professional development programme for organ donation dr dermot mckeown dr paul mcandrew andrew...
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Professional Development Programme for Organ Donation
Dr Dermot McKeownDr Paul McAndrewAndrew Broderick
15th June 2010
Donor Management Master Class
“Driving improved organ donation within your hospital”
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Professional Development Programme for Organ Donation
UK Heartbeating Donors 2008-2009
2
Kidney Liver Pancreas Thoracic
612 584(95%)
559(91%)
308(50%)
233(38%)
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Professional Development Programme for Organ Donation
UK Heartbeating Donors 2008-2009
3
612 584 559
308
233
0
100
200
300
400
500
600
700
Total Kidney Liver Pancreas Thoracic
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Professional Development Programme for Organ Donation
Unit Experience
4
UK ICU HBD 2008-9
0
20
40
60
80
100
120
>10 3 to 10 1 to 2 None
Number of Units
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Professional Development Programme for Organ Donation
What Does This Mean?
5
• 65% of units have 2 or fewer donors per year
• 23% of donors are from ICU with 1-2 donors per year
• 4% of units have 10 or more donors per year, 28% of total donor
population
• Need to increase thoracic donation
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Professional Development Programme for Organ Donation
Masterclass Objectives
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• To empower clinical leads to raise awareness of the importance of
donor management in maximising the gift of donation and to put into
place or facilitate effective measures that will increase the number
and quality of organs retrieved from heartbeating brainstem dead
donors
• To nurture a wider understanding of the principles of donor
assessment
• To reduce the number of patients who are not tested for brainstem
death on the grounds of cardio-respiratory instability
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Professional Development Programme for Organ Donation
Agenda
1 Brainstem Death and Management of the Organ Donor 09.30 – 10.00
2 Cardiovascular Management and Cardiac Donation 10.00 – 10.25
3 Respiratory Management and Lung Donation 10.25 – 10.50
Break 10.50 – 11.05
4 Group Discussion 11.05 – 11.35
5 Donor Assessment and Process 11.35 – 12.00
6 Critical Care support to Donor Operation 12.00 – 12.20
7 Case Studies 12.20 – 12.50
8 Summary & Close 12.50 – 13.00
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Professional Development Programme for Organ Donation
Plan for Session
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• Review of physiology of typical donor
• Detailed review
Cardiovascular management and cardiac donation
Respiratory management, fluids and lung donation
• Practicalities of donor management
Organisation and co-ordination
Theatre management
• Case discussions
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Brainstem Death and management of the organ donorDermot McKeown
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Professional Development Programme for Organ Donation10
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Professional Development Programme for Organ Donation11
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Professional Development Programme for Organ Donation12
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Professional Development Programme for Organ Donation
Progression to Brainstem Death (BSD)
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1. Increased ICP
2. Bradycardia
3. Hypertension
• “Sympathetic Storm”
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Professional Development Programme for Organ Donation
Level of Care
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• Full ICU care facilitates appropriate BSD testing
• After BSD testing, continued care maintains potential for donation
• Discussion with relatives
• Donor Management
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Professional Development Programme for Organ Donation
Changes following Brainstem Death (BSD)
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• Cardiovascular
• Hypothermia
• Diabetes Insipidus
• Disseminated Intravascular Coagulation
• Pulmonary
• Inflammation
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Professional Development Programme for Organ Donation
Incidence of Changes
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• Hypotension 81%
• Diabetes Insipidus 65%
• DIC 28%
• Cardiac arrhythmias 25%
• Pulmonary oedema 18%
• Metabolic acidosis 11%
Physiologic changes During Brain Stem Death – Lessons for Management of the Organ
Donor. The Journal of Heart & Lung Transplantation Sept 2004 (suppl)
