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TRANSCRIPT
Organ Donor Management:What to Expect After Brain Death
Heather Angell, RN, MSNOrgan Procurement Coordinator
Pathophysiology
o Lossofbrainstemfunctionresultsinsystemicphysiologicinstability:
o Lossofvasomotorcontrolleadstoahyperdynamicstateo Cardiacarrhythmiaso Lossofrespiratoryfunctiono Lossoftemperatureregulation→hypothermiaoHormonalimbalance→DI,hypothyroidism
Effective Donor Management
o StabilizetheDonoro FacilitatebraindeathexamorDCDtool
oManagetheDonoro Tooptimizethefunctionandviabilityofalltransplantableorgans
o Evaluateeachorgano Bedsideliverbiopsy,ECHO,bronchoscopy
21peopledieeachdayawaitingalife‐savingorgantransplant
Effective Donor Management
oRequiresclinicalexpertise,vigilance,flexibility,andtheabilitytoaddressmultiplecomplexclinicalissuessimultaneouslyandeffectively.
oRequirescollaborationamongUWOTD,donorhospitalcriticalcarestaffandconsultants,andtransplantprogramstaff.
Effective Donor Management
oDonorcareisnotusuallyassumeduntilafterconsentfordonationhasbeenobtained.
o Itisappropriatetocollaboratepriortobraindeath,consent,etc.,topreventdeathandkeeptheoptionoforgandonationopen.
Effective Donor Management
oRevisionofexistingordersorplacementofnewmedicalordersisintendedto:o D/Cmedicationsnolongerneededorappropriate(e.g.,anticonvulsants,Mannitol,sedatives,antipyretics)
o Continueneededmedicationsortherapy(e.g.,vasoactivedruginfusions,IVfluids,ventsettings)
o Create“callorders”thatinformbedsidepersonnelofthegoalsforphysiologicparametersandalertOPCofchangesindonorstatus
Following the Diagnosis of Brain Death
o Therapyshiftsinemphasisfromcerebralresuscitationtooptimizingorganfunctionforsubsequenttransplantation.
o Thenormalsequelaeofbraindeathresultsincardiovascularinstability&poororganperfusion.
o Medicalstaffmustfocuson:o providinghemodynamicstabilization.o supportofbodyhomeostasis.o maintenanceofadequatecellularoxygenationanddonororganperfusion.
o Withoutappropriateintervention,braindeathisfollowedbysevereinjurytomostotherorgansystems.Circulatorycollapsewillusuallyoccurwithin48hrs.
Autonomic/Sympathetic Storm
oReleaseofcatecholaminesfromadrenals(EpinephrineandNorepinephrine)resultsinahyper‐dynamicstate:o Tachycardiao ElevatedC.O.o Vasoconstrictiono Hypertension
Failure of the Hypothalamus Results in:
o Impairedtemperatureregulation‐ hypothermiaorhyperthermia
o Leadstovasodilationwithouttheabilitytovasoconstrictorshiver(lossofvasomotortone)
o Leadstoproblemswiththepituitary
Normal Pituitary Gland
o Controlledbythehypothalamus
oReleasesADHtoconservewater
o Stimulatesthereleaseofthyroidhormone
Pituitary Failure
oPituitaryFailureResultsin:oADHceasestobeproduced=DiabetesInsipidus
oCanleadtohypovolemiaandelectrolyteimbalances
oLeadstoproblemswiththethyroidgland
Normal Thyroid Gland
o Produceshormonesthatincreasethemetabolicrateandsensitivityofthecardiovascularsystemo Levothyroxine(T4)o Triiodothyronine(T3)
Thyroid Failure
o Thyroidfailureleadsto:
o Cardiacinstability
o Labilebloodpressure
o Potentialcoagulationproblems
Cardiovascular System
IntensiveCareManagement
o “Rulesof100’s”o MaintainSBP>100mmHGo HR<100BPMo UOP>100ml/hro PaO2>100mmHg
o Aggressivefluidresuscitativetherapydirectedatrestoringandmaintainingintravascularvolumeo SBP>90mmHg(MAP>60mmHg)orCVP~10mmHg
Neurogenic Pulmonary Edema
o Braindeathisassociatedwithnumerouspulmonaryproblems
o Thelungsarehighlysusceptibletoinjuryresultingfromtherapidchangesthatoccurduringthecatecholaminestorm
o Left‐sidedheartpressuresexceedpulmonarypressure,temporarilyhaltingpulmonarybloodflow
o Theexposedlungtissueisseverelyinjured,resultingininterstitialedemaandalveolarhemorrhage,astatecommonlyreferredtoasneurogenicpulmonaryedema
Release of Plasminogen Activator DIC
oResultsfromthepassageofnecroticbraintissueintothecirculation
o LeadstocoagulopathyandsometimesprogressesfurthertoDIC
oDICmaypersistdespitefactorreplacementrequiringearlyorganrecover
(Alsoaffectedbyhypothermia,releaseofcatecholamines&hemodilutionasa
resultoffluidresuscitation)
Organ Donor Management(In a Nut Shell)
oHypertension HypotensionoExcessiveUrinaryOutputoImpairedGasExchangeoElectrolyteImbalancesoHypothermia
Hypotension Management
o FluidBolus– NSorLR(FollowedbyMIVFNSor.45NS)
o Considercolloids(seriously)o Thyroxine(T4 protocol)oVasopressinoDopamineoNeosynephrine
T4 Protocol
oBackgroundo Braindeathleadstosuddenreductionincirculatingpituitaryhormones
o Mayberesponsibleforimpairmentinmyocardialcellmetabolismandcontractilitywhichleadstomyocardialdysfunction
o Severedysfunctionmayleadtoextremehypotensionandlossoforgansfortransplant
o ECHOafter6hoursofstartingT4o Heartcath
T4 Protocol
oBoluso 15mg/kgMethylpredo 20mcgT4 (Levothyroxine)o 20unitsofRegularInsulino 1ampD50W
o Infusiono 200mcgT4in500mlNSo Runat25ml/hr(10mcg/hr)o TitratetokeepSBP>100
Monitorpotassiumlevelsclosely!
