transplant.bc.ca

1. DCD PANBC October 29, 2011 Greg Grant transplant.bc.ca

2. Disclosures • BC Transplant • St Paul’s Hospital • Mt. St. Jospeh’s Hospital • Vancouver General Hospital • BC Women’s Hospital • BC Ambulance

3. OBJECTIVES • -Understand the Types of Organ Donation • -Understand the Differences between Brain Death and DCD

4. Types of Donation • Living • Kidney • Liver • Brain Death • Lung, Heart, Liver, Pancreas, Kidney • Deceased Donation • Cornea, Skin, Bone • Kidney, Liver, Pancreas Islet Cells

5. Case History • 49 year old man • Witnessed collapse at 10:25 • Struck Head and small abrasion • ALS arrived 1034 – PEA • ROSC 10:55 - Down time 30 minutes • SPH – No criteria for angio – Inf/Lat ST Dep • CT no acute bleed • GCS 3 – Cooling Protocol

6. History • Exertional chest pain x 6 months • Increasing pain over last week • Elevated LDL, Hypertension, Mild Asthma, • Fluticasone, • Alcohol 12 drinks per week

7. Initial Labs • Initial Bloods • Troponin 0.09 • Lactate 5.9 • 12 hours later • Troponin 22.5 • Lactate 1.4 • CK 1091

8. Course in ICU – Day 2 • Cooling protocol stopped after 24 hours: • CT Head and Spinal protocol • 24 hours : Very abnormal c/w diffuse ischemic injury • Neurology Consult • Intact brain stem reflexes, no response to painful stimulation, arm movements with cough, - just coming off cooling

9. Course in ICU – Day 3 • Diffuse myoclonus, needed suppression for ventilation • Treated with Midazolam and then transitioned to Propofol

10. Course in ICU – Day 4 • Continued myoclonus • EEG • Off sedation for 8 hours • Burst suppression pattern noted without seizure activity • CT Scan • Progression with loss of grey-white differentiation, particularly in basal ganglia, • Further effacement of Sulci

11. Course in ICU – Day 5 • Neurology Consult • Myoclonus still present on face with occasional whole body movements. • Pupils brisk, dolls eyes intact, corneal intact, gag present. • Diffuse spasticity of arms and legs with sustained clonus in ankles and down going toes. • No withdrawl to painful stimulus. • Breathing on PS 5 peep 5, normothermic

12. Direction of Care • Family meeting with Wife and support • Attending Intensivist discussed prognosis • Decision made to change to comfort care • Donation team met with family • Consent obtained for donation • Second Physician opinion re Comfort Care

13. Consent • Explanation of the procedure • 24 hours delay to obtain tests for donation • Extubation • Regular comfort care • When becoming unstable Heparin • If died in 90 minutes 2 physicians examine and declare • 2 minutes in the ICU room • Travel to OR anti-room • Reconfirmation death – 2 physicians – • To OR

14. Comfort Care • Family and friends present in the room during extubation • Patient died 23 minutes after extubation • Family left shortly after declaration • To OR for donation