Brain DeathBrain Death& &

Organ Donor Organ Donor ManagementManagement

Roni Lawrence, RN, BSN, CPTCRoni Lawrence, RN, BSN, CPTCClinical ManagerClinical Manager

Organ Procurement CoordinatorOrgan Procurement Coordinator

University of Wisconsin University of Wisconsin

Organ Procurement OrganizationOrgan Procurement Organization

1-866-UWHC OPO1-866-UWHC OPO

(1-866-894-2676)(1-866-894-2676)

Effective Donor Effective Donor ManagementManagement

• Stabilize the donor – Facilitate brain Stabilize the donor – Facilitate brain death exam or DCD Tool.death exam or DCD Tool.

• Manage the donor – To optimize the Manage the donor – To optimize the function and viability of all function and viability of all transplantable organs.transplantable organs.

““In 2006, 6,805 patients with end organ failure died In 2006, 6,805 patients with end organ failure died waiting for a life-saving transplant”waiting for a life-saving transplant”

Effective DonorEffective Donor ManagementManagement

• Requires clinical expertise, vigilance, Requires clinical expertise, vigilance, flexibility, and the ability to address flexibility, and the ability to address multiple complex clinical issues multiple complex clinical issues simultaneously and effectively.simultaneously and effectively.

• Requires collaboration among the Requires collaboration among the OPO, donor hospital critical care staff OPO, donor hospital critical care staff and consultants, and transplant and consultants, and transplant program staff.program staff.

Effective Donor Effective Donor ManagementManagement

• Donor care is not usually assumed Donor care is not usually assumed until after consent for donation has until after consent for donation has been obtained.been obtained.

• It is appropriate to collaborate prior It is appropriate to collaborate prior to brain death, consent, etc, to to brain death, consent, etc, to prevent death and keep the option of prevent death and keep the option of organ donation open.organ donation open.

Effective Donor Effective Donor ManagementManagement

• Revision of existing orders or placement of Revision of existing orders or placement of new medical orders is intended to:new medical orders is intended to:

• D/C medications no longer needed or D/C medications no longer needed or appropriate (e.g., anticonvulsants, appropriate (e.g., anticonvulsants, mannitol, sedatives, antipyretics)mannitol, sedatives, antipyretics)

• Continue needed medications, or therapy Continue needed medications, or therapy (e.g., vasoactive drug infusions, IV fluids (e.g., vasoactive drug infusions, IV fluids and vent settings)and vent settings)

• Create “call orders” that inform bedside Create “call orders” that inform bedside personnel of the goals for physiologic personnel of the goals for physiologic parameters and alert OPC of changes in parameters and alert OPC of changes in donor status.donor status.

Diagnosing Diagnosing and and

Declaring Declaring Brain DeathBrain Death

Uniform Determination of Death ActUniform Determination of Death Act

An individual who has sustained either: An individual who has sustained either:

(1)(1)irreversible cessation of circulatory and respiratory irreversible cessation of circulatory and respiratory function function

or or (2) irreversible cessation of all functions of the (2) irreversible cessation of all functions of the entire entire

brainbrain, including the , including the brain stembrain stem, is dead. A , is dead. A determination of death must be made in accordance determination of death must be made in accordance with accepted medical standards.with accepted medical standards.

JAMA JAMA Nov 13, 1981 – Vol 246, No. 19Nov 13, 1981 – Vol 246, No. 19

Diagnosis of Brain DeathDiagnosis of Brain Death• Brain death is a Brain death is a clinical diagnosisclinical diagnosis. It . It

can be made without confirmatory can be made without confirmatory testing if you are able to establish the testing if you are able to establish the etiology, eliminate reversible causes of etiology, eliminate reversible causes of coma, complete fully the neurologic coma, complete fully the neurologic examination and apnea testing.examination and apnea testing.

• The diagnosis requires demonstration The diagnosis requires demonstration of the absence of both cortical and of the absence of both cortical and brain stem activity, and demonstration brain stem activity, and demonstration of the irreversibility of this state.of the irreversibility of this state.

