Organ Recovery & Preservation

CPTC Review Course

Christina B. Pippin, RN, CPTC

Understanding the

Procurement Process

Donor stability during transport…

• BE PREPARED!!!• IV access (patent labeled lines)

• Pumps (consolidate IV bags & ensure the pump is charged)

• Fluid/IV drug availability / supply (be prepared to bolus)

• Emergency drugs (unstable donors)

• Always use bedside monitor for transport (check vital signs & identify norms)

• Anesthesia (utilize for transport)

Ventilation & Transport…

• Thorough suctioning

• Check 02 tank / ambu bag

• Consider use of PEEP valve for elevated PEEP requirements

• PEEP >20 – consider ventilator

• Monitor 02 saturation

Preparing the Operating Room…

• Large O.R. suite• Staffing the O.R.-

(Circulating RN, CST, Anesthesia)• OPO supplies / O.R. pack• Host hospital set-up -

major tray, CV tray, sternal saw, retractors (chest & balfour), electro-cautery units, back tables, IV poles, etc.

• SUCTION, SUCTION, SUCTION!!!• Have PRBC’s available (2 units)• Stat labs & pathology if needed (alert early)• Anesthesia meds (steroids, diuretics, muscle

relaxants, heparin, antibiotics, hormones, GI preps

• Patient chart, key plate, & X-rays• Perfusion supplies (flush, tubing, A/V

catheters, containers, labels - OPTN policy 5.5)

• Misc. supplies (ice, sterile slush, warming blanket/heat lamps, crash cart with internal paddles, & biopsy supplies)

Aseptic Technique

• Asepsis – absence of pathenogenic organisms.– Exogenous microorganisms cause surgical

infections

• Aseptic Technique – practice of preventing infection by minimizing exposure to exogenous microbes

– Maintaining aseptic technique during organ preservation:

1. Be aware of sterile fields (patient, personnel, back-tables,

etc)2. Monitor sterile field for potential

contaminants

Common in-situ cannulation sites:• Splenic or portal vein for abdominal organ

recovery• Abdominal aorta for abdominal organ recovery • Pulmonary artery for lung recovery • Aortic root for heart recovery

Documentation & verbal reports…

• Review with O.R. charge nurse:-Verification of death-Signed document of gift / designation (Consent)-Patient’s medical record-Documentation of team members / license data.

• Review written guidelines with anesthesia personnel per AOPO requirement & identify the following:-Vascular access-Vasopressors- Parameters for VS, fluid replacement, & pharmacologic provisions / restrictions

• Review with Recovering surgeon:-ABO (must sign, date, & time form per

new CMS regulation)-Brain death notes -Consent-Serology results

Operating Room Responsibilities(Scrub)

• Follow acceptable O.R. scrub guidelines

• Don sterile gown/gloves using aseptic technique

• Perform surgical “time-out” prior to incision to ensure that all teams have the same expectations

• Assist recovery surgeons as directed

• Assist in setting up perfusion tubing

• Assist in setting up back-tables for package & labeling

• Provide the necessary tissue typing materials for each team (blood, spleen and/or lymph nodes)

• Obtain blood cultures per OPO policy

Operating Room Responsibilities(Circulator)

1. Ensure that each recovering surgeon verifies ABO with signature, date, and time (new CMS regulation).

2. Assist with patient transfer to O.R. table & perform surgical time-out to verify expectations.

3. Assist with patient positioning per surgeon preference

4. Make sure down-drain bag is at the head of table

5. Provide each team’s recovery personnel with appropriate documentation (chart copy, ABO, BD notes, serologies, consent, etc.)

6. Ensure sterile slush & ice is available for packaging prior to cross-clamp. Assist with packaging & verify labeling

7. Obtain spleen, blood, & lymph node requirements for each organ recovery team

8. Ensure that each guest team receives a copy of donor chart with ABO, BD notes, & consent

9. Make sure TRANSPORT IS AVAILABLE FOR EXPEDITED DEPARTURE of recovery team following procurement.

Coordinating Transportation…

• Ask guest teams if any pre-recovery treatments are required.

• Know your FBO (flight base of operation), where the plane will park / closest airport.

• Obtain ETA & tail number on the aircraft of each guest team.

• Arrange for prompt and reliable transportation to and FROM the host hospital for each guest team.

• Discuss time limits, issues, or expectations with all teams.

• Assist visiting teams with expedited departure following cross-clamp (samples, packaging, transportation).

Medications & ProcurementWhy are they given???

• Solu-Medrol – Cell Stabilization

• Mannitol / Lasix – Diuresis

• Regitine, Thorazine, Verapimil – Vasodilatation & even distribution of preservative solutions.

• Heparin – Blood thinner

• Antibiotics – Prophylactic therapy

• Hormones (T4, T3, Prostaglandin in heart/lung recovery) – Vasodilatation

• Special GI preps for pancreas & intestine recovery (antibiotics / betadine) – Prophylactic treatment

Understanding Preservation Techniques

When we understand “WHY and HOW” tissue damage occurs...

what we do & how we do it inevitably becomes “second nature”.

