Preserving the Donation Opportunity. Shared Goals Maintain urine output Maintain oxygenation...
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Transcript of Preserving the Donation Opportunity. Shared Goals Maintain urine output Maintain oxygenation...
Preserving the Donation Opportunity
Shared Goals
• Maintain urine output• Maintain oxygenation• Maintain normothermia• Maintain normoglycemia• Prevent/treat infection
Optimize organ perfusion and medical suitability
What are the most common Challenges
1. Hypotension (hypovolemia, vasodilatory shock)
2. Diabetes Insipidus / Hypernatremia
3. Oliguria
4. Metabolic (acid/base, electrolytes, glucose)
5. Hypoxemia, Ventilator settings
6. Hypothermia
Hemodynamics
•Goal: Maintain Systolic BP>90; CVP of 6-8 mmHg
•Hypotension /hypertension•Heart rate fluctuations-dysrhythmias•Coagulopathy
•Interventions-CVP < 6 and (H &H) normal Lactated Ringers or Normal Saline fluid bolus of 500 cc over 30 minutes for SBP < 90 mmHg.-CVP < 6 and (H&H) < 8, then administer 1-2 units of PRBC’s
Vasoactive IV fluids/drips
• Vasopressors commonly used are: – Dopamine
– Epinephrine
– Neosynephrine
– Levophed/Norepinephrine
– Vasopressin (AVP) low dose
• Goal: Maintain PO2>100mm Hg and pH7.35-7.45
• Potential Problems:
– Hypoxemia – Acid Balance Disturbances– Neurogenic pulmonary edema
• Interventions:
– Tidal volume of 7-10cc’s/kg – Steriods – Suctioning; in-line treatments – Therapeutic bronchoscopy– PEEP (5)
Oxygenation
Acid- Base and Electrolytes
Goals• pH -7.35-7.45• Electrolytes- Na, K, Ca, Mg, P - WNL• Glucose- < 150• U/O 1-3 ml/kg/min
Interventions• Adjustments of Vent and/or Na Bicarbonate IV • Appropriate IVF – LR, NS, .5 NS (Depending on Na, K, Gluc)• Appropriate supplementation FOR K+ ,Ca++, Mg++,P+++
• Insulin –bolus and/or continuous drip• DDAVP or Fluids, Diuretics, Mannitol
• Goal: Maintain Urine Output 1ml/kg/hr in the Adult or 2ml/kg/hr in the Child
• Potential Problems: – Diabetes insipidus
– Hyperglycemia
• Interventions:– Volume replacement
– DDAVP / vasopressin
– K+ replacement
Urine Output
Goal: Maintain Core Temperature Between 97-100 F
• Hypothermia
• Hyperthermia
• Interventions
• Heating/cooling blankets
Temperature
Other IV fluids (drips)
• Dobutamine--used to treat heart failure, may be combined with dopamine. May be used as a pressor in pediatric patients
• Vasopressin--used to treat shock, diabetes insipidus; enhances the effectiveness of other vasoactive medications. May be used as a pressor in pediatric patients
• Nipride--used to treat hypertension • Esmolol, Verapamil, Adenosine---used to correct
irregular heartbeats
InfectionGoal: Ensure Absence of Infection
Use of Broad Spectrum Antibiotics
Obtaining cultures as needed
Blood
Sputum
Urine
Monitor WBC’s
TemperatureGoal: Maintain Core Temperature Between 97-100 F
Hypothermia
Hyperthermia
Family Preparation
What can You Do
• Check yourself
• Offer open honest communication
• Have them tell you what they understand the situation to be
• Offer them support by involving pastoral Care
Allowing families time to process the death and brain death explanation is IMPORTANT
“Decoupling” - separating the brain death explanation from the request for organ donation
Decoupling may be a valuable tool in obtaining consent for donation
Siminoff, et al concluded that the most important factor in obtaining consent was time spent with the OPO
Creating the Bridge
Hospital is an advocate of organ donation Patient Care Conferences Timely notification Appropriate requester Families satisfaction with quality of care Frequent communication Time with loved one Understanding of brain death
*Source: JAMA July 4, 2001 and Collaborative High Leverages Changes
Pre-request Conference
• A sensitive, timely and informed consent
• How to accomplish…. “huddle” with hospital staff to determine: The key decision maker Family’s understanding of the grave prognosis Review communication plan Determine who, when, where and how the communication will
occur Revise the plan as needed
Guiding principles
•For the family, their grief and loss are primary, not the donation— and all of our actions are guided by this awareness.
•We are not taking something from families. We are giving information to families about an important opportunity:
To consider the opportunity of donation
Wouldn’t it be Nice?