R. Erff, D.O., R. Erff, D.O., Walter Reed Army Medical CenterWalter Reed Army Medical Center

Etiology of Brain DeathEtiology of Brain Death

• Severe head traumaSevere head trauma

• Aneurismal subarachnoid hemorrhageAneurismal subarachnoid hemorrhage

• Cerebrovascular injuryCerebrovascular injury

• Hypoxic-ischemic encephalopathyHypoxic-ischemic encephalopathy

• Fulminant hepatic necrosisFulminant hepatic necrosis

• Prolonged cardiac resuscitation or asphyxiaProlonged cardiac resuscitation or asphyxia

• Tumors Tumors R. Erff, D.O., R. Erff, D.O., Walter Reed Army Medical CenterWalter Reed Army Medical Center

Prerequisites to the Prerequisites to the DiagnosisDiagnosis

Evidence of acute CNS catastropheEvidence of acute CNS catastrophecompatible with brain death:compatible with brain death:- Clinical or NeuroimagingClinical or Neuroimaging

Exclusion of reversible medical conditions Exclusion of reversible medical conditions that can confuse the clinical assessment:that can confuse the clinical assessment:

- Severe electrolyte, acid base and endocrine Severe electrolyte, acid base and endocrine disturbancedisturbance

- Absence of drug intoxication and poisoningAbsence of drug intoxication and poisoning- Absence of sedation and neuromuscular blockadeAbsence of sedation and neuromuscular blockade- Hypotension (suppresses EEG activity and CBF)Hypotension (suppresses EEG activity and CBF)- Absence of severe hypothermia (core temp < 32 C)Absence of severe hypothermia (core temp < 32 C)

Brain Stem ReflexesBrain Stem Reflexes• Cranial nerve examinationCranial nerve examination::- No pupillary response to light. Pupils No pupillary response to light. Pupils

midline and dilated 4-6mm.midline and dilated 4-6mm.- No oculocephalic reflex (Doll’s eyes) – No oculocephalic reflex (Doll’s eyes) –

contraindicated in C- spine injury.contraindicated in C- spine injury.- No oculovestibular reflex (tonic deviation No oculovestibular reflex (tonic deviation

of eyes toward cold stimulus) – of eyes toward cold stimulus) – contraindicated in ear trauma.contraindicated in ear trauma.

- Absence of corneal reflexesAbsence of corneal reflexes- Absence of gag reflex and cough to Absence of gag reflex and cough to

tracheal suction.tracheal suction.

Apnea TestingApnea Testing • Once coma and absence of brain stem reflexes Once coma and absence of brain stem reflexes

have been confirmed have been confirmed Apnea testingApnea testing..• Verifies loss of most rostral brain stem functionVerifies loss of most rostral brain stem function• Confirmed by Confirmed by PaCO2 > 60mmHgPaCO2 > 60mmHg or or PaCO2 PaCO2

> 20mmHg over baseline value.> 20mmHg over baseline value.• Testing can cause hypotension, severe cardiac Testing can cause hypotension, severe cardiac

arrhythmias and elevated ICP.arrhythmias and elevated ICP.• Therefore, apnea testing is performed last in Therefore, apnea testing is performed last in

the clinical assessment of brain death.the clinical assessment of brain death.• Consider Consider confirmatory testsconfirmatory tests if apnea test if apnea test

inconclusive.inconclusive.

Apnea TestingApnea Testing

• Following conditions Following conditions mustmust be met before be met before apnea test can be performed:apnea test can be performed:

- Core temp > 32.0 C (90 F).Core temp > 32.0 C (90 F).

- Systolic blood pressure > 90mmHg.Systolic blood pressure > 90mmHg.

- EuvolemiaEuvolemia

- Corrected diabetes insipitusCorrected diabetes insipitus

- Normal PaCO2 ( PaCO2 35 - 45 mmHg).Normal PaCO2 ( PaCO2 35 - 45 mmHg).

- Preoxygenation (PaO2 > 200mmHg).Preoxygenation (PaO2 > 200mmHg).

Brain Death in ChildrenBrain Death in Children• Clinical exam is same as in adults.Clinical exam is same as in adults.• Testing criteria depends on age of childTesting criteria depends on age of child..

- - Neonate < 7 days Neonate < 7 days Brain death testing is Brain death testing is not validnot valid..

- - 7 days – 2 months7 days – 2 months- Two clinical exams and two EEG 48 hrs apart.- Two clinical exams and two EEG 48 hrs apart.

- - 2 months – 1 year2 months – 1 year- Two clinical exams and two EEG 24 hrs apart.- Two clinical exams and two EEG 24 hrs apart.- or two clinical exams, EEG and blood flow study.- or two clinical exams, EEG and blood flow study.

