Breakout Session C:
Preserving the Opportunity –
Before and After Consent
Moderator:
• Adam Teller, OneLegacy
Presenters:
• Lydia Lam, MD, LAC + USC Medical Center
• Keith Markillie, RN, OneLegacy
Preserving the
Opportunity:
Before and After Consent
Moderator:
Adam Teller, Procurement Transplant Coordinator
OneLegacy
“How To Be”
 Being in Action!
 The Answers Are In the Room
 “Report out” on Questions to Run-on:
 Scribe
 Spokesperson
 All Teach / All Learn
Question to Run-On
How do your standards
of care preserve the
opportunity for the gift
of life?
Objectives
By the end of this presentation, the
attendee will be able to:
1. Understand the impact of a DNR and
donation
2. Recognize pathophysiology of
traumatic brain injury
3. Anticipate common interventions for
optimal donor management
Lydia Lam, MD
Division of Acute Care Surgery and Surgical Critical Care
Los Angeles County + USC Medical Center
Los Angeles, CA
DNR Decision
What does the DNR decision mean to
the family?







No Chest Compressions?
No Shock?
No Medications?
No Labs?
No Fluids?
No Diagnostic Tests?
Allow natural death?
“Do not harm?” or “Do not treat?”
DNR Decision
What does the DNR decision mean to the
healthcare team?



Routine decision in the Critical Care Unit
Stop all treatment immediately or no
aggressive treatment after cardiac arrest?
DNR decision has its own “culture of
understanding” that varies by hospital, unit,
physician and nurse
“Do not harm?” or “Do not treat?”
Donation Decision
Understanding the donation option
clinically:
 Maintaining blood pressure
 Normalizing electrolytes
 Managing oxygenation and organ perfusion
 Balancing Intake and Output
 Assessing brain death accurately
How can a family give the gift of life when the
organs are not preserved for transplantation?
Balancing DNR and Donation
Traumatic Brain Injury (TBI)
Overall Clinical Deterioration
+ DNR Decision by Next-of-Kin
+ Fatal Diagnosis (Brain Death?)
How is this interpreted in your ICU?
What can be expected from your team?
How can we be proactive for this family?
Pathophysiology of
Traumatic Brain Injury
Physiologic collapse frequently
accompanies TBI:
Hypotension
Endocrine Dysfunction
Pulmonary Dysfunction
Hematologic Dysfunction
Pathophysiology of
Traumatic Brain Injury
Hypotension:
 “Autonomic storms”
 Smooth muscle ATP depleted = vasomotor
hypotension
 Anticipate BP spike followed by BP drop
 Titrate Vasopressors
 Diuretics
 Consider Fluid Resuscitation
 Closely monitor Intake and Output – DI?
Pathophysiology of
Traumatic Brain Injury
Endocrine Dysfunction:
 Hypothalamic injury -> pituitary dysfunction
 Thyroid dysfunction = T4 Infusion
 Reduction of Antidiuretic Hormone / DI
 ADH = Vasopressin Infusion
 Glycemic control disrupted
 Insulin infusion
 Relative deficiency of corticosteroids
 Solumedrol Infusion
Pathophysiology of
Traumatic Brain Injury
Pulmonary Dysfunction:
 Neurogenic pulmonary edema
 Systemic hypertension + LV dysfunction
 Primary pneumatocyte dysfunction
 Iatrogenic injury due to aggressive resuscitation
 Exacerbated by intubation, aspiration
&atelectasis
 Concurrent blunt lung injury common
 Parenchymal injury problematic in immunosuppressed
recipients
Pathophysiology of
Traumatic Brain Injury
Hematologic Dysfunction:
 Thrombocytopenia
 Platelets as needed
 Coagulopathy/DIC
 FFP / Cryo as needed
 Hypothermia
 Keep them warm!
What are Traumatic Brain Injury
Guidelines?
Hospital approved guidelines
for treating patients with
Traumatic Brain Injury
What are Traumatic Brain Injury
Guidelines?
Prevent secondary injury, even with grave
prognosis
 Secondary injury includes other organs, as well as
the brain
Maintain Organ Perfusion
 Volume Load
 Maintain adequate CVP & MAP
 Oxygenation
 Correct electrolyte abnormalities
Why Implement Traumatic
Brain Injury Guidelines?