J Heart Lung Transplantation 2004 (suppl)
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Professional Development Programme for Organ Donation
Donor Management
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• Shift of Goals, but still Intensive
Care
• Increase numbers of donors
• Increase number of organs per
donor
• Improve function of transplantable
organs
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Professional Development Programme for Organ Donation
Evidence for Donor Management
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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
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Professional Development Programme for Organ Donation
Donor Management
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• All donors are potential multiorgan donors
• Aim to make all organs transplantable
• Maintain or improve function
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Professional Development Programme for Organ Donation
Goals
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General Stability
Target Values
Mean Arterial Pressure
60-80 mmHg
CVP 4-10 mmHg
Heart Rate 60-100
Rhythm sinus
Target Values Cardiac Index >2.1 l/min/m2
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Professional Development Programme for Organ Donation
General Care
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• Continue ICU care
• Temperature control
• Give methylprednisolone, review drugs
• Donor Management Guideline
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Professional Development Programme for Organ Donation22
http://www.atca.org.au/
Guidelines
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Professional Development Programme for Organ Donation23
Guidelines
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Professional Development Programme for Organ Donation24
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Professional Development Programme for Organ Donation
General Care “Bundle”
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• Continue ICU care
• Temperature control
• Give methylprednisolone, review drugs
• Donor Management Guideline
• Consider escalation of monitoring
• Relatives may be at bedside
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Professional Development Programme for Organ Donation
Review Notes
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• Intravascular volume
• Review treatment goals
• Osmotic therapy and urine output
• Co-ordinator will review in detail
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Professional Development Programme for Organ Donation27
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Professional Development Programme for Organ Donation
Cardiovascular
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Hormonal Package
Increased Activity:
• Assess clinically
• Invasive monitoring
• Intravenous fluid
• Vasoactive drugs: vasopressor/inotrope
• ECHO
Flow Monitoring
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Professional Development Programme for Organ Donation
xxx
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Professional Development Programme for Organ Donation30
Figure 1: Odds of an organ being recovered and transplanted: Hormonal Resuscitation (HR) verses Non-Hormonal Resuscitation (NHR)
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Professional Development Programme for Organ Donation
Respiratory
31
• Head up positioning
• Lung protective ventilation
• PEEP and lowest possible FiO2
• Recruitment
• Avoid overhydration
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Professional Development Programme for Organ Donation
Diabetes Insipidus
32
• Common in BSD
• Posterior pituitary
• Polyuria, electrolyte disturbance
• Hypovolaemia
• Fluids
• Vasopressin/DDAVP
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Professional Development Programme for Organ Donation
Other Issues
33
• Electrolyte disturbances
• Blood and Coagulopathy
• Spinal reflexes
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Professional Development Programme for Organ Donation
Other Issues
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Professional Development Programme for Organ Donation35
• Donor Referrals + 57%
• Potential Donors + 19%
• Actual donors + 82%
• Lost donors (CVS) 39 to 5 (-87%)
• Organs per donor 3.8-3.6 (-6.5%)
• Organs recovered + 71%
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Professional Development Programme for Organ Donation
Donor Co-ordination
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• Donor assessment
• Donor management
• Offering organs
• Thoracic units
• Retrieval team
• Theatre time
• Transport
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Professional Development Programme for Organ Donation
Questions?
