Moderator:• Adam Teller, OneLegacyPresenters:• Lydia Lam, MD, LAC + USC Medical Center• Keith Markillie, RN, OneLegacy

Breakout Session C:Preserving the Opportunity –

Before and After Consent

Preserving the Opportunity:

Before and After ConsentModerator:

Adam Teller, Procurement Transplant CoordinatorOneLegacy

“How To Be”Being in Action!

The Answers Are In the Room

“Report out” on Questions to Run-on: Scribe Spokesperson

All Teach / All Learn

Question to Run-On

How do your standards of care preserve the

opportunity for the gift of life?

ObjectivesBy the end of this presentation, the attendee will be able to:1. Understand the impact of a DNR and

donation2. Recognize pathophysiology of

traumatic brain injury3. Anticipate common interventions for

optimal donor management

Preserving the Opportunity:

Before and After ConsentLydia Lam, MDDivision of Acute Care Surgery and Surgical Critical Care Los Angeles County + USC Medical CenterLos Angeles, CA

DNR DecisionWhat does the DNR decision mean to

the family? No Chest Compressions? No Shock? No Medications? No Labs? No Fluids? No Diagnostic Tests? Allow natural death?

“Do not harm?” or “Do not treat?”

DNR DecisionWhat does the DNR decision mean to the healthcare team? Routine decision in the Critical Care Unit Stop all treatment immediately or no

aggressive treatment after cardiac arrest? DNR decision has its own “culture of

understanding” that varies by hospital, unit, physician and nurse

“Do not harm?” or “Do not treat?”

Donation DecisionUnderstanding the donation option clinically:Maintaining blood pressureNormalizing electrolytesManaging oxygenation and organ perfusionBalancing Intake and OutputAssessing brain death accurately

How can a family give the gift of life when the organs are not preserved for

transplantation?

Balancing DNR and DonationTraumatic Brain Injury (TBI)

Overall Clinical Deterioration+ DNR Decision by Next-of-Kin + Fatal Diagnosis (Brain Death?)

How is this interpreted in your ICU?What can be expected from your team?How can we be proactive for this family?

Pathophysiology of Traumatic Brain Injury

Physiologic collapse frequently accompanies TBI:

HypotensionEndocrine DysfunctionPulmonary DysfunctionHematologic Dysfunction

Pathophysiology of Traumatic Brain Injury

Hypotension:“Autonomic storms”Smooth muscle ATP depleted = vasomotor

hypotensionAnticipate BP spike followed by BP dropTitrate Vasopressors

DiureticsConsider Fluid ResuscitationClosely monitor Intake and Output – DI?

Pathophysiology of Traumatic Brain Injury

Endocrine Dysfunction:Hypothalamic injury -> pituitary dysfunction

Thyroid dysfunction = T4 InfusionReduction of Antidiuretic Hormone / DI

ADH = Vasopressin InfusionGlycemic control disrupted

Insulin infusionRelative deficiency of corticosteroids

Solumedrol Infusion

Pathophysiology of Traumatic Brain InjuryPulmonary Dysfunction:Neurogenic pulmonary edema

Systemic hypertension + LV dysfunctionPrimary pneumatocyte dysfunctionIatrogenic injury due to aggressive resuscitationExacerbated by intubation, aspiration

&atelectasisConcurrent blunt lung injury common

Parenchymal injury problematic in immunosuppressed recipients

Pathophysiology of Traumatic Brain InjuryHematologic Dysfunction:Thrombocytopenia

Platelets as neededCoagulopathy/DIC

FFP / Cryo as neededHypothermia

Keep them warm!

What are Traumatic Brain Injury Guidelines?

Hospital approved guidelines for treating patients with Traumatic Brain Injury

What are Traumatic Brain Injury Guidelines?

Prevent secondary injury, even with grave prognosis

Secondary injury includes other organs, as well as the brain

Maintain Organ PerfusionVolume LoadMaintain adequate CVP & MAPOxygenationCorrect electrolyte abnormalities

Why Implement Traumatic Brain Injury Guidelines?

