Transcript The Donor and I

ICU Management of the
Organ Donor
Bradley J. Phillips, MD
Burn-Trauma-ICU
Adults & Pediatrics
Case
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19 yof unrestrained MVC
Unresponsive at scene
P 120, SBP 70, agonal breathing
Intubated at scene, IV’s
Transported to BMC
Case
• Primary exam
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ET in place with CO2
BS bilaterally
BP 80
Neuro - pupil dilated/fixed, unresponsive
• Secondary exam
– significant head soft tissue/bony trauma
– distended abdomen
Case
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IVF/Blood
NGT/Foley
Labs drawn
Xrays
– CXR/pelvis/lat cspine - negative
– CTH - open skull fracture, massive swelling, loss of
ventricular space, frontal SDH
– CTA - negative
Issues
• Brain Death
• Organ Donation
• Management of the Donor
Brain Death
• Brain death = Death
• General criteria
– cerebral and brain stem functions absent
• do NOT include spinal reflexes
– condition is irreversible
– cessation of all brain function persists after an
appropriated period of observation and adequate
trial of therapy
Brain Death
• Guidelines
– detailed neurologic exam
• off any sedative drugs
• normothermic
– confirmatory neuro exam 6-12 hours later
– ? Confirmatory test
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apnea test
radionuclide cerebral imaging
Xe-CT cerebral blood flow
4-vessel angiogram
Brain Death
• Pronounced as soon as brain death occurs
• Cardiac arrest usually 72 hours after brain death
Organ Donation
• Consideration of patients as organ donors should in
no way interfere with treatment
• Required by law to report patients to Organ Bank
• “Presumed Consent”
• Patients failing criteria for whole organ donation
frequently meet tissue donation criteria
• Heart Beating vs Non-beating donors
Donor Criteria
• General
– no cancer except skin or
brain
– no systemic infection
– no hepatitis
– no h/o TB/syphilis
– no h/o IVDA
– no prolonged
hypotension or asystole
– no ARF/CRF
– ? Age < 70
• Specific
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Cr < 1.8, BUN < 20
No hypertension (K)
No UTI (K)
No diabetes (P)
No visible lung damage by CXR
(Lu)
PaO2 > 250 on <=100%
Nl EKG/no CAD (H)
Sputum clear on Bronch (Lu)
Nl liver function tests (Li)
Donor Management
• Concerns
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Temperature
Hemodynamics/perfusion
Oxygenation
Urine output
Case
• Initial neuro exam no brain stem function
• VS: HR 100 SBP 120 RR 12 UOP 300 cc/hr
• Labs
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Hct 38
ABG pH 7.48/32/112/24 (SIMV 14/600/40%)
Na 147/K 3.0/Cl 108/Cr 0.4/BUN 18
Tox + opiates
Case
• 12 hours later
– VS: HR 120 SBP 90 RR 12 UOP 400 cc/hr
– Neuro exam: no brain stem function
– LABS
• HCT 45
• NA 167/K 4.5/Cl 118
• pH 7.50/30/100/28 (SIMV 14/700/40%)
Donor Management
• Maintain core temperature > 35 C
• Restore normal circulatory volume
• Support blood pressure
– Hydration
– Pressors (norepi or dopamine)
• minimal dose possible
– Treat hyperglycemia (>180)
• insulin qtt
• Treat cardiac arrest agressively
Donor Management
• Monitor electrolytes closely
– if hypernatremia = D5 1/4 NS
– if UOP > 500 cc/hr lower D5 and no KCL
• Maintain brisk diuresis
– UOP 1-2 cc/kg
– IVF
• UOP 1-2 cc/kg use D5 1/2 NS c 20 meq KCL
• UOP > 2 cc/kg use replacement IVF cc for cc
Diabetes Insipidus (DI)
• Impairment of water conservation (pure water)
• Suspect Diabetes Insipidus
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Trauma involving hypothalamus/pituitary
UOP > 500 cc/hr ( 7 cc/kg/hr)
Na > 150 mEq/L
Serum Osm > 310
Low urine sodium
Diabetes Insipidus
• Management
– Replace free water (D5W or D5 1/4 NS)
– Drugs
• DDAVP
– SQ or nasal
– SQ 0.03 mg/kg
• Pitressin
– IV or SQ
– IV 0.4 to 2.5 units/hr
• Adjust UOP to 100-200 cc/hr
– Follow serum Na
End Points of Therapy
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SBP: 100-120 mm Hg
CVP: 8-20 mm Hg
PAWP 12-15 mmHg
PaO2: 80-100 mm Hg
SaO2: > 95%
UOP: 100-200 ml/hr (1-2 cc/kg)
pH: 7.35-7.35
Hgb: 10-12 g/dl
Donor Labs
• Common
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Chemistry/CBC/ Coags
ABO blood group
CXR/EKG
