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Optimising the brain-stem dead donor

Optimising the brain-stem dead donor

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Optimising the brain-stem dead donor

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  1. Optimising the brain-stem dead donor Dr Gerlinde Mandersloot National Clinical Lead - Donor Optimisation Dr Gerlinde Mandersloot 20th April 2012 1 Organ Donation Past, Present and Future

  2. Challenges • Physiological consequences of BSD Organ Donation Past, Present and Future

  3. ‘Collateral damage’ • Hormonal • Diabetes insipidus • Hypovolaemia • Hypernatraemia • T3 / T4 reduces • ACTH • Blood glucose • Hypothermia 5 Organ Donation Past, Present and Future

  4. Incidence of organ involvement • Hypotension 81% • Diabetes insipidus65% • DIC 28% • Cardiac dysrhythmias 25% • Pulmonary oedema 18% • Metabolic acidosis 11% J Heart Lung Transplantation 2004 (suppl) 6 Organ Donation Past, Present and Future

  5. Challenges • Physiological consequences of BSD • Stabilisation and brainstem death testing Organ Donation Past, Present and Future

  6. 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

  7. Challenges • Physiological consequences of BSD • Stabilisationand 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

  8. Make sure they aren’t hypovolaemic, please Decent perfusion, good gases and BP, it can only get worse Give me a CVP of 6-10 Just get on with it!! Lots of fluid please -better function earlier Fluid overload is a problem for us-if we get goals with less that’s good I’d like 10-12 Too much-less than 6

  9. 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 11 Organ Donation Past, Present and Future

  10. Organ Donation Past, Present and Future

  11. 13 Organ Donation Past, Present and Future

  12. 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

  13. Organ Donation Past, Present and Future

  14. Organ Donation Past, Present and Future

  15. 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

  16. 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) 18 Organ Donation Past, Present and Future

  17. Organ Donation Past, Present and Future

  18. 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