Ensure consistent management of the critically ill patient

Maintain homeostasis for accurate brain death assessment

Prevent “secondary injury” to organs, even with grave prognosis

Provide a clinical bridge between determination of brain death and family’s decision on donation

Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation(Salim et al. J Trauma 2005; 58: 991-994)

LAC + USC Standardized organ donor management protocol

Before-after study (January 1998) of ADM institutionJanuary 1995-December 2002

Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation(Salim et al. J Trauma 2005; 58: 991-994)

Vasopressors if MAP <70DopamineLevophedVasopressin

Hormones for maximal vasopressors.InsulinSolumedrolT4

Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation(Salim et al. J Trauma 2005; 58: 991-994)

878 patients referred, 460 (53.4%) patients potential organ donors and 161 (34.3%) actual donors.

# patients referred increased 57%# of potential donors increased 19%# of actual donors increased 82%# of patients lost to cardiovascular collapse

decreased 87%# of organs recovered increased 71%

How to Implement TBI Guidelines in your Hospital?Clinical EducatorCritical Practice CommitteeCritical Care LeadershipCritical Care Physicians or Medical Director

Sample Guidelines available at:www.onelegacy.org

DNR DecisionWhat does the DNR decision mean to the family? No Chest Compressions? No Shock? No Medications? No Labs? No Fluids? No Diagnostic Tests? Allow natural death?

“Do not harm?” or “Do not treat?”

SummaryCritical care teams can honor the DNR decision

while preserving the option of donation.

Pathophysiology of Traumatic Brain Injury can be anticipated and treated.

TBI Guidelines can be implemented to prevent “step down” in clinical management and preserve the family’s donation option.

The Care and Management of Consented Brain Dead Organ Donors

Keith Markillie PTC, RN, BSNOneLegacy

Best Practices Approach to Saving Lives

&Preserving the Opportunity for

Organ Donation

Organ Donor Management

Similar to Traumatic Brain Injury Guidelines: “What’s good for the patient is good for the donor”

Treatment of Brain Death– Standardizes donor management within OneLegacy– Maximize the organs recovered per donor

Organ Donor Management

1. MAP 60 – 110 mmHg 2. CVP 4 - 12mmHg3. EF > 50% 4. </= 1 pressor used AND:

a. Dopamine </= 10 mcg/kg/min b. Neosynephrine </= 100 mcg/minc. Norepinephrine </= 10 mcg/min d. Vasopressin </= 2.4 units/hour

(0.04 units/min)

5. ABG pH 7.3-7.5

1. PaO2:FiO2 ratio >300 on PEEP = 5

2. Serum Sodium <155 3. Urine output 1-3 mL/kg/hour4. Glucose < 1505. Hemoglobin > 10

Track hormone replacement usage

Hormonal Replacement

Post brain death endocrine changes– There is a sharp decrease in T3 and T4 to 50% of

normal within one hour of brain death & down to Zero after 16 hours

– Cortisol levels decrease to 50% after one hour and continue to decrease

– Antidiuretic Hormone decrease significantly and completely disappear after 6 hours

– Insulin decreased to 20% of baseline by 13 hours

>>Transplantation, Vol 83, pp 1396-1402, no 11, December 15, 2006

Hormonal Imbalances

Research findings suggest that after brain death aerobic metabolism changes to anaerobic cellular metabolism

ATP and creatinine phosphate deplete & lactate increases which leads to decreased cardiac function

After T4 infusion, lactate decreases, glucose utilization increases and the mitochondria resume aerobic energy generation

>>Transplantation, Vol 83, pp 1396-1402, no 11, December 15, 2006

T-4 Protocol

Give IV boluses of the following:– 20 mcg T-4 IV push– 20 units regular insulin– 50 mL dextrose 50%– 30 mg/kg Solumedrol (2 grams max)

