Professional Development Programme for Organ Donation Dr Dermot McKeown Dr Paul McAndrew Andrew...

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”


UK Heartbeating Donors 2008-2009

2

Kidney Liver Pancreas Thoracic

612 584(95%)

559(91%)

308(50%)

233(38%)



3

612 584 559

308

233

0

100

200

300

400

500

600

700

Total Kidney Liver Pancreas Thoracic


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


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


Masterclass Objectives

6

• 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


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

7


Plan for Session

8

• 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

Brainstem Death and management of the organ donorDermot McKeown

Professional Development Programme for Organ Donation10


Progression to Brainstem Death (BSD)

13

1. Increased ICP

2. Bradycardia

3. Hypertension

• “Sympathetic Storm”


Level of Care

14

• Full ICU care facilitates appropriate BSD testing

• After BSD testing, continued care maintains potential for donation

• Discussion with relatives

• Donor Management


Changes following Brainstem Death (BSD)

15

• Cardiovascular

• Hypothermia

• Diabetes Insipidus

• Disseminated Intravascular Coagulation

• Pulmonary

• Inflammation


Incidence of Changes

16

• 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)


Donor Management

17

• Shift of Goals, but still Intensive

Care

• Increase numbers of donors

• Increase number of organs per

donor

• Improve function of transplantable

organs


Evidence for Donor Management

18

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


Donor Management

19

• All donors are potential multiorgan donors

• Aim to make all organs transplantable

• Maintain or improve function


Goals

20

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


General Care

21

• Continue ICU care

• Temperature control

• Give methylprednisolone, review drugs

• Donor Management Guideline


http://www.atca.org.au/

Guidelines


Guidelines


General Care “Bundle”

25

• Continue ICU care

• Temperature control

• Give methylprednisolone, review drugs

• Donor Management Guideline

• Consider escalation of monitoring

• Relatives may be at bedside


Review Notes

26

• Intravascular volume

• Review treatment goals

• Osmotic therapy and urine output

• Co-ordinator will review in detail


Cardiovascular

28

Hormonal Package

Increased Activity:

• Assess clinically

• Invasive monitoring

• Intravenous fluid

• Vasoactive drugs: vasopressor/inotrope

• ECHO

Flow Monitoring


xxx

29


Figure 1: Odds of an organ being recovered and transplanted: Hormonal Resuscitation (HR) verses Non-Hormonal Resuscitation (NHR)


Respiratory

31

• Head up positioning

• Lung protective ventilation

• PEEP and lowest possible FiO2

• Recruitment

• Avoid overhydration


Diabetes Insipidus

32

• Common in BSD

• Posterior pituitary

• Polyuria, electrolyte disturbance

• Hypovolaemia

• Fluids

• Vasopressin/DDAVP


Other Issues

33

• Electrolyte disturbances

• Blood and Coagulopathy

• Spinal reflexes


Other Issues

34


• 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%


Donor Co-ordination

36

• Donor assessment

• Donor management

• Offering organs

• Thoracic units

• Retrieval team

• Theatre time

• Transport


Questions?

37


Summary

38

• Brainstem death triggers complex pathophysiology

• Active Donor Management can treat this, and maximise donation

• Guidelines assist standard management

• Future developments

Cardiovascular Management and Cardiac DonationIncreasing Cardiac Donation



40



41


UK Cardiothoracic Donors 2008-9

42

Age 0-17 18-34 35-49 50-59 60+

Donors 23 74 87 51 15


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


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


Assume all donors can be cardiac donors

45


Targets

46

• Rate 60-100, sinus

• MAP 60-80 mmHg

• CVP ~ 4-10 mmHg

• CI > 2.1 l.min-1.m-2


Clinical and Translational Research

47


Adverse Factors

54

Effects of ‘Sympathetic Storm’

• Potentially huge rise in catecholamines

• Worse with rapid ICP rise

Effects of vasodilation

• Relative hypovolaemia

• Afterload reduction

Volume status


Assessing Volume Status

55

• Review charts, examine patient

• Vital signs and postural effects

• ‘Numbers’