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Professional Development Programme for Organ Donation
Summary
38
• Brainstem death triggers complex pathophysiology
• Active Donor Management can treat this, and maximise donation
• Guidelines assist standard management
• Future developments
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Cardiovascular Management and Cardiac DonationIncreasing Cardiac Donation
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Professional Development Programme for Organ Donation
UK Heartbeating Donors 2008-2009
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Professional Development Programme for Organ Donation
UK Heartbeating Donors 2008-2009
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Professional Development Programme for Organ Donation
UK Cardiothoracic Donors 2008-9
42
Age 0-17 18-34 35-49 50-59 60+
Donors 23 74 87 51 15
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Professional Development Programme for Organ Donation
Ideal Heart Donor
43
< 55 Female, < 50 Male, Good PMH
• No diabetes
• Non-smoking
• No drugs
CVS stable
• Rhythm, normal ECG, no or minimal support
• Good function on ECHO, no LVH
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Professional Development Programme for Organ Donation
Expanded Criteria
44
Age < 65
• No cardiac PMH that precludes transplantation
• ECG without definitive pathology
• Consider smokers, hypertension, arrest or arrythmia, drug abuse,
vasopressor use
• Driven by recipient characteristics
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Professional Development Programme for Organ Donation
Assume all donors can be cardiac donors
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Professional Development Programme for Organ Donation
Targets
46
• Rate 60-100, sinus
• MAP 60-80 mmHg
• CVP ~ 4-10 mmHg
• CI > 2.1 l.min-1.m-2
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Professional Development Programme for Organ Donation
Clinical and Translational Research
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Professional Development Programme for Organ Donation49
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Professional Development Programme for Organ Donation50
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Professional Development Programme for Organ Donation51
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Professional Development Programme for Organ Donation52
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Professional Development Programme for Organ Donation53
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Professional Development Programme for Organ Donation
Adverse Factors
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Effects of ‘Sympathetic Storm’
• Potentially huge rise in catecholamines
• Worse with rapid ICP rise
Effects of vasodilation
• Relative hypovolaemia
• Afterload reduction
Volume status
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Professional Development Programme for Organ Donation
Assessing Volume Status
55
• Review charts, examine patient
• Vital signs and postural effects
• ‘Numbers’
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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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Professional Development Programme for Organ Donation
Priorities
57
Volume
Restore Tone
• Effective Circulating Volume:
Myocardial perfusion
Cardiac function
Organ perfusion
• Avoid Overload
Inotropes?• Optimise cardiac output
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Professional Development Programme for Organ Donation
Assessing Volume Status
58
• Review charts, examine patient
• Vital signs and postural effects
• ‘Numbers’
• Systolic pressure variation
• Response to therapy
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Professional Development Programme for Organ Donation
Flow Measurement
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• Clinical
• Waveforms
• LiDCO
• PiCCO
• Doppler
• Serial ECHO
• PAWPC
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Professional Development Programme for Organ Donation
Volume Therapy
60
• Consider vascular tone
• Restore tone: Vasopressin
• Balanced Colloid or Crystalloid
• Look for significant response
• Flow monitoring
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Vasopressin
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• Vasoconstriction: V1 receptor
• Water reabsorption: V2 receptor
• Increased ACTH secretion: V3 receptor
• (Vasodilation at low concentration - Oxytocin receptors)
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Professional Development Programme for Organ Donation
Priorities (cont’d)
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• Intravascular Volume
• Vascular tone / Vasopressin
• Flow parameters
Direct Cardiac Index
Adequacy of resuscitation
• Appropriate catecholamines
• (T3 , Hydrocortisone, GTN)
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Venkateswaran R V et al. Eur Heart J 2009;30:1771-1780Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: [email protected]
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: [email protected]
Venkateswaran R V et al. Eur Heart J 2009;30:1771-1780
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Intensive management benefits all organs
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Continued Review
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• CVS and adequacy of resuscitation
• Fluid and Electrolytes
• Offering system and liasion with accepting units
• Specialist treatments or investigations
• Continued ICU and theatre management
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Questions?
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Summary
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• Heart donors are precious
• Treat all donors as potential heart donors
• Donor management crucial
• Volume status, Vascular tone (Vasopressin)
• Role of Flow monitoring
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Respiratory Management and Lung DonationIncreasing Lung Donation
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Objectives
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• Understand the effects of the pathophysiology of brainstem death on
lung function
• Understand the consequences of the necessary ventilatory support
for lung function
• Understand how active donor management can improve the number
of lungs offered
• Understand how lung management conflicts with management of
other systems
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UK Heartbeating Donors 2008-2009
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UK Heartbeating Donors 2008-2009
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Professional Development Programme for Organ Donation
UK Cardiothoracic Donors 2008-9
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Age groups
0-17 18-34 35-49 50-59 60+
Number of donors 23 74 87 51 15
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The Lung Donor
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Lung donors, in common with other organ donors are often
classified into :
•Ideal
•Extended criteria
It has become clear that both
donor pools are important and
can meet with clinically
successful outcomes
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Professional Development Programme for Organ Donation
The Ideal Lung Donor (1/2)
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• Age <55 years
• Chest X ray clear
• PaO2 > 39.4 kPa (300mmHg) when FiO2 = 1.0 & PEEP = 5cmH2O?
