Optimising the brain-stem dead donor

Dr Gerlinde Mandersloot

20th April 2012

Optimising the brain-stem dead

donorDr Gerlinde Mandersloot

National Clinical Lead - Donor Optimisation

Organ Donation Past, Present and Future 1

Challenges

4Organ Donation Past, Present and Future

• Physiological consequences of BSD

‘Collateral damage’

• Hormonal • Diabetes insipidus

• Hypovolaemia• Hypernatraemia

• T3 / T4 reduces• ACTH• Blood glucose

• Hypothermia


Incidence of organ involvement

• Hypotension 81%

• Diabetes insipidus 65%

• DIC 28%

• Cardiac dysrhythmias 25%

• Pulmonary oedema 18%

• Metabolic acidosis 11%

J Heart Lung Transplantation 2004 (suppl)


Challenges


• Physiological consequences of BSD• Stabilisation and brainstem death testing

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

Challenges


• Physiological consequences of BSD• Stabilisation and 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

Give me a CVP of 6-10

Too much-less than 6

I’d like 10-12

Just get on with it!! Make sure they aren’t hypovolaemic, please

Fluid overload is a problem for us-if we get goals withless that’s good

Lots of fluid please-better function

earlier

Decent perfusion, good gases and BP, it can only

get worse

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


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


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

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)


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

Optimising the brain-stem dead donor

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