Urinalysis
• Uncommon
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LFT/Amylase/lipase
Hepatitis/HIV/CMVscreen
Urine /blood/sputum cultures
Bronchoscopy/Echo/Catheterization
Transplantation Facts
• Maximum organ preservation times
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heart/lung
pancreas
liver
kidney
4-6 hrs
8-16 hrs
12-24 hrs
24-36 hrs
Transplantation Facts
• Waiting /yr
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Renal 35,253
Liver 7,995
Heart 3,797
Lung 2,368
Kidney/Panc 1488
Pancreas 339
Intestine 87
• Transplants / yr
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Renal 10,891
Liver 3922
Heart 2361
Lung 871
Kidney/Panc 914
Pancreas 110
Intestine (recently
restarted)
On Death Row, China's Source of Transplants
THE gruesome details of China's trade in human organs harvested from Death Row were
revealed in detail for the first time in Washington last week by a young doctor from the
People's Republic newly fled to the West.
As horror stories, they compare with the experiments carried out in Nazi concentration
camps. Prisoners are killed to order so that doctors can take their body parts, including - in at
least one case - while a victim's heart was still beating.
Wang Guoqi, 38, speaking to congressmen, confirmed that condemned men, and sometimes
women, are executed to order so that their organs can be transplanted into wealthy recipients
from the West and Far East.
Dr Wang was a burns specialist at the Paramilitary Police Hospital in Tianjin, under the
control of the People's Liberation Army, whose senior generals are believed to make large
profits from the trade. He claims that after execution, bodies were taken to the hospital
where every part that could be sold was stripped from the corpse
Increasing Organ Donation
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Identify key contact individuals
Develop hospital policy
Procurement agency visibility
Education hospital staff
Institute early on-site donor evaluation
Provision of feedback to hospital staff
Non-beating donors?
O’Brien, et al. Arch Surg, 1996
Average Cost 1st Year
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Heart
Liver
Kidney
Lung
$253,200
$314,500
$116,100
$265,900
• includes evaluation/candidacy/procurement/hospital/
physician/follow up/immunosuppression
Transplant Facts
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Every 27 minutes someone transplanted
Every 18 minutes name added to waiting list
Every 144 minutes potential recipient dies
Transplant centers: 279
– Kidney 251
– Heart 166
– Pancreas 121
Liver 118
Lung 93
Intestine 27
Kidney Transplant Survival
• Living related (20%)
– Perfect match 95%
– Half match 90%
– Zero match 92%
• Cadaveric (80%)
– Six antigen 90%
– all other 85%
– retransplant 70%
Transplant Survival
1 - YR
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Heart
Liver
Lung
Intestines
84%
80%
75%
50%
3 -YR
77% (graft)
69% (graft)
55% (graft)
50% (patient)
Healing of the biliary
anastomosis after liver
transplant most depends on
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Length of donor and recipient bile duct
The amount of reperfusion injury induced
Intact portal venous flow
Intact hepatic arterial flow
Adequate immunosuprression
HLA matching is not necessary
for liver transplant
True. Only ABO compatibility
is required.
Wound healing is not
significantly delayed in patients
being treated with
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Cyclosporine A
Prednisone
Azathioprine
Doxorubicin
Radiation Therapy
Initiation of steroids can be
delayed for induction therapy or
for oliguria after renal transplant.
True.
Major cause of graft loss in
heart and kidney allografts is
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E.
Acute rejection
Hyperacute rejection
Vascular thrombosis
Chronic rejection
Graft infection
Incidence of acute rejection in
liver transplantation?
50%
Major cause of mortality after
orthotopic liver transplant
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B.
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Primary nonfunction of graft
Hyperacute rejection
Acute rejection
Chronic rejection
Infection