- - Age > 1 year to 18 yearsAge > 1 year to 18 years- Two clinical exams 12 hrs apart, confirmatory - Two clinical exams 12 hrs apart, confirmatory study - Optional study - Optional

Confirmatory TestingConfirmatory Testing• Purely optionalPurely optional when the clinical criteria are when the clinical criteria are

met unambiguously.met unambiguously.• A confirmatory test is needed for patients in A confirmatory test is needed for patients in

whom specific components of clinical testing whom specific components of clinical testing cannot be reliably evaluatedcannot be reliably evaluated- Coma of undetermined origin- Coma of undetermined origin- Incomplete brain stem reflex testing- Incomplete brain stem reflex testing- Incomplete apnea testing- Incomplete apnea testing- Toxic drug levels- Toxic drug levels- Children younger than 1 year old.- Children younger than 1 year old.- Required by institutional policy- Required by institutional policy

R. Erff, D.O., R. Erff, D.O., Walter Reed Army Medical CenterWalter Reed Army Medical Center

Confirmatory Tests forConfirmatory Tests for Brain Death Brain Death

• Cerebral Blood Flow (CBF) Studies Cerebral Blood Flow (CBF) Studies – Cerebral AngiographyCerebral Angiography– Nuclear Flow StudyNuclear Flow Study

• EEG (when brain scan is not utilized)EEG (when brain scan is not utilized)

Cerebral AngiographyCerebral Angiography

Normal Blood FlowNormal Blood Flow No Blood FlowNo Blood Flow

Nuclear Flow StudyNuclear Flow Study

Elements of brain Elements of brain death declarationdeath declaration

• DateDate• TimeTime• Detailed Detailed

documentation of documentation of Clinical Exam Clinical Exam including specifics including specifics of Apnea Testingof Apnea Testing

• Physician Physician signaturesignature

What to expect What to expect after brain deathafter brain death

PathophysiologyPathophysiology

• Loss of Loss of brain stem functionbrain stem function results in results in systemic physiologic instability:systemic physiologic instability:

- Loss of vasomotor control leads to a Loss of vasomotor control leads to a hyperdynamic state.hyperdynamic state.

- Cardiac arrhythmias Cardiac arrhythmias

- Loss of respiratory function Loss of respiratory function

- Loss of temperature regulation Loss of temperature regulation HypothermiaHypothermia

- Hormonal imbalance Hormonal imbalance DI, hypothyroidism DI, hypothyroidism

Perioperative Perioperative ManagementManagement

• Following the diagnosis of Brain DeathFollowing the diagnosis of Brain Death

Therapy shifts in emphasis from cerebral Therapy shifts in emphasis from cerebral resuscitation to optimizing organ fxn for subsequent resuscitation to optimizing organ fxn for subsequent transplantation.transplantation.

The normal sequelae of brain death results in The normal sequelae of brain death results in cardiovascular instability & poor organ perfusion.cardiovascular instability & poor organ perfusion.

Medical staff must focus on:Medical staff must focus on:-- Providing hemodynamic stabilization.Providing hemodynamic stabilization.-- Support of body homeostasis.Support of body homeostasis.-- Maintenance of adequate cellular oxygenation Maintenance of adequate cellular oxygenation and and donor organ perfusion.donor organ perfusion.

Without appropriate intervention brain death is Without appropriate intervention brain death is followed by severe injury to most other organ followed by severe injury to most other organ systems. Circulatory collapse will usually occur systems. Circulatory collapse will usually occur within 48hrs. within 48hrs.

Autonomic/Sympathetic Autonomic/Sympathetic StormStorm

• Release of Release of catecholamines from catecholamines from adrenals (Epinephrine adrenals (Epinephrine and Norepinephrine) and Norepinephrine) results in a hyper-results in a hyper-dynamic state:dynamic state:

– TachycardiaTachycardia– Elevated C.O.Elevated C.O.– VasoconstrictionVasoconstriction– HypertensionHypertension

Failure of the Hypothalamus Failure of the Hypothalamus results in:results in:

• Impaired temperature regulation - Impaired temperature regulation - hypothermia or hyperthermiahypothermia or hyperthermia

• Leads to vasodilation without the Leads to vasodilation without the ability to vasoconstrict or shiver (loss ability to vasoconstrict or shiver (loss of vasomotor tone)of vasomotor tone)

• Leads to problems with the pituitary ...Leads to problems with the pituitary ...