After initial bolus start T-4 drip– 200 mcg in 500mL NS at 25mL/hour initially (10

mcg/hour)– Titrate as needed to maintain BP– Continue drip to procurement

Solumedrol

Used in conjunction with T-4 Corticosteroid replacement for lowered cortisol

levels in brain dead patientsUsed routinely throughout care of the donor

Vasopressin/Pitressin

Used as hormone replacement of ADH from posterior pituitary gland in brain dead patient

Very effective in treating DI related hypotensionMay or may not give 1 unit IV bolus of vasopressin before

starting dripDrip rate is 0.5 – 2.4 units/ hourClosely observe Urine Output—don’t make the donor

anuric

Insulin

Monitor glucose every 2 hours

Treat with insulin drip rather than SQ

Keep 80-150Utilize hospital or

OneLegacy protocol

Treatment beyond Hormones

Organ PerfusionBalance electrolytesCorrect coagulopathyCorrect metabolic acidosisOptimize oxygenation and ventilationAntibiotic usage

Organ Perfusion

Maintain MAP 60 – 110mmHg1. Consider invasive hemodynamic monitoring2. Adequate hydration to maintain euvolemia

• Crystalloids, colloids, blood products• Free water

3. Vasopressor support• Dopamine• Vasopressin• Neosynephrine• Levophed

4. 2D Echo to evaluate function once resuscitated & pressors low dose

Balance Electrolytes

Monitor and treat electrolytes maintaining: Sodium: 134 – 145 mMol/LPotassium: 3.5 – 5.0 mMol/LMagnesium: 1.8 – 2.4 mEq/LPhosphorus: 2.0 – 4.5 mg/dLIonized Calcium: 1.12 – 1.3 mmol/L

Correct Coagulopathy

Maintain normothermia 36 – 37.5 degrees Celsius (96.8 – 99.5 degrees Fahrenheit)

Maintain hemoglobin > 10.0 g/dL & hematocrit > 30%

If PT > 2.0, consider transfusion of FFPIf Fibrinogen is 70 - 100, consider FFP. If < 70,

consider cryoprecipitateIf platelets < 50, consider platelet transfusion

Metabolic Acidosis

Adequate perfusionVolume resuscitationSodium Bicarbonate

Use judiciously with high sodiumFind other reasons for acidosis

(respiratory, kidney failure, electrolytes)Use potassium and sodium acetate to

supplement electrolytes

Oxygenation/Ventilation

Early bronchoscopy to clear secretionsRoutine use of SolumedrolGood pulmonary toiletingBreathing treatments/MDINarcan earlyLung recruitment

– PEEP maneuvers– I:E ratio manipulation

Antibiotic Usage

ALL patients get antibiotics! Dosages can be adjusted to size and kidney clearance

Less than 5 days = ZosynGreater than 5 days = Vancomycin + LevaquinMay need other coverage, depending on pre-

donor conditionID consult? Never a bad idea with “strange

circumstances”

Organ Donor Management

1. MAP 60 – 110 mmHg 2. CVP 4 - 12mmHg3. EF > 50% 4. </= 1 pressor used AND:

a. Dopamine </= 10 mcg/kg/min b. Neosynephrine </= 100 mcg/minc. Norepinephrine </= 10 mcg/min d. Vasopressin </= 2.4 units/hour

(0.04 units/min)

5. ABG pH 7.3-7.5

1. PaO2:FiO2 ratio >300 on PEEP = 5

2. Serum Sodium <155 3. Urine output 1-3 mL/kg/hour4. Glucose < 1505. Hemoglobin > 10

Track hormone replacement usage

Final Thoughts

“Everyone of us can help make this difference …Because that truly is the Right Thing to Do.”

Dr. Kenneth Moritsugu, MDUS Deputy Surgeon General

Question to Run-On

How do your standards of care preserve the opportunity for the gift

of life?