Transcript Just what happens in the ICU

Preserving the Donation
Opportunity
Shared Goals
Optimize organ perfusion and medical suitability
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Maintain urine output
Maintain oxygenation
Maintain normothermia
Maintain normoglycemia
Prevent/treat infection
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:
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Dopamine
Epinephrine
Neosynephrine
Levophed/Norepinephrine
Vasopressin (AVP) low dose
Oxygenation
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Goal: Maintain PO2>100mm Hg and pH7.35-7.45
Potential Problems:
– Hypoxemia
– Acid Balance Disturbances
– Neurogenic pulmonary edema
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Interventions:
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Tidal volume of 7-10cc’s/kg
Steriods
Suctioning; in-line treatments
Therapeutic bronchoscopy
PEEP (5)
Acid- Base and Electrolytes
Goals
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pH -7.35-7.45
Electrolytes- Na, K, Ca, Mg, P - WNL
Glucose- < 150
U/O 1-3 ml/kg/min
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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
Urine Output
• 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
Temperature
Goal: Maintain Core Temperature Between 97-100 F
• Hypothermia
• Hyperthermia
• Interventions
• Heating/cooling blankets
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
Infection
Goal: Ensure Absence of Infection
Use of Broad Spectrum
Antibiotics
Obtaining cultures as needed
Blood
Sputum
Urine
Monitor WBC’s
Temperature
Goal: 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
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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?