Normal Pituitary GlandNormal Pituitary Gland

• Controlled by the Controlled by the hypothalamushypothalamus

• Releases ADH to Releases ADH to conserve waterconserve water

• Stimulates the Stimulates the release of thyroid release of thyroid hormonehormone

Pituitary Failure results in:Pituitary Failure results in:

• ADH ceases to be produced = Diabetes ADH ceases to be produced = Diabetes InsipidusInsipidus

• Can lead to hypovolemia and electrolyte Can lead to hypovolemia and electrolyte imbalancesimbalances

• Leads to problems with the thyroid Leads to problems with the thyroid gland gland

Normal Thyroid Normal Thyroid GlandGland

• Produces hormones that increase the metabolic rate and sensitivity of the cardiovascular system

Levothyroxine (T4)Triiodothyronine (T3)

Thyroid FailureThyroid Failure

Leads to:Leads to:

Cardiac instabilityCardiac instability

Labile blood pressureLabile blood pressure

Potential coagulation Potential coagulation problemsproblems

Cardiovascular SystemCardiovascular System

Intensive care management Intensive care management • ““Rules of 100’s”Rules of 100’s”

-- Maintain SBP > 100mmHGMaintain SBP > 100mmHG-- HR < 100 BPMHR < 100 BPM-- UOP > 100ml/hrUOP > 100ml/hr-- PaO2 > 100mmHgPaO2 > 100mmHg

• Aggressive fluid resuscitative therapy Aggressive fluid resuscitative therapy directed at restoring and maintaining directed at restoring and maintaining intravascular volume. SBP > 90mmHg intravascular volume. SBP > 90mmHg (MAP > 60mmHg) or CVP ~ 10 mmHg.(MAP > 60mmHg) or CVP ~ 10 mmHg.

Neurogenic Pulmonary EdemaNeurogenic Pulmonary Edema

Brain death is associated with numerous Brain death is associated with numerous pulmonary pulmonary problemsproblems

The lungs are highly susceptible to injury resulting The lungs are highly susceptible to injury resulting

from from the rapid changes that occur during the the rapid changes that occur during the catecholamine catecholamine storm storm

Left-sided heart pressures exceed pulmonary Left-sided heart pressures exceed pulmonary pressure, pressure, temporarily halting pulmonary blood flowtemporarily halting pulmonary blood flow

The exposed lung tissue is severely injured, The exposed lung tissue is severely injured, resulting in resulting in interstitial edema and alveolar interstitial edema and alveolar hemorrhage, a state hemorrhage, a state commonly referred to as commonly referred to as neurogenic pulmonary edemaneurogenic pulmonary edema

Release of Plasminogen Release of Plasminogen Activator Activator DIC DIC

Results from the passage of necrotic brain tissue into the Results from the passage of necrotic brain tissue into the circulationcirculation Leads to coagulopathy and sometimes progresses further to DIC Leads to coagulopathy and sometimes progresses further to DIC DIC may persist despite factor replacement requiring early organ DIC may persist despite factor replacement requiring early organ recoveryrecovery

(Also affected by hypothermia, release of catecholamines & hemodilution (Also affected by hypothermia, release of catecholamines & hemodilution as a result of fluid resuscitation)as a result of fluid resuscitation)

Organ Donor Organ Donor ManagementManagement

(in a nutshell)(in a nutshell)

• Hypertension Hypertension Hypotension Hypotension

• Excessive Urinary OutputExcessive Urinary Output

• Impaired Gas Exchange Impaired Gas Exchange

• Electrolyte ImbalancesElectrolyte Imbalances

• Hypothermia Hypothermia

Hypotension Hypotension ManagementManagement

Fluid Bolus – NS or Fluid Bolus – NS or LR LR (Followed by MIVF NS or .45 (Followed by MIVF NS or .45 NS)NS)

Consider colloidsConsider colloids

(seriously)(seriously)

DopamineDopamineNeosynephrineNeosynephrineVasopressinVasopressinThyroxine Thyroxine (T4 protocol)(T4 protocol)

T4 ProtocolT4 ProtocolBackground Background

• Brain death leads to sudden reduction Brain death leads to sudden reduction in circulating pituitary hormones in circulating pituitary hormones

• May be responsible for impairment in May be responsible for impairment in myocardial cell metabolism and myocardial cell metabolism and contractility which leads to contractility which leads to myocardial dysfunctionmyocardial dysfunction

