Engaging icu teams
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Engaging ICU Teams. Randy Janczyk, MD, FACS William Beaumont Hospital Royal Oak, Michigan. Case 1.

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Engaging icu teams

Engaging ICU Teams

Randy Janczyk, MD, FACS

William Beaumont Hospital

Royal Oak, Michigan


Case 1

Case 1

  • 41 year old white female, history of 48 hour severe headache. EMS called when patient experienced seizure and became unresponsive. Pinpoint pupils which were fixed and dilated upon arrival to EC. Head CT demonstrated very large Intraparenchymal hemorrhage with uncal herniation. Patients clinical exam consistent with brain death.

  • PMH unremarkable


Case 11

Case 1

  • EC arrival1500

  • ICU arrival2100

  • OPO Referral 2200

  • OPO Evaluation2300

    Overnight Condition

  • BP80 - 90’sMax. dose: Dopa, NeoUo: > 900/hr

  • Labs:CVP:

  • Donation Consent0800

    • Na 170

  • Medical Management Started 1100


Major concerns

Major Concerns

  • Marginal Blood Pressure

  • High Dose Pressors

  • No Central Venous Access

    • Complications with peripheral administration of vasoactive drips

    • Unable to assess adequacy of resuscitation / direct therapy

  • No Arterial Line

  • Additional vasopressors added

  • High Urine Output

    • Concerning in Brain injured patient

      • DI

      • Osmotic diuresis

  • No Labs

    • Risk of significant electrolyte abnormalities

      • Large volume diuresis / IV Fluid replacement


Quality improvement

Quality Improvement

Did the ICU team manage this patient well?

NO

Why NOT?

Patient Identified as:

“NOT Salvageable/ Treatable”

Treatment initiated only after consent to donate


Catastrophic brain injury

Catastrophic Brain Injury

“Not a surgical candidate”

“Prognosis Poor”

“Vegetable”

“Family probably won’t donate”

“Waste of Time”

Therefore

NO REASON TO TREAT PATIENT


Cultural change

Cultural Change

Treat every patient as if they are your loved one

There are NO rule outs

There is always the potential of Organ Donation

Sometimes patients actually get better and go home

Avoid Premature judgement and closure


Missed opportunities

Missed Opportunities

  • EC arrival1500

  • ICU arrival2100

  • OPO Referral2200

  • OPO Evaluation2300

  • Donation Consent0800

  • Medical Management Started 1100

    • 12 hours inadequately treated BP

    • 12 hours inadequately treated DI

      • Na170

Timely referral

Optimal medical management HUDDLE

Donor Death, ATN,  graft survival

Delay in Brain Death Exam,  Incidence 1 graft non function,  graft survival


Congratulations

Congratulations !!!

Successful Procurement and Transplantation

2 Kidneys

1 Liver


No harm no foul

…No Harm No Foul …

  • Shock15 - 24 hours

    • Severe metabolic acidosis and electrolyte imbalance

      • May preclude timely brain death determination

      • End Organ dysfunction

        • Levophed - “leav-em-ded” - Mortality

        • Donor Death

        • Poor quality grafts - unable to donate

        • Graft “looks” ok

          • Primary Graft Dysfunction


Brain death effects

Brain Death Effects

  • 53% of donors suffered sustained hypotension

  • More common in those treated with inotropic agents in the presence of a low CVP and in patients with DI not treated with ADH replacement


Dopamine

Dopamine

  • Does not

    • Improve renal function

    • Alter outcome of renal failure

    • Improve hepatosplanchnic circulation

  • Does

    • Suppress secretion and function of anterior pitutary

      • TSH and Growth hormone

  • Levophed

    • Increased mean perfusion pressures without adverse effect on renal and splanchnic blood flow as compared to dopamine in septic patients

      (Low SVR, similar to brain death physiology)


Vasopressin

Vasopressin

  • Undetectable levels of vasopressin in up to 87% donors

  • Warsaw

    • 20% developed DI

    • 31% had hemodynamic instability

  • Yoshioka ( low dose vasopressin and epinephrine )

    • Hemodynamic stability average 23 days after brain death

    • Vasopressin decreased amount of epinephrine required

    • Preservation of renal function for mean of 14 days

  • Pennefather

    • Decrease in Urine output ( Rx DI, prevent Over-diuresis )

    • Decrease in plasma osmolality

    • Increase in Mean Arterial Pressure and SVR

    • Decrease in Dopamine dose

  • Kinoshita

    • Increase MAP 17 mmHg

    • Discontinue vasopressors in 40%, Decrease in additional 40%


Kidneys

Kidneys

  • Hemodynamically Unstable Donors

    • Increased Renal graft failure and ATN

    • Increased early graft non-function

  • Dopamine

    • Reduced graft survival in patients on high dose dopamine

    • Increased incidence of ATN

  • Hypernatremia

    • Increased incidence of ATN and primary graft non-function


Donor factors affecting liver transplant outcome

Age

Sex

ABO Blood Type

Cause of Death

Macrosteatosis

Endotoxins and Cytokines

ICU LOS

Ischemia Times

Hypernatremia

Nutrition and Liver Glycogen

Hypotension/Vasoactive Drugs

Preconditioning for I/R

Donor Factors Affecting Liver Transplant Outcome

Not Amenable to Change

Amenable to Change

Powner Prog Transplantation 2004;14:241-249


Clinical variables affecting short term graft function

Clinical Variables Affecting Short-term Graft Function

Odds Ratio

Totsuka Txp Proceed 2004; 36: 2215-2218


Influence of high donor sodium on post operative graft function effect of correction

Influence of High Donor Sodium on Post-Operative Graft Function: Effect of Correction

Na > 155peak

Na < 155final

#36

Na < 155 #118

Na > 155 #27

Totsuka Liver Txp Surg 1995; 5: 421-428


In regards to patient care

In Regards to Patient Care….

  • We already know how to properly care for the majority of conditions.

  • We often overlook the simple interventions or fail to implement interventions in a timely manner.

  • Only a small portion of patients will fail to respond to timely therapy or have conditions not amenable to typical treatments.


Donor management pearls

Donor Management Pearls

  • Good Old Fashioned Critical Care

    • Treat every patient as if they are going to survive

  • Prevent Iatrogenic Complications

    • Easier to prevent than to fix (salvage)

      • Autonomic Storm (Heart)

      • Neurogenic Pulmonary Edema (Lungs)

    • Treat every patient as if they are going to survive

    • Start appropriate ICU therapies as early as possible

      • Via OPO in a consented brain dead patient

      • Via OPO in a consented pending brain dead patient

      • Via ICU upon OPO recommendations of “Best Practices”

    • Remind and continually educate hospital colleagues

      • This is not just “a dead guy”

      • This potential donor may save 8 lives

      • Optimal care is good for brain injury survivors and potential organs

      • Next time they will start appropriate therapies before you arrive

      • Work with your hospitals to develop catastrophic brain injury guidelines


Donor management pearls1

Donor Management Pearls

  • Vasopressin

    • Stabilize BP

    • Treat DI

      • Prevent fluid and electrolyte abnormalities

  • Goal directed fluid therapy

    • Wean Pressors

    • Avoid overload (esp. lungs)

  • Pressure Control Ventilation (APRV)(IRV)(PEEP)

    • Maximize Mean Airway Pressure

    • Prevent alveolar collapse and atelectasis

      • Avoid shear injury

      • PREVENT NEUROGENIC PULMONARY EDEMA

        • NARCAN alone won’t cut it

    • All organs benefit from oxygen, All organs suffer from a lack of it


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