurgeon

Donor Coordinators

Brain Death

Physiologic Effects of Brain Death

Effects of Brain DeathHypotension 81%

Diabetes Insipidus 65%

DIC 28%

Arrhythmias 25%

Pulmonary Edema 18%

Metabolic Acidosis 11%

Martin Smith JHLT 2004

Aggressive management Early ID of donors

Admit to ICU

PA catheter

IVF resuscitation

VP to maintain MAP >70 if IVF fail

Hormonal treatment when dopamine or DBE > 10 mcg/kg/mn

Management of complications of brain death

Thyroid Hormone Decreased T3 (triiodothyronine) and conversion of T4 (thyroxine) to T3 after

brain death

Results in lactic acidosis, hypotension

Thyroid hormone is a positive inotrope

Shown to reverse lactic acidosis in experimental model

Hormone Replacement TherapyIncreases Organ Salvage

N= 123

Aggressive management + T4

Organ recovery 3.9 +/- 1.7 vs. 3.2 +/- 1.7, P=0.048

Retrospective study

Improves Outcomes UNOS analysis

Addition of T4

46% decrease in risk of death at 30 days

48% decrease in risk of graft dysfunction

Salim et al. Clinical Trans 2007

Rosedale et al. Transplantation 2003

Interventions

Importance of Serial Echos16 patients with WMA

13 with EF < 50%

12 patients improved EF between echos 1 and 2

Responsiveness to dobutamine is acceptable

Zaroff et al. JHLT 2003

Hemodynamics

Hemodynamics of Forward Flow

Cardiac OutputCardiac Output

Heart RateHeart Rate Stroke VolumeStroke Volume

PreloadPreload ContractilityContractility AfterloadAfterload

Hemodynamics of Forward Hemodynamics of Forward FlowFlow

Cardiac OutputCardiac Output(CO, CI)(CO, CI)

Heart RateHeart Rate(HR)(HR)

Stroke VolumeStroke Volume(SV, SVI)(SV, SVI)

PreloadPreload(CVP, RAP)(CVP, RAP)

(PCWP, PAOP, LAP)(PCWP, PAOP, LAP)

ContractilityContractility(RVSW, RVSWI)(RVSW, RVSWI)(LVSW, LVSWI)(LVSW, LVSWI)

AfterloadAfterload(PVR, PVRI)(PVR, PVRI)(SVR, SVRI)(SVR, SVRI)

Hemodynamic Monitoring

Hemodynamic Measured Values

TermTerm DescriptionDescription Normal ValuesNormal Values

CVPCVPRAPRAP

Central venous pressureCentral venous pressureRight atrial pressureRight atrial pressure

0-8 mmHg0-8 mmHg

RVPRVP Right ventricular pressureRight ventricular pressure 25/5 mmHg25/5 mmHg

PAPPAP Pulmonary artery pressurePulmonary artery pressure 25/12 mmHg25/12 mmHg

PCWPPCWPPAOPPAOP

Pulmonary capillary wedge pressurePulmonary capillary wedge pressurePulmonary artery occlusion pressurePulmonary artery occlusion pressure

10 mmHg10 mmHg

LAPLAP Left atrial pressureLeft atrial pressure 8 mmHg8 mmHg

HRHR Heart RateHeart Rate 60-100 60-100 beats/min (in beats/min (in

adults)adults)

Hemodynamic Goals

SBP >100 <150, DBP >50, <90

HR<100 >50

CVP 4-6

UO 1-2cc/kg/hr

Sustained hypotension increases inflammatory response from previous pro-inflammatory activation by sympathetic discharge associated with brain stem herniation (Arbor, 2005)

Volume Resuscitation

Resuscitation NaCl

CVP <4, Na+ <150, UO <1-2cc/kg/hr

D5W-Na+ >150

Colloids-avoid 5% albumin

Maintenance IVF

Na+ <150-D51/2 NS Na+ >150-D5W

Addition of K+ per serum K+ levels and frequency of K+ replacement

Rate-adjust to maintain CVP 4-6, UO 1-2cc/kg/hr

Hypotension Hypertension SBP <100, HR <100

Dopamine-max 20 mcg/kg/min

SBP <100, HR >100

Neosynephrine-max 200mcg/min Fluid Resuscitation

NaCl- bolus if CVP <4, Na+ <150 D5W-Na+ >150

SBP <100, EF <40%, CVP >6 Dobutamine

BP 150/90, HR >100

Labetalol 10-20mg IVP Q10min, max 300mg

Esmolol gtt 50mcg/kg/min-titrate max 200mcg/kg/min

BP 150/90, HR <100

Nipride gtt

0.1mcg/kg/min-titrate max 8mcg/kg/min

Arrhythmias Tachycardia in absence of hypotension

Diltiazem

Esmolol

Labetalol Arrythymia-atrial/ventricular

Diltiazem

Esmolol

Amiodarone

Hemodynamic Impact of Commonly Used Meds in Donor Management

Agent C.O./C.I.