• Severe dysfunction may lead to Severe dysfunction may lead to extreme hypotension and loss of extreme hypotension and loss of organs for transplantorgans for transplant

TT44 Protocol ProtocolBolus:Bolus: 15 mg/kg Methylpred15 mg/kg Methylpred 20 mcg T20 mcg T44 (Levothyroxine) (Levothyroxine)

20 units of Regular Insulin20 units of Regular Insulin 1 amp D1 amp D5050WW

Infusion:Infusion: 200 mcg T200 mcg T44 in 500 cc NS in 500 cc NS

Run at 25 cc/hr (10 mcg/hr)Run at 25 cc/hr (10 mcg/hr) Titrate to keep SBP >100Titrate to keep SBP >100 Monitor Potassium levels closely!Monitor Potassium levels closely!

Vasopressin (AVP, Vasopressin (AVP, Pitressin)Pitressin)

• Low dose shown to Low dose shown to reduce inotrope reduce inotrope useuse

• Plays a critical role in restoring Plays a critical role in restoring vasomotor tonevasomotor tone

Vasopressin ProtocolVasopressin Protocol

4 unit bolus 4 unit bolus 1- 4 u/hour – 1- 4 u/hour – titrate to keep SBP >100 or MAP titrate to keep SBP >100 or MAP

>60>60

DiabetesDiabetes InsipidusInsipidus ManagementManagement

Treatment is aimed at correcting hypovolemiaTreatment is aimed at correcting hypovolemia

Desmopressin (DDAVP) 1 mcg IV, may repeat x Desmopressin (DDAVP) 1 mcg IV, may repeat x 1 after 1 hour.1 after 1 hour.

Replace hourly U.O. on a volume per volume Replace hourly U.O. on a volume per volume basis with MIVF to avoid volume depletionbasis with MIVF to avoid volume depletion

Leads to electrolyte depletion/instability Leads to electrolyte depletion/instability monitor monitor closelyclosely to avoid hypernatremia and hypokalemia to avoid hypernatremia and hypokalemia

DiabetesDiabetes InsipidusInsipidus

• Goal is UOP 1-3 Goal is UOP 1-3 ml/kg/hrml/kg/hr

• Rule of thumb – Rule of thumb – 500 ml UOP per 500 ml UOP per hour x 2 hours is DIhour x 2 hours is DI

• Severe cases – Severe cases – Notify OPC. Assess Notify OPC. Assess clinical situation.clinical situation.

Impaired Gas Impaired Gas ExchangeExchange ManagementManagement

• Maintain PaO2 of >100 and a Maintain PaO2 of >100 and a saturation >95%saturation >95%

• Monitor ABG’s q2h or as Monitor ABG’s q2h or as requested by OPOrequested by OPO

• PEEP 5 cm, HOB up 30PEEP 5 cm, HOB up 30oo

• Increase ET cuff pressure Increase ET cuff pressure immediately after BD declarationimmediately after BD declaration

• Aggressive pulmonary toilet Aggressive pulmonary toilet (Keep suctioning & turning q2h)(Keep suctioning & turning q2h)

• CXR (Radiologist to provide CXR (Radiologist to provide measurements & interpretation)measurements & interpretation)

• OPO may request bronchoscopyOPO may request bronchoscopy

• CT of chest requested in some CT of chest requested in some casescases

Correct Impaired Gas Exchange Correct Impaired Gas Exchange and Maximize Oxygenation!and Maximize Oxygenation!

Most organ donors are referred with:Most organ donors are referred with:

Chest traumaChest traumaAspirationAspirationLong Hospitalization with bed rest resulting in Long Hospitalization with bed rest resulting in

atelectasis or pneumoniaatelectasis or pneumoniaImpending Neurogenic Pulmonary EdemaImpending Neurogenic Pulmonary Edema

Brain Death contributes to and Brain Death contributes to and complicates all of these conditionscomplicates all of these conditions

Impaired Gas ExchangeImpaired Gas ExchangeGoals…Goals…

• Goals are to maintain health of lungs for Goals are to maintain health of lungs for transplant while transplant while optimizing oxygen delivery to optimizing oxygen delivery to other transplantable organsother transplantable organs

• Avoid over-hydration Avoid over-hydration

• Ventilatory strategies aimed to protect the Ventilatory strategies aimed to protect the lunglung

• Avoid oxygen toxicity by limiting Fi02 to Avoid oxygen toxicity by limiting Fi02 to achieve a Pa02 100mmHg & PIP < 30mmHg.achieve a Pa02 100mmHg & PIP < 30mmHg.

