Optimising the brainstem dead donor

Optimising the
brain-stem dead
donor
Dr Gerlinde Mandersloot
National Clinical Lead - Donor Optimisation
Dr Gerlinde Mandersloot
20th April 2012
Organ Donation Past, Present and Future
1
Challenges
• Physiological consequences of BSD
Organ Donation Past, Present and Future
4
‘Collateral damage’
• Hormonal
• Diabetes insipidus
• Hypovolaemia
• Hypernatraemia
• T3 / T4 reduces
• ACTH
• Blood glucose
• Hypothermia
Organ Donation Past, Present and Future
5
Incidence of organ involvement
• Hypotension
81%
• Diabetes insipidus
65%
• DIC
28%
• Cardiac dysrhythmias
25%
• Pulmonary oedema
18%
• Metabolic acidosis
11%
J Heart Lung Transplantation 2004 (suppl)
Organ Donation Past, Present and Future
6
Challenges
• Physiological consequences of BSD
• Stabilisation and brainstem death testing
Organ Donation Past, Present and Future
7
Stabilisation of a patient to
facilitate neurological examination
• Difficulties in defining futility, especially in survivors
• Replace by concept of ‘Best Interests’
•
Not only medical factors taken into account
• Stabilisation of patient prior to BSD testing
•
Brainstem death testing is part of a neurological examination of the patient
•
•
•
Clinical in the majority of cases
Ancillary tests where required
Active management may be necessary in order to examine accurately
• Continued care after BSD to explore possibility of
donation
• Integral part of every End of Life Care Plan
Challenges
• Physiological consequences of BSD
• Stabilisation and brainstem death testing
• Consistent donor optimisation
• 65% of units have 2 or fewer donor per year
• 23% of donors are from these units
• Only 4% units have 10 or more donor per year, 28% of the total donor
population
Organ Donation Past, Present and Future
9
Decent perfusion, good
Just get
with
it!! only
gases
andonBP,
it can
get worse
Lots of fluid please
-better function
I’d like 10-12
earlier
Give me a CVP of 6-10
Make sure they aren’t
hypovolaemic, please
Fluid overload is a
problem for us-if
Too
than 6
wemuch-less
get goals with
less that’s good
Evidence
• 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
Organ Donation Past, Present and Future
11
Organ Donation Past, Present and Future
12
Organ Donation Past, Present and Future
13
Unifying practice across the UK
• Optimisation tool
•
•
•
•
•
Non-controversial (or not too controversial)
Not too complicated
One side of an A4 ?
Buy-in from retrieval / transplant community
Easy to audit
• Extended Care Bundle with two components
• Prescription: medical staff
• Implementation
• Critical care nurses
• SN-ODs
• ‘Scouts’
• Monitoring implementation
Organ Donation Past, Present and Future
14
Organ Donation Past, Present and Future
15
Organ Donation Past, Present and Future
16
Priorities, if not already addressed
• Assess fluid status and correct hypovolaemia with fluid boluses
as required
• Perform lung recruitment manoeuvre(s) as at risk of atelectasis
following apnoea tests
• Identify, arrest and reverse effects of Diabetes insipidus
• Introduce vasopressin infusion: reduces Norepinephrine
requirements and treats DI
• Methylprednisolone, 15 mg/kg to max of 1g, as soon as
possible
Organ Donation Past, Present and Future
17
Hormonal treatment
• Vasopressin
• Reduction in other vaso-active drugs
• Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time)
• Liothyronine (T3)
• No clear evidence for use
• May add haemodynamic stability in very unstable donor
• Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team
• Methylprednisolone in all cases
• Dose: 15 mg/kg up to 1g
• Insulin
• At least 1 unit/h (occasionally may need to add glucose infusion)
• ‘Tight’ glycaemic control (4 - 10 mmol/l)
Organ Donation Past, Present and Future
18
Organ Donation Past, Present and Future
19
Monitoring optimisation
• Implementation: use of care bundle
• Adherence easy to monitor
• Audit first 5 priorities
• Results of optimisation evaluated
• Number of organs retrieved
• Increase in cardiothoracic organs retrieved
• Quality of organs: graft function in recipients
• Delayed graft function
• Quality: biomarkers
• Duration of graft function: long term project
Organ Donation Past, Present and Future
20
Download
Related flashcards

Emergency medicine

24 cards

Security

27 cards

Surgery

42 cards

Orthopedics

21 cards

Hygiene

25 cards

Create Flashcards