 Ensure consistent management of the critically
ill patient
 Maintain homeostasis for accurate brain death
assessment
 Prevent “secondary injury” to organs, even with
grave prognosis
 Provide a clinical bridge between determination
of brain death and family’s decision on
donation
Aggressive Organ Donor Management
Significantly Increases the Number of Organs
Available for Transplantation
(Salim et al. J Trauma 2005; 58: 991-994)
 LAC + USC Standardized organ donor management
protocol
 Before-after study (January 1998) of ADM institution
 January 1995-December 2002
Aggressive Organ Donor Management
Significantly Increases the Number of
Organs Available for Transplantation
(Salim et al. J Trauma 2005; 58: 991-994)
 Vasopressors if MAP <70
 Dopamine
 Levophed
 Vasopressin
 Hormones for maximal vasopressors.
 Insulin
 Solumedrol
 T4
Aggressive Organ Donor Management
Significantly Increases the Number of Organs
Available for Transplantation
(Salim et al. J Trauma 2005; 58: 991-994)
 878 patients referred, 460 (53.4%) patients potential
organ donors and 161 (34.3%) actual donors.
 # patients referred increased 57%
 # of potential donors increased 19%
 # of actual donors increased 82%
 # of patients lost to cardiovascular collapse
decreased 87%
 # of organs recovered increased 71%
How to Implement TBI
Guidelines in your Hospital?
Clinical Educator
Critical Practice Committee
Critical Care Leadership
Critical Care Physicians or Medical Director
Sample Guidelines available at:
www.onelegacy.org
DNR Decision
What does the DNR decision mean to
the family?







No Chest Compressions?
No Shock?
No Medications?
No Labs?
No Fluids?
No Diagnostic Tests?
Allow natural death?
“Do not harm?” or “Do not treat?”
Summary
 Critical care teams can honor the DNR decision
while preserving the option of donation.
 Pathophysiology of Traumatic Brain Injury can be
anticipated and treated.
 TBI Guidelines can be implemented to prevent
“step down” in clinical management and preserve
the family’s donation option.
The Care and Management of Consented
Brain Dead Organ Donors
Keith Markillie PTC, RN, BSN
OneLegacy
Best Practices Approach to
Saving Lives
&
Preserving the Opportunity for
Organ Donation
Organ Donor Management
 Similar to Traumatic Brain Injury
Guidelines: “What’s good for the patient
is good for the donor”
 Treatment of Brain Death
– Standardizes donor management within OneLegacy
– Maximize the organs recovered per donor
Organ Donor Management
1.
2.
3.
4.
MAP 60 – 110 mmHg
CVP 4 - 12mmHg
EF > 50%
</= 1 pressor used AND:
a. Dopamine </= 10 mcg/kg/min
b. Neosynephrine </= 100 mcg/min
c. Norepinephrine </= 10 mcg/min
d. Vasopressin </= 2.4 units/hour
(0.04 units/min)
5. ABG pH 7.3-7.5
1. PaO2:FiO2 ratio >300 on
PEEP = 5
2. Serum Sodium <155
3. Urine output 1-3 mL/kg/hour
4. Glucose < 150
5. Hemoglobin > 10
Track hormone
replacement usage
Hormonal Replacement
 Post brain death endocrine changes
– There is a sharp decrease in T3 and T4 to 50% of
normal within one hour of brain death & down to Zero
after 16 hours
– Cortisol levels decrease to 50% after one hour and
continue to decrease
– Antidiuretic Hormone decrease significantly and
completely disappear after 6 hours
– Insulin decreased to 20% of baseline by 13 hours
>>Transplantation, Vol 83, pp 1396-1402, no 11, December 15, 2006
Hormonal Imbalances
 Research findings suggest that after brain death aerobic
metabolism changes to anaerobic cellular metabolism
 ATP and creatinine phosphate deplete & lactate increases
which leads to decreased cardiac function
