Optimal Donor Management in Critical Care - A Case Study

1. Donor Case StudiesOptimal Management Harbor-UCLA Critical Care – Organ Donation Symposium April 12, 2010 Brant Putnam, MD FACS Trauma / Acute Care Surgery / Surgical Critical Care Harbor-UCLA Medical Center

2. What is OPTIMAL donor management? = GOOD CRITICAL CARE

3. OPTIMAL donor management begins PRIOR to proclamation of brain death. The ICU nurses and physicians are jointly responsible for optimal donor management, not just the OPO.

4. If the patient has not been formally pronounced brain dead, then the patient is alive. Who is not willing to provide good critical care to a live patient? NO ONE

5. Case #1 • 63yo male found lying against a wall • Possible fall vs. assault • Large laceration to occipital area • GCS 1-4-1 • Pupils sluggish

6. Case #1 • Called as a “Tier II” (high acuity) trauma • A - Patent, but not protected • B - Spontaneous, clear bilaterally • C - P = 86 BP – 150 • D - Unresponsive GCS = 1-4-1 Pupils 32, sluggish Blood from left ear

7. Case #1 • Intubated in the ED for airway protection • Taken for CT scan for suspected severe traumatic brain injury

8. Multiple intra- parenchymal hemorrhages Large left subdural hematoma (w/ midline shift)

9. Case #1 • Neurosurgery consultation  • To OR immediately for bilateral craniectomy + evacuation ICH and SDH • GCS 1-1-1 • Coagulopathic and HD unstable intra-op • Prognosis deemed poor leaving the OR

10. Patient transported to ICU Case #1 Labetalol given Levophed started What do you think happened here?

11. Case #1: So to review… Herniation

12. Brain Herniation • Often accompanied by catecholamine storm • Hypertension • Tachycardia • Avoid anti-hypertensives

13. Management Goal #1 Appropriate hemodynamic resuscitation to maintain perfusion to potential organs for donation Maintain MAP 65-100 mmHg Place central venous line; fluid resuscitation to CVP 4-10 cm H20 Use of < 1 vasopressor Dopamine < 10 mcg/kg/min Levophed < 10 mcg/min Neosynephrine < 60 mcg/min Consider hormonal resuscitation with T4 protocol

14. What should happen next?? • Begin testing for brain death • One Legacy notification (actually should have already been notified!!!) • Clinical optimization

15. When to notify One Legacy…

16. Case #1: What did happen…. • Next morning… 1200 noon • One Legacy notified • Physician to hold family conference to discuss poor prognosis • No new orders written…

17. No new orders written… What do you think is going on here? Management?

18. Diabetes Insipidus • Excretion of large amounts of severely dilute urine • “Central” – no ADH release from brain • Kidney can not concentrate urine • Therapy • DDAVP (desmopressin acetate) • Synthetic analogue of ADH • Free water replacement • Frequent monitoring of serum Na

19. What was done… • DDAVP given at 1900 • Free water replacement started next morning (POD #2)… • M.D. “brain death evaluation when electrolytes correct”

20. Management Goal #2 Maintain perfusion to all organs Goal urine output 1-3 cc/kg/hr Suspect DI if U/O > 200 cc/hr x 2 hrs Treat with DDAVP and fluid (free H2O) Keep serum Na 135-155

21. Meanwhile… • POD #3 Management? Insulin drip finally started next morning at 0900

22. Management Goal #3 Potential donors are critically ill patients Tight glucose control applies Increase frequency of Accu-checks Increase sliding scale Insulin drip as needed Goal is to keep serum glucose < 150

23. As time passes . . . Multiple ventilator alarms PIPs 45-50 Low exhaled tidal volumes O2 sats 85% Increase TVs to 1 L to maintain sats 88-90% Is this the best ventilator management?

24. Management Goal #4 Maintain good oxygenation PaO2/FiO2 ratio > 300 Reduce FiO2 to reduce oxygen toxicity Avoid high PEEP effects on hemodynamics Maintain adequate ventilation ABG pH 7.30-7.45 Avoid barotrauma to lungs PIPs < 32 cm H20

25. Case #1: POD #4 0300 1st Brain Death Note written (Note: 75 hours after herniation event) 1000 2nd Brain Death Note written 1455 One Legacy obtains consent for all organs and tissue

26. Case #1: Outcome HD deterioration to near-code Poor organ function Crashed donor to OR because of instability Kidneys recovered Kidney biopsy results poor No organs suitable for transplant

27. Case #2 – Getting it right . . . 22yo male S/P pedestrian struck by auto x 2 GCS 1-1-1 Lost pulses on arrival; CPR x 12 min Devastating brain injury One Legacy notified within 4 hours of arrival

28. Case #2

29. Case #2 Ongoing resuscitation IV fluid to CVP 8 Blood products to keep Hb near 10 Correction of coagulopathy Use of Levophed to maintain MAP > 65 Addition of T4 within 4 hours Adequate oxygenation / ventilation ABG 7.39 / 40 / 118 / 24 / -2 / 99% PaO2 / FiO2 = 350 PIPs 22-24

30. Case #2 Early treatment of DI DDAVP Free water replacement Na 150-154 Tight glycemic control with insulin drip Loss of brainstem functions First BD note < 12 hours after arrival

31. Case #2 Outcome - 7 organs transplanted at local centers: Right lung Left lung Heart Liver Right kidney Left kidney Pancreas

32. Case #3: Steven 17yo male S/P skateboarding accident GCS 1-1-1 Severe DAI, small SDH on CT scan Devastating brain injury

33. Case #3: Steven

34. Donor Management Goals Appropriate hemodynamic resuscitation MAP 65-100 CVP 4-10 EF 50-70% Use of < 1 vasopressor Hormonal resuscitation with T4 protocol ALL organs Lungs, ALL Heart, ALL Heart, ALL ALL

35. Donor Management Goals Good oxygenation / ventilation PaO2/FiO2 ratio ABG pH 7.30-7.45 PIPs < 32 cm H20 Urine output 1-3 cc/kg/hr Serum Na 135-155 Glucose < 150 Lungs Lungs, ALL Lungs Kidney Liver Pancreas