The Cell The fundamental unit of life…

On average, the human body contains ten trillion cells. If you could count them at a rate of one cell per second it would take you 5,200 years to complete the task… The cells in our bodies serve various purposes and therefore differ in size, shape, and function… but they all have the same basic “environmental” requirements. Understanding these requirements will help guide your practice with both donor management methods and organ procurement technique.

From Cells to Tissues…

Tissues are a collection of similar cells that group together to perform a specialized function…

There are 4 primary tissue types in the human body:

1. Epithelial tissue2. Connective tissue3. Muscle tissue4. Nerve tissue

From Tissues to Organs…

An organ is a structure that contains at least two different types of tissue working together for a common purpose…

Connective Tissue

Epithelial Tissue

Muscle Tissue

Nerve Tissue

Autonomic nervous tissue innervates cardiac muscle

Illustration of a cross section of the left ventricle

Why is the human cell important to understanding the organ preservation process???

Organs are only as functional as the cells that compose them

1. The cell membrane provides structure to the cell and an active interface with the extracellular environment.

2. The stability of the membrane to water and chemical permeability depends on the lipid bilayer as well as tight control of temperature, Ph, & osmolarity…

Organ ischemia and preservation disrupt all of these relations.

Phagocytosis

Goal of Organ Preservation

A.

Acute cellular swelling

B.

Normal cells

C.

Swelling & Rupture

1.1. Suppress and/or minimize cellular swellingSuppress and/or minimize cellular swelling

2.2. Minimize the metabolic processMinimize the metabolic process

3.3. Provide adequate hydration Provide adequate hydration

4.4. Minimize ischemia and reperfusion injury to Minimize ischemia and reperfusion injury to stabilizing cell permeabilitystabilizing cell permeability

5.5. If possible, remove any accumulation of metabolic If possible, remove any accumulation of metabolic waste incurred during the recovery and preservation waste incurred during the recovery and preservation period.period.

6.6. Cellular anabolism and catabolism are the two Cellular anabolism and catabolism are the two opposing forces comprising metabolism. Preservation opposing forces comprising metabolism. Preservation methods attempt to minimize catabolism and support methods attempt to minimize catabolism and support anabolism.anabolism.

7.7. Hypothermia effectively reduces all aspects of Hypothermia effectively reduces all aspects of metabolismmetabolism

TTo prevent organ damage by creating a homeostatic cellular environment until transplantation of the graft can occur…

Phases of Organ Damage

• Warm ischemic phase – The interruption of circulation to the donor organ until the organ is flushed with hypothermic preservation solution.

• Cold ischemic phase – From the time the

organ is preserved in a hypothermic state until transplant.

Mechanisms of Tissue Injury…

1. Compromised integrity of the cell

2. Reperfusion injury

Compromised Composition of the Cell…

• Homeostasis is maintained by active transport, exchanging molecules across a semi-permeable membrane.

• Intracellular fluid is high in K+

• Extracellular fluid is high in Na+

• The sodium potassium (ATP) pump exchanges electrolytes between the intra- and extracellular environments. Alteration in the mechanism causes a converse relationship in the major electrolytes resulting in water transfer between intra- and extracellular environments creating cellular swelling and cell death

• Acid-base maintenance must remain stable at a pH of 7.31-7.45. Extreme acidotic environments compromise cell activities or cause cell death. Normal to slightly basic environments improve cell survival

Compromised Composition of the Cell…

Energy substrates are essential to cell maintenance. Energy substrates are end products of carbohydrate, fat, and protein metabolism that provide the cell with the components for internal active energy-consuming processes. Oxygen is essential to the intracellular conversion of these substrates to energy. Without essential nutrients of oxygen, cells cannot effectively maintain normal metabolism. Anaerobic metabolism can provide very basic energy requirements for a limited time.

Reperfusion Injury

During ischemic states, increased intracellular calcium levels activate specific cell enzymes that result in a cascade of reactions that form hydrogen peroxide, a potent oxidant capable of injuring the cell by oxidizing lipid membranes and cellular proteins. Hydrogen peroxide then produces a cascade of oxygen free-radicals. The damaging effects of oxygen free-radicals begin on reperfusion of the organ.

On reperfusion, oxygen is suddenly available, and metabolism proceeds rapidly, resulting in a sudden production of reactive oxygen intermediates. The cellular pathways to scavenge oxygen free-radicals are overwhelmed, and cellular injury ensues.

Solutions are the Solution!

