Donor Management of
the Consented Donor
Presented by
Adam J. Teller, CPTC
Procurement Transplant Coordinator
Ms. Anne Gulatto
Overview
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OneLegacy
UNOS ( United Network for Organ Sharing)
Collaborative Practice
Donor management
Success stories
OneLegacy
• Founded in 1977
• Not for profit
• Federally funded and designated by CMS as an
OPO
• Licensed by California as a tissue bank
• Serving 220 hospitals, 14 transplant centers & 18.1
million residents
• Serve seven counties in Southern California
Umbrella
Organizations
• United Network for Organ Sharing
• Maintains the National Organ Transplant
Waiting List under contract with the U.S.
Department of Health and Human Services
• American Association of Tissue Banks
• Provides tissue banking standards to promote
quality and safety in tissue transplantation
• Association of Organ Procurement
Organizations
• Recognized as the national representative of
organ procurement organizations (OPOs)
• The EBAA is the nationally recognized
accrediting body for eye banks
United Network for
Organ Sharing (UNOS)
• Maintains U.S. organ transplant waiting list
• Determines national organ donation policy
• Private, non-profit organization that operates the Organ
Procurement & Transplantation Network & U.S.
Scientific Registry of Transplant Recipients
• Under contract with Center for Medicare & Medicaid
Services (CMS) of the U.S. Dept. of Health & Human
Services
Collaborative Practice
• OPO and hospital will identify the Best Practices
and implement them collaboratively
• Best Practices include
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Early Referral
Effective Request Process
Donor councils
Education
Tracking of hospital performance
Consistency of donor management
Patients on the UNOS
Waiting List
Heart
Lung
Heart/Lung
Liver
Kidney
Kidney/Pancreas
Pancreas
Intestine
Local
218
174
12
3,407
17,273
445
120
26
National
3,158
1,839
72
15,951
84,331
2,196
1,469
245
TOTAL
21,675
106,916
Source: UNOS
April 9th 2010
UNOS Organ Allocation
Policy
Potential recipients are ranked by these criteria:
Urgency of Need
For heart & liver patients, the sickest
at the top of the list
Blood Type
ABO must be compatible
Size
Height and weight must be
compatible
Tissue Typing
For kidneys & pancreas
OneLegacy Donor
Service Area
• Local
– Seven-county area
• Regional
– We are in Region 5
• National
– A total of 11 UNOS
Regions in the U.S.
Organs & Tissues That
May Be Transplanted
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ORGANS
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● Kidneys
● Liver
● Heart
● Lungs
● Pancreas
● Sm. Intestine
TISSUES
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Cornea/Eyes
Heart Valves
Skin
Bone
Tendons
Cartilage
Veins
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Donor Management
• Procurement Transplant Coordinator (PTC) discontinues all
previous orders and writes new orders
– The PTC is responsible for the management of the multiple organ
donor from the consent through the operating room recovery
process.
– This first set of orders will be one or two full pages, (standardized
orders) and yes, everything is STAT….have I said how much we
appreciate your hard work?
Donor Management
• Central line and A-lines are inserted if not already
done
• Central lines: IJ or SC for accurate readings of CVP
measurement.
Donor Management General Goals
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SBP 90-110 mmHg
U/O 1-3 cc/kg
HR 60-140
PAWP 7-12
Serum electrolytes WNL-Checked q 6 hours and prn
CBC and coags WNL-Hct at least 30
SPO2 >95%
PaO2 90-110 torr
pH 7.35-7.45
PCO2 35-45 torr
General Goals
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Frequent ABG’s (q 2-4 hours)
PIP <32 mm Hg
Lowest possible Fio2
Turn, bag and suction q 2 hours
Antibiotic coverage
– Zosyn 3.375 grams, Levaquin 750 mg, Vanco1 gram
• Control of DI
Donor Management
• PCXR after line placement
– If lungs are being procured, a PCXR is required at least
every 6 hours
• Fluid deficit correction
• Evaluation of pressors and possible addition of T-4
(levothyroxine) drip
• First dose of 1 gram Solumedrol IVP
• Electrolyte, base deficit correction
• Addition of broad spectrum antibiotics
Vasopressin
• Aka: 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 1-2 units IV bolus of Vasopressin
before starting drip
• Drip rate is 0.5-2 units/ hour
• Closely observe Urine Output—don’t make the donor
anuric
DI Treatment
• Look at total I/O –since admission
– Output mismatch with increased Na and decreased K+
suggests DI
• Treat with Vasopressin/DDAVP
• Calculate total volume deficit and replace with 0.9% or
0.45NS
FORMULA:
• 0.6 x body weight in kg = 1X
• Serum Na x 1X divided by normal Na = X2
• X2 – X1 = total volume deficit in liters
• Note that this may be 10 or 12 liters so give replacement over
12 to 24 hours
Electrolyte Imbalances