H.R. Preload(CVP,

PCWP)

Contractility

(RVSWI, LVSWI)

Afterload(PVR, SVR)

BP

Diuretics(Lasix,

Bumex, etc.)

or or or

Dopamine(Inotrope)

(esp. in hypo-volemia

or (esp. in doses > 10 mcg/kg/mi

n)

Dobutamine(Dobutrex)

or or

Neosynephrine

Norepinephrine

(Levophed)

Vasopressin or

PulmonaryGOALS

SaO2 96%, PaO2 100 on 40% FiO2, PCO2 35, CVP 4-6

PaO2 >350 on 100% FiO2

CXR clear

UO 1-2cc/kg/hr

Interventions Lasix, Torsemide, Bumex

Aggressive pulmonary toilet (Link vest/CPT vest Q2hrs)

Early bronchoscopy

Aggressive Ventilator management

Ventilatory ManagementTV 10cc/kgPEEP 5cm H2OFiO2-adjust keeping SaO2 >96%, PaO2 >100. Keep FiO2 at lowest

setting I/E Ratio 1:2Rate-PCO2 x rate/40End expiratory pause 0.5 secSigh 1.5xTV Q2hrs (if able)PIP <30

Pulmonary Recruitment Maneuvers

Anesthesia bag w/manometer

Inflate and deliver breath to 40cm pressure hold x45 secs as tolerated-may repeat hourly PRN

PEEP 10 x2hrs

Pulmonary: medications

Albuterol/Atrovent neb Q4HRS, Q2HRS PRNSolumedrol 2G IV (30mg/kg <70kg) followed by 1 G (15mg/kg

<70kg) in 12 hrsDopamine 3mcg/kg/min (if not infusing, absence of HTN)Zosyn 3.375G IV Q6HRSNarcan 8mg IVP-use with quick herniation syndromes, not

effective in anoxic/occlusive CVA

Neurogenic Pulmonary Edema Common occurrence with brain death

Within minutes to hours of CNS insult

Blast Theory

Permeability Defect Theory

Neurogenic Pulmonary Edema: Blast Theory

Massive sympathetic dischargeSystemic arterial hypertension, peripheral

vasoconstriction, increased pulmonary arterial pressure and pulmonary mircovascular vasoconstriction

Pulmonary congestion with development of pulmonary edema

Endothelial damage

Permeability Defect TheoryNPE caused by neurologic increase in capillary permeability

Sympathetic stimulation affects vasculature permeability from altered endothelium allowing fluid to enter the interstitial space

Management of NPE Narcan

8 mg IVP x1

-Shown to prevent/reduced NPE in sheep (Peterson, et al. 1983)

-Suggests role of endorphins in alteration of pulmonary capillary permeability

-Controversial

-May increase spinal reflexes

Diabetes Insipidus Hypothalamic/hypophyseal loss of function limiting posterior pituitary ADH

production

UO > 250cc/hr x2 hours

Vasopressin gtt

DDAVP IVP

Crystalloid bolus

Anaerobic MetabolismLevothyroxine (T4) gtt

Any remaining hypothalamic/pituitary function too low to maintain adequate hormone levels causing anaerobic metabolism and mitochondrial dysfunction

Increased lactate and pyruvate levels with decreased cortisol levels are associated w/increased vasopressor/inotropic requirements and decreased myocardial contractility

Anaerobic metabolism cont. T4 (Levothryoxine)

T4 400mcg/500cc D5W

Pre-medicate in rapid succession in order as follows:

1 amp D50 IVP x1

2 G Solumedrol IVP x1 (If 1 G already given as ordered above give an additional 1 G IVP)

20U regular insulin IVP X1

20 mcg T4 IVP x1

Start T4 IV gtt at 10mcg/hr, max 50mcg/hr. Rate increases determined by Donation Coordinator.

CoagulopathyCommon occurrence with direct brain injury (GSW,

penetrating/blunt injury)

-rapid consumption of circulating clotting factors from release of thromboplastin, fibrinogen and tissue plasminogen (DIC)

Dilution

-large volume resuscitation with colloids and crystalloids

-not as common

Coagulopathy: Management

-FFP

-platelets

-cryoprecipitate

-vitamin K IV

Hemodynamic Strategy #1:Optimize Fluid StatusVolume resuscitation important before

initiating pressors

Target wedge pressure (5 - 10 mmHg)

Target CVP (4 - 7 mmHg)

Target SVR (800 - 1200 dynes/sec/cm-5)

Consider replacing urine output ml/ml with D5W 0.45%NaCl + 20 mEq KCl/liter

Target cardiac index > 2.5 L/min/m2

Hormonal resuscitation Methylprednisolone (SoluMedrol)Vasopressin Triiodothyronine or thyroxine

Vasoactive infusions Dopamine DobutamineLevophedNeosynephrine

Hemodynamic Strategy #2:Hemodynamic Strategy #2:Optimize Cardiac OutputOptimize Cardiac Output

Pressure = Flow x ResistancePressure = Flow x Resistance Blood Pressure = C.O. x SVRBlood Pressure = C.O. x SVR Vasoactive infusions effecting blood Vasoactive infusions effecting blood

pressure pressure Dopamine Dopamine DobutamineDobutamine LevophedLevophed NeosynephrineNeosynephrine

Hemodynamic Strategy #3:Hemodynamic Strategy #3:Optimize Blood PressureOptimize Blood Pressure

Summary Aggressive management results in improved organ availability

Aggressive management improves outcomes

Reassess!

Involve the transplant center

Case 22 yo male potential donor

Motorcycle accident

OPO called prior to brain death

History of occasional cocaine use, ETOH

No medical history

No significant family history

Case: Exam BP 87/60 HR 115 O2 sat 100%

No JVD, Lungs clear, trace edema

What initial steps should you take?

Patient receives aggressive hydration while undergoing assessment

8 hours later, BP still 85/60 HR 118

What next?

Echo EF probably normal, but concern for basilar hypokinesis, mild RV dilatation;

pictures are limited

RA 12 PA 34/15 PCWP 15 CI 4

What are your options?

Other potential issues: patient is CMV +, potential recipient is CMV-

What if patient were HCV +

The other side 55yo patient with ischemic cardiomyopathy

History of MI

PA 70/45 prior to VAD, now 45/22 with PCWP 17

BMI 33 kg/m2

What are the considerations for this patient?