 After T4 infusion, lactate decreases, glucose utilization
increases and the mitochondria resume aerobic energy
generation
>>Transplantation, Vol 83, pp 1396-1402, no 11, December 15, 2006
T-4 Protocol
 Give IV boluses of the following:
–
–
–
–
20 mcg T-4 IV push
20 units regular insulin
50 mL dextrose 50%
30 mg/kg Solumedrol (2 grams max)
 After initial bolus start T-4 drip
– 200 mcg in 500mL NS at 25mL/hour initially (10
mcg/hour)
– Titrate as needed to maintain BP
– Continue drip to procurement
Solumedrol
 Used in conjunction with T-4
 Corticosteroid replacement for lowered cortisol
levels in brain dead patients
 Used routinely throughout care of the donor
Vasopressin/Pitressin
 Used as hormone replacement of ADH from posterior
pituitary gland in brain dead patient
 Very effective in treating DI related hypotension
 May or may not give 1 unit IV bolus of vasopressin before
starting drip
 Drip rate is 0.5 – 2.4 units/ hour
 Closely observe Urine Output—don’t make the donor
anuric
Insulin
 Monitor glucose every 2
hours
 Treat with insulin drip rather
than SQ
 Keep 80-150
 Utilize hospital or
OneLegacy protocol
Treatment beyond Hormones
 Organ Perfusion
 Balance electrolytes
 Correct coagulopathy
 Correct metabolic acidosis
 Optimize oxygenation and ventilation
 Antibiotic usage
Organ Perfusion
Maintain MAP 60 – 110mmHg
1. Consider invasive hemodynamic monitoring
2.
Adequate hydration to maintain euvolemia
• Crystalloids, colloids, blood products
• Free water
3. Vasopressor support
• Dopamine
• Vasopressin
• Neosynephrine
• Levophed
4. 2D Echo to evaluate function once resuscitated & pressors low
dose
Balance Electrolytes
Monitor and treat electrolytes maintaining:
 Sodium: 134 – 145 mMol/L
 Potassium: 3.5 – 5.0 mMol/L
 Magnesium: 1.8 – 2.4 mEq/L
 Phosphorus: 2.0 – 4.5 mg/dL
 Ionized Calcium: 1.12 – 1.3 mmol/L
Correct Coagulopathy
 Maintain normothermia 36 – 37.5 degrees
Celsius (96.8 – 99.5 degrees Fahrenheit)
 Maintain hemoglobin > 10.0 g/dL & hematocrit
> 30%
 If PT > 2.0, consider transfusion of FFP
 If Fibrinogen is 70 - 100, consider FFP. If < 70,
consider cryoprecipitate
 If platelets < 50, consider platelet transfusion
Metabolic Acidosis
 Adequate perfusion
 Volume resuscitation
 Sodium Bicarbonate
 Use judiciously with high sodium
 Find other reasons for acidosis (respiratory,
kidney failure, electrolytes)
 Use potassium and sodium acetate to
supplement electrolytes
Oxygenation/Ventilation
 Early bronchoscopy to clear secretions
 Routine use of Solumedrol
 Good pulmonary toileting
 Breathing treatments/MDI
 Narcan early
 Lung recruitment
– PEEP maneuvers
– I:E ratio manipulation
Antibiotic Usage
 ALL patients get antibiotics! Dosages can be
adjusted to size and kidney clearance
 Less than 5 days = Zosyn
 Greater than 5 days = Vancomycin + Levaquin
 May need other coverage, depending on predonor condition
 ID consult? Never a bad idea with “strange
circumstances”
Organ Donor Management
1.
2.
3.
4.
MAP 60 – 110 mmHg
CVP 4 - 12mmHg
EF > 50%
</= 1 pressor used AND:
a. Dopamine </= 10 mcg/kg/min
b. Neosynephrine </= 100 mcg/min
c. Norepinephrine </= 10 mcg/min
d. Vasopressin </= 2.4 units/hour
(0.04 units/min)
5. ABG pH 7.3-7.5
1. PaO2:FiO2 ratio >300 on
PEEP = 5
2. Serum Sodium <155
3. Urine output 1-3 mL/kg/hour
4. Glucose < 150
5. Hemoglobin > 10
Track hormone
replacement usage
Final Thoughts
“Everyone of us can help make this difference
…Because that truly is the Right Thing to Do.”
Dr. Kenneth Moritsugu, MD
US Deputy Surgeon General
Question to Run-On
How do your standards of care
preserve the opportunity for the gift
of life?