• ~40% of brain dead patients experience
hypokalemia of less than 2.5 mEq/liter
• Hypocalcemia, Hypophostemia may also ensue and
may lead to myocardial depression
• Hypernatremia and hypomagnesemia may occur,
especially with DI
Coagulopathy
• Frequently seen in head trauma patients
– GSW, SAH, Blunt trauma
– Probably due to large amounts of tissue fibrinolytic
agent (native tPa) from the necrotic brain into systemic
circulation
• Treat with appropriate blood products
– Platelets, FFP, Cryoprecipitate, PRBC’s (leukocyte
reduced)
• Hct should be at least 30 for multiple organ recovery
Donor Management
Heart
– 12 Lead EKG (serial)
– Echocardiogram (serial)
– Cardiac Enzymes CPK / MB, Troponin levels
– Hormone replacement (T-4,Vasopressin, Steroids)
– Cardiac Cath
• Usually done on heart donors > 45 years old
• May be necessary if pt is < 45 years old and has significant risk factors
Echocardiogram
• Effective in screening for anatomic abnormalities
• Determine the physiological and hemodynamic
stability / function
• Tool to measure effectiveness of management
– Hormone replacement
– Fluid management
Donor Management
Lung
• Changes after brain death occurs
• Absence of bronchospasm due to death of brain stem and
medulla oblongata
• Declining function of bronchial submucosal glands
• Decreased or absent function of cilia
– These changes result in accumulation of mucus in the dependent
lobes of the lungs
• Potential for neurogenic pulmonary edema
– Thought to occur as a result of dysfunction of neuroepithelial bodies
found in the epithelium of the alveoli and distal bronchioles
Donor Management
Lung
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Maintain pCo2 35-45, pH 7.35-7.45
Keep patient warm
Maximize tidal volume; 12-15cc/kg
Aggressive chest PT
Maintain CVP 6-10
Use colloid vs. crystalloid for fluid replacement
Humidify at 100% relative humidity
Over inflate ETT cuff
Donor Management
Lung
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Initiate pressure control ventilation and 1:1 I:E ratio
PEEP of at least 5
Keep PIP < 32
Lowest possible FiO2
– Goal is PO2 of >125 on 40% and/or PF ratio >300
• Bag and Suction q2 hours
• Chest PT, postural drainage,
• ABG’s q 2 hours and prn
Donor Management
Lung
• Possible use of Narcan 8-10 mg IVP
• Alveolar Recruitment Maneuvers
– CPAP of 30 for 1 or more minutes
– Gradual increase of PEEP to 15-20 over 1-2 minutes
• Pressure Control ventilation
• Antibiotic coverage: Levaquin 500mg q 24h and Zosyn
3.375 grams q 8 hour, Vancomycin 1 gram q 24 hours
Donor Management
Lung
• Chest X-Ray (serial)
• Bronchoscopy (serial)
– Sputum gram stain and C&S
• ABG on 40% and 100%
• Possible Chest CT
– Usually for Trauma Patients and patients with significant history
Donor Management
Liver
• Maintain Na < 150
• Correct Electrolyte Imbalances
• Serial Liver Enzymes
• Tap water NG Lavage
• Possible Abdominal Ultrasound / CT
Donor Management
Kidney
• Avoid DI
• Serial UA with micro
• Renal dose dopamine 2-5 mcg/kg/min
• Serial BUN/ Creatinine
Donor Management
Pancreas
• Serial Amylase, Lipase
• Blood glucose ( <150 mg/dl )
• Minimize usage of IV dextrose
• Tight glucose control
Donor Management
Continued
“ 92% of organs that fail to meet
transplantation criteria on initial
evaluation can be functionally
resuscitated.”
Zaroff, JZ. Et al. Consensus Conference Report: Maximizing use of
organs recovered from the cadaver donor: Cardiac recommendations”.
Circulation 2002;106:836.
The Gift of Life
For many families:
• The gift of organ and tissue donation is the only
positive experience in the tragic chain of events
surrounding the loss of their loved one.
• It can help give meaning
to an otherwise
senseless event that
has occurred.
Donor Management
Remember!
The survival of transplanted organs depends
heavily on pre donor and donor management
implementations
Lily
2008
1984
Liver tumor,
awaiting
transplant
Matthew Bemis,
Lily’s donor
1985
Tong Tong Hao
(Recipient)
“She runs,
jumps and
plays everyday
instead of sitting
in the stroller.”
– Yehong & Frost,
Tong Tong’s parents
Ms. Anne Gulatto
Additional Resources
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UNOS Critical Pathway for the Organ Donor:
http://www.unos.org/resources/pdfs/CriticalPathwayPoster.pdf
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Zaroff, JZ. Et al. Consensus Conference Report: Maximizing use of organs
recovered from the cadaver donor: Cardiac recommendations”. Circulation
2002;106:836.
• Zaroff, JZ. Echocardiographic evaluation of the potential cardiac donor. J Heart
Lung Transplant 2004; 23(95):S250.
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The Role of Thyroid Hormone in Donation, Transplantation and Cardiovascular
Disease (Medical Management to Optimize Donor Organ Potential February 23-25,
2004
California Health and Safety Code, sections 7150-7156.5, 7180-7184.5 and 71887195.