Vasopressin(AVP, Pitressin)
o Lowdoseshowntoreduceinotropeuse
o Playsacriticalroleinrestoringvasomotortone
oVasopressinProtocolo 4unitboluso 1‐ 4u/hour– titratetokeepSBP>100orMAP>60
Diabetes Insipidus Management
o Treatmentisaimedatcorrectinghypovolemia
oDesmopressin(DDAVP)1mcgIV,mayrepeatx1after1hour
oReplacehourlyurineoutputonavolumepervolumebasiswithMIVFtoavoidvolumedepletion
o Leadstoelectrolytedepletion/instabilitymonitorcloselytoavoidhypernatremiaandhypokalemia
Diabetes Insipidus
oGoalisUOP1‐3ml/kg/hr
oRuleofthumb– 500mlUOPperhourx2hoursisDI
o Severecases– NotifyOPC,assessclinicalsituation
Impaired Gas Exchange Management
o MaintainPaO2of>100andasaturation>95%
o MonitorABG’sq2horasrequestedbyOPO
o PEEP5cm,HOBup30oo IncreaseETcuffpressureimmediatelyafterBDdeclaration
o Aggressivepulmonarytoilet(keepsuctioning&turningq2h)
o CXR(radiologisttoprovidemeasurements&interpretation)
o OPOmayrequestbronchoscopyo CTofchestrequestedinsomecases
Correct Impaired Gas Exchange and Maximize Oxygenation!
oMostorgandonorsarereferredwith:oChesttraumaoAspirationoLonghospitalizationwithbedrestresultinginatelectasisorpneumonia
o ImpendingNeurogenicPulmonaryEdema
Braindeathcontributestoandcomplicatesalloftheseconditions.
Impaired Gas ExchangeGoals…
oGoalsaretomaintainhealthoflungsfortransplantwhileoptimizingoxygendeliverytoothertransplantableorgans
oAvoidover‐hydration
oVentilatorystrategiesaimedtoprotectthelung
oAvoidoxygentoxicitybylimitingFi02toachieveaPa02100mmHg&PIP<30mmHg
Electrolyte Imbalance ManagementHypokalemia
IfK+ <3.4– AddKCLtoMIVF(anticipatelowK+ withDI&T4 administration)
HypernatremiaIfNA+ >155– ChangeMIVFtoincludemorefreeH20,FreeH20bolusesdownNGtube(thisisoftentheresultofdehydration,NA+ administration,
andfreeH20loss2o todiureticsorDI)
Calcium,Magnesium,andPhosphorusDeficienciesherecommon…oftenrelatedtopolyuriaassociated
withosmoticdiuresis,diuretics&DI.
o Monitortemperaturecontinuouslyo NOtympanic,axillaryororaltemperatures.Centralonly.
o Placepatientonhypothermiablankettomaintainnormalbodytemperature
o Inseverecases(<95degreesF)consider:o warminglightso coveringpatient’sheadwithblankets
o hotpacksintheaxillao warmedIVfluidso warminspiredgas
Hypothermia Management
Anemia
o Hematocrit<24%mustbetreated
o Transfuse2unitsPRBC’simmediately
o Reassess1oaftercompletionof2ndunitandrepeatinfusionof2unitsifHCTremainsbelow24%
o Assessforsourceofbloodlossandtreataccordingly
Incidence of Pathophysiologic Changes Following Brain Death
PhysiologicchangesDuringBrainStemDeath– LessonsforManagementoftheOrganDonor.TheJournalofHeart&LungTransplantationSept2004(suppl)
Hypotension 81%DiabetesInsipidus 65%DIC 28%Cardiacarryhythmias 25%Pulmonaryedema 18%Metabolicacidosis 11%
Why We Do This!
Fromanorgandonorfamilymember:
Weareforevergratefulthatthedoctorsaskedifwewouldconsiderorgandonation.Itwaslikearayofsunshineinthevoid.Wecouldn’taskforabettergiftthantohavesomethingpositivecomefromour
tragedy.ApartofRobwouldnowlivethroughothers.