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


Priorities

57

Volume

Restore Tone

• Effective Circulating Volume:

Myocardial perfusion

Cardiac function

Organ perfusion

• Avoid Overload

Inotropes?• Optimise cardiac output


Assessing Volume Status

58

• Review charts, examine patient

• Vital signs and postural effects

• ‘Numbers’

• Systolic pressure variation

• Response to therapy


Flow Measurement

59

• Clinical

• Waveforms

• LiDCO

• PiCCO

• Doppler

• Serial ECHO

• PAWPC


Volume Therapy

60

• Consider vascular tone

• Restore tone: Vasopressin

• Balanced Colloid or Crystalloid

• Look for significant response

• Flow monitoring


Vasopressin

61

• Vasoconstriction: V1 receptor

• Water reabsorption: V2 receptor

• Increased ACTH secretion: V3 receptor

• (Vasodilation at low concentration - Oxytocin receptors)


Priorities (cont’d)

62

• Intravascular Volume

• Vascular tone / Vasopressin

• Flow parameters

Direct Cardiac Index

Adequacy of resuscitation

• Appropriate catecholamines

• (T3 , Hydrocortisone, GTN)


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]


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


Intensive management benefits all organs

65


Continued Review

66

• CVS and adequacy of resuscitation

• Fluid and Electrolytes

• Offering system and liasion with accepting units

• Specialist treatments or investigations

• Continued ICU and theatre management


Questions?

67


Summary

68

• Heart donors are precious

• Treat all donors as potential heart donors

• Donor management crucial

• Volume status, Vascular tone (Vasopressin)

• Role of Flow monitoring

Respiratory Management and Lung DonationIncreasing Lung Donation


Objectives

70

• 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



71



72


UK Cardiothoracic Donors 2008-9

73

Age groups

0-17 18-34 35-49 50-59 60+

Number of donors 23 74 87 51 15


The Lung Donor

74

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


The Ideal Lung Donor (1/2)

75

• 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


The Ideal Lung Donor (2/2)

76

• 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


Assume all donors can be lung donors

77


Pathophysiology

78

1. Pre-brainstem death

2. Brainstem death

3. Post brainstem death


Pathophysiology

79

• Trauma

• Aspiration

• Infection

Pre-Brainstem Death

1

• Catecholamine

surge

• Systemic

inflammatory

response

Brainstem Death

2

• Conflict

• Lungs v The Rest

Post Brainstem Death

3


Targets

80

• Protective lung ventilation

• Lowest FiO2 possible

• Lung recruitment

• Early steroids

• Minimise lung water


The Conflicts

81

• Fluid management and lung water

The lungs versus the circulation

Flow

• Lung damage

Acute Lung Injury (ALI)

Acute Respiratory Distress Syndrome (ARDS)

Ventilatory strategies


Ventilation

82

Ventilation is associated with characteristic types of damage:

• Barotrauma

• Volutrauma

• Infection

• Aspiration


Management

83

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%


SALT

84

The SALT protocol adopted a number of strategies:

• Education

• Active donor management

Prevent aspiration

Recruitment

Restricting fluid administration

Diuretics

Flow directed therapy


Lung Computed Tomography during a Lung Recruitment Manoeuvre in Patients with Acute Lung Injury

86

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


Other Options

87

Hormone therapy

• Vasopressin & the dual role

Antidiuresis

Vasoconstriction

• T3

Cardiovascularly unstable

Steroids

• Methylprednisolone 15mg/kg

• As soon as brain death confirmed


Assessment

88

• Ventilation parameters

• History

• CXR

• Gas exchange

• Bronchoscopy


The Expanded Criteria Lung Donor

89

• 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


Maximizing the number of Lungs for LTx

90



91

PaO2 231mmHg (30.8 kPa)



92


PV PaO2

94 mmHg(12.4kPa)



93


PV PaO2 353 mmHg

(47 kPa)

PV PaO2

94 mmHg(12.4kPa)


Assessment Strategies

94

• Bronchoscopy

• Direct inspection

• Extra-corporeal perfusion


Extracorporeal Perfusion

95


Questions?

96

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