• Absence of chest trauma
• No evidence of aspiration or sepsis
• Absence of purulent secretions at bronchoscopy
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The Ideal Lung Donor (2/2)
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• Absence of organisms on sputum gram stain
• No history of primary pulmonary disease
• Tobacco history <20 pack-years
• ABO compatibility
• No prior cardiopulmonary surgery
• Size match
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Professional Development Programme for Organ Donation
Assume all donors can be lung donors
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Pathophysiology
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1. Pre-brainstem death
2. Brainstem death
3. Post brainstem death
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Pathophysiology
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• Trauma
• Aspiration
• Infection
Pre-Brainstem Death
1
• Catecholamine
surge
• Systemic
inflammatory
response
Brainstem Death
2
• Conflict
• Lungs v The Rest
Post Brainstem Death
3
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Targets
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• Protective lung ventilation
• Lowest FiO2 possible
• Lung recruitment
• Early steroids
• Minimise lung water
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The Conflicts
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• Fluid management and lung water
The lungs versus the circulation
Flow
• Lung damage
Acute Lung Injury (ALI)
Acute Respiratory Distress Syndrome (ARDS)
Ventilatory strategies
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Ventilation
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Ventilation is associated with characteristic types of damage:
• Barotrauma
• Volutrauma
• Infection
• Aspiration
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Management
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Lung protocols:
• San Antonio Lung Transplant donor management protocol (SALT) Impact of a lung transplantation donor-management protocol on
lung donation and recipient outcomes. Am J Respir Crit Care Med. 2006 Sep
15;174(6):710-6
Ventilator care bundles:
• Head of the bed elevated to 30 degrees
• Ulcer prophylaxis
• DVT prophylaxis
• (Daily sedation hold)
• Pmax < 30cmH2O, Pplat < 25cmH2O
• Lowest FiO2 to maintain SpO2 > 95%
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SALT
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The SALT protocol adopted a number of strategies:
• Education
• Active donor management
Prevent aspiration
Recruitment
Restricting fluid administration
Diuretics
Flow directed therapy
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Professional Development Programme for Organ Donation
Lung Computed Tomography during a Lung Recruitment Manoeuvre in Patients with Acute Lung Injury
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Here we see recruitment in a number of lungs:
•Can have a dramatic
effect on PaO2 values and
PaO2/FiO2 ratios, creating
the ideal donor
•Can also reduce lung
water
•After procedures
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Other Options
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Hormone therapy
• Vasopressin & the dual role
Antidiuresis
Vasoconstriction
• T3
Cardiovascularly unstable
Steroids
• Methylprednisolone 15mg/kg
• As soon as brain death confirmed
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Professional Development Programme for Organ Donation
Assessment
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• Ventilation parameters
• History
• CXR
• Gas exchange
• Bronchoscopy
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Professional Development Programme for Organ Donation
The Expanded Criteria Lung Donor
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• Age >55 years, up to 70 years
• CXR infiltrates are not important
• Purulent secretions
Organisms
• Pack-years > 20
• Unilateral lung damage
• PaO2 > 30kPa (FiO2 1.0, PEEP 5cmH2O)
Pulmonary Venous PvO2 >40kPa
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Professional Development Programme for Organ Donation
Maximizing the number of Lungs for LTx
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Maximizing the number of Lungs for LTx
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PaO2 231mmHg (30.8 kPa)
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Maximizing the number of Lungs for LTx
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PaO2 231mmHg (30.8 kPa)
PV PaO2
94 mmHg(12.4kPa)
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Maximizing the number of Lungs for LTx
93
PaO2 231mmHg (30.8 kPa)
PV PaO2 353 mmHg
(47 kPa)
PV PaO2
94 mmHg(12.4kPa)
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Professional Development Programme for Organ Donation
Assessment Strategies
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• Bronchoscopy
• Direct inspection
• Extra-corporeal perfusion
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Extracorporeal Perfusion
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Professional Development Programme for Organ Donation
Questions?
96