Electrolyte Imbalance Electrolyte Imbalance ManagementManagement

HypokalemiaHypokalemia

If KIf K++ < 3.4 – Add KCL to MIVF < 3.4 – Add KCL to MIVF (anticipate low K(anticipate low K++ with DI & T with DI & T44 administration) administration)

HypernatremiaHypernatremia

If NAIf NA++ >155 – >155 – Change MIVF to include more free HChange MIVF to include more free H220, 0, Free HFree H220 boluses down NG tube (this is often the result of 0 boluses down NG tube (this is often the result of dehydration, NAdehydration, NA++ administration, and free H administration, and free H220 loss 20 loss 2oo to to

diuretics or DI)diuretics or DI)

Calcium, Magnesium, and PhosphorusCalcium, Magnesium, and PhosphorusDeficiencies here common…often related to Deficiencies here common…often related to polyuria associated with osmotic diuresis, polyuria associated with osmotic diuresis,

diuretics & DI.diuretics & DI.

Hypothermia Hypothermia ManagementManagement

• Monitor temperature Monitor temperature continuouslycontinuously

• NO tympanic, axillary or NO tympanic, axillary or oral temperatures. Central oral temperatures. Central only.only.

• Place patient on Place patient on hypothermia blanket to hypothermia blanket to maintain normal body maintain normal body temperaturetemperature

• In severe cases (<95 In severe cases (<95 degrees F) consider:degrees F) consider:– warming lightswarming lights– covering patient’s head with covering patient’s head with

blanketsblankets– hot packs in the axillahot packs in the axilla– warmed IV fluidswarmed IV fluids– warm inspired gaswarm inspired gas

AnemiaAnemia

Hematocrit < 30% must Hematocrit < 30% must be treatedbe treated

Transfuse 2 units PRBC’s Transfuse 2 units PRBC’s immediatelyimmediately

Reassess 1Reassess 1oo after after completion of 2completion of 2ndnd unit and unit and repeat infusion of 2 units if repeat infusion of 2 units if HCT remains below 30%HCT remains below 30%

Assess for source of blood Assess for source of blood loss and treat accordinglyloss and treat accordingly

Incidence of pathophysiologic Incidence of pathophysiologic changes following Brain Death:changes following Brain Death:

- - HypotensionHypotension 81%81%-- Diabetes InsipidusDiabetes Insipidus 65%65%-- DICDIC 28%28%-- Cardiac arrhythmiasCardiac arrhythmias 25%25%-- Pulmonary edemaPulmonary edema 18%18%-- Metabolic acidosisMetabolic acidosis 11%11%

Physiologic changes During Brain Stem Death – Lessons for Physiologic changes During Brain Stem Death – Lessons for Management of the Organ Donor. Management of the Organ Donor.

The Journal of Heart & Lung Transplantation Sept 2004 (suppl)The Journal of Heart & Lung Transplantation Sept 2004 (suppl)

Organ Donation Organ Donation ProcessProcess

• Evaluate organ function Evaluate organ function • Labs (& UA) within 6 Labs (& UA) within 6

hours of surgeryhours of surgery• Type and ScreenType and Screen• Consent signedConsent signed• Serology testingSerology testing• Medical Social HistoryMedical Social History• Locate potential Locate potential

recipientsrecipients• Manage hemodynamicsManage hemodynamics• Arrange operating roomArrange operating room

The Teams...The Teams...Your Hospital- Anesthesia - Anesthesia

- Primary Care Physician or Intensivist (For DCD)- Primary Care Physician or Intensivist (For DCD)

- Surgical Technician/Scrub NurseSurgical Technician/Scrub Nurse

- Circulating NurseCirculating Nurse

Abdominal Transplant Team- Surgeon- Surgeon

- Physician Assistant- Physician Assistant

- Surgical Recovery Coordinator- Surgical Recovery Coordinator

Cardiothoracic Team- Surgeon- Surgeon

- Surgical Fellow- Surgical Fellow

- Surgical Recovery Coordinator- Surgical Recovery Coordinator

Organ Preservation TimeOrgan Preservation Time

• Heart: 4-6 hours

• Lungs: 4-6 hours

• Liver: 12 hours

• Pancreas: 12-18 hours

• Kidneys: 72 hours

• Small Intestines: 4-6 hours