• Flush and perfusate solutions contain energy substrates• Removes blood components & metabolic waste during perfusion• Rapidly cools organs flushed in-situ & significantly inhibits metabolism • Provides electrolyte balance / cellular homeostasis• Preserves the Na, K+, ATP pump which prevents ionic shifts / limits cellular swelling• Stabilizes Ph in the extracellular space / prevents acidosis & destruction of the cell• Free radical scavenger components protect against peroxidation

• Several Perfusion Solutions Available• UW (University of Wisconsin, Belzer’s)• HTK • Euro-Collins• Celsior• Perfadex

Organ preservation carefully modulates the cellular environment to retain viability, and suppress many metabolic functions which occur under 'normal' circumstances. Metabolic inhibition prevents normal catabolism that causes severe or irreversible cellular damage. Inhibition is achieved by hypothermia, and chemical blockade of metabolic activities. Metabolic maintenance, the second approach, attempts to sustain metabolic activities as close to physiologic normalcy as is feasible

Prep & Packaging

Donor Prep• Pt should be shaved prior to prep

• Utilize preferred prep solution or pre-packaged prep pack

• Don sterile gloves

• Maintain sterile field throughout prep process

• Full chest and abdominal prep (chin to pubic bone, 2” from bed side to side)

• Clean the umbilicus first with q-tip and prep solution

• Start in center of incision area and extend in outward to edges of prep area

• Do not go over previously prepped area unless with new prep applicator

Organ Packaging• Minimize potential contamination by utilizing separate back-tables

• Always perform surgical hand scrub prior to donning sterile gown and gloves

• The organ must be protected by a triple sterile barrier and one rigid container which, if sterile, may be considered one of the triple barriers

• The rigid barrier is not required for liver or lungs

Labeling

• Ensure all organs and specimens are obtained, packaged and labeled in accordance with current OPTN requirements

• Any organ and/or tissue label must include UNOS number, ABO, date and time of collection and type of tissue

• Any organ and/or tissue recovered must be packaged in accordance with OPTN requirements

• Blood vessels recovered for the purpose of anastamosis that have the potential for being “banked” by the transplant center must be labeled in accordance with OPTN requirements

A few points on preservation method…

Purpose of preservation is to provide viable organs for transplantation which immediately function when transplanted

– Two methods of organ preservation• Static cold storage (ice 4-8 degrees Celsius)

• Machine perfusion

– Cold storage most widely used (CS)• Does not eliminate metabolic waste

• Does not allow for organ function evaluation during preservation

• Does not add nutrients during storage

– Machine perfusion (MP)• Recent increases in utilization

• Allows what cold storage does not• Recent SRTR data supports lower incidence of delayed graft function in MP kidneys as

compared to CS kidneys

Cold Ischemia Times

Organ Accepted CIT Hours

Heart 3-4

Lung 3-5

Liver <24

Kidney (CS) 24-36

Kidney (MP) 72

Pancreas 12-24

Intestine 6

Document Data Associated with Organ Recovery

• Blood products administered, type, amount

• Type and amount of flush solutions and flush characteristics

• Warm ischemia time

• Type of storage solution

• Type of recovery procedure; i.e., kidneys – en bloc, in situ flush

• Aortic cross-clamp time and date

• Description of typing material available

• Anatomical description

• Kidneys – (unless en bloc) include number of vessels and approximate length and diameter of each

• Extra-renals – include a description of any injuries or abnormalities

• Organs retrieved and disposition

• The OPO assures that an operative procedure note is provided by the recovery surgeon for the donor's hospital medical record and OPO record (does not correspond to Interpretative guideline).

Q.A.

Document Data Associated with Organ Recovery

• Recovery blood pressure and urine output information;

• Recovery medications;

• Type of recovery procedure (e.g., en bloc); flush solution and method (e.g., in situ); and flush storage solution;

• Description of typing material available, including, as a minimum for each kidney:

– One 7 to 10ml. clot (red topped) tube for ABO Verification, plus

– 2 ACD (yellow top) tubes

– 3 to 5 lymph nodes

– One 2 X 4 cm wedge of spleen in culture medium, if available

• Anatomical description, including number of blood vessels, ureters, and approximate length of each, injuries to or abnormalities of the blood

Q.A.

Document Data Associated with Organ Recovery

• 3.5.9.2 Desirable Information for Kidney Offers:

– With each kidney offer, the Host OPO or donor center is encouraged to provide the recipient center with the following biopsy information for all ECD kidneys and for all non-ECD kidneys at the request of the accepting surgeon. To ensure an optimal kidney biopsy, it is recommended that:

• (i) the wedge technique be used;

• (ii) the sample measures approximately 10mm (length) x 5mm (width) x 5mm (depth);

• (iii) a minimum of 25 glomeruli are captured in the sample; and

• (iv) a frozen section slide or the biopsy material accompanies the kidney for review.

– Provide copy of biopsy report and post to Donornet

Document Data Associated with Organ Recovery

Document data (con’t)

• Warm-time: note any time lapse where in the organs are not being perfused (i.e.: donor has become asystolic prior to cross-clamp)

• Any biopsies taken; organs biopsied, location of area of biopsy, reason for biopsy, disposition of biopsy tissue or slide

• Operative note: must be present for each organ documenting the process of the surgical procedure. Must be signed by the surgeon performing the procedure

Case Conclusion

Post-mortem care

• Refer to hospital policy on care of the decedent

• Assist with care of body according to hospital/coroner/ME policy; may include cleansing body, removal of lines, external fixation devises, drains

• Arrange/assist with transport to morgue

• Verify proper documentation of final disposition of decedent

Make the Call…

• Notify agencies and individuals of case completion prior to leaving facility

• Refer to OPO Standards

• May included, but not be limited to nursing office, tissue agency, eye bank, family, funeral home, Medical Examiner, etc.