Breathe Easy:Making Lung Offers That Can Be Accepted

Adam Bell, BS, CCEMT-P, CPTC

Donor Network of Arizona

NATCO Annual Meeting Aug 11, 2014

Disclosures

There are no financial conflicts of interest from the presenters for this approved course.

All individuals in positions to control content of the educational activity have disclosed all financial relationships and there are no conflicts of interest.

There is no commercial support of this educational activity.

There is no off-label usage/no product related to this activity.

Objectives

Identify 3 reasons transplant center physicians may not be familiar with offers when they become primary

List 5 things an OPO can do to speed allocation and acceptance of lungs

List 8 elements of a “complete” lung offer

Describe 3 factors transplant centers can consider to help identify which recipients might be appropriate for a given set of lungs

The Need

As of today 1,653 people in the US are waiting for a lung transplant

Indications for Lung Transplant

Congenital

Idiopathic Pulmonary

Fibrosis

Cystic Fibrosis

Pulmonary HTN

A1AT , COPD

CLAD

…and recipients have myriad comorbidities

Ethical Concepts in Organ Allocation

Beneficence

Non-Malfeasance

Justice (equitable distribution)

We don’t work in sales. Our goal must be to help recipients rather than to place organs.

If it’s bad: write it in neon!

Why isn’t the Transplant Center familiar with my offer?They gave a “Prov Yes.”

Incomplete offers

Call centers and non-physician staff taking offers

Decision makers are busy

Offer may change before becoming “primary”

What do Transplant Centers want?

To transplant organs with good long-term outcomes

That’s really it, but, they have to protect recipients from bad offers, and that’s our fault.

UNOS Requirements

Elements of a “Complete” lung offer

Using Donor Highlights

FBO and ground time info

Allocation plan and laterality issues

DCD tool

Direct Centers to what their organ needs (LU team see Echo, and CT-chest)

If “backing up” Who will be recovering what and when, Will you delay XC?

Attachments in UNET

Are NOT available in mobile view

Searchable documents are best

Legibility is an issue

Small, discrete, well labeled attachments are better

If it matters: Type it into UNET!

Med-Soc Follow up

Old Op-notes re chest surgeries

High Risk

H&P vs. Med-Soc

Travel

Place of birth? (Immunization Hx)

Highlights MUST Reflect Reality

Same Donor

TB

Where is your donor from?Travel?Immunization? → + PPD

Maps by CDC

TB 2

Never tested +, but…

Ever tested at all?

Hx and follow up

Latent TB QuantiFeron test (24 hrs)

CDC QuantiFeron info

CT is more sensitive than CXR

Bronchoscopy findings

Did secretions clear easily?

Did they re-accumulate?

Aspiration? (Of What? Where?)

Legibility of report

Clarify findings before Dr. leaves

A good bronch formasks the tough questions

Pulmonary Contusions

Hard to eval pre-OR

(progressive process)

CT

Fx sternum or scapula? (Force)

Have a plan for R and L separately PRN

Pulm venous gas in OR?

Ex-Vivo perfusion may provide eval tool in non-inflammatory setting

When to CT

30+ pack years (maybe 20)

Suspicion for TB or consolidated pneumonia

Significant chest trauma

Most donors over 60

Pulm Embolism

Need to R/O malignancy

Worth 1,000 words…

Quiz Show

Vent: PIP, rate, mode, PEEP, Tidal Vol, FiO2, I:E ratio (in APRV high and low times and P high and low also)

Recruitment: When relative to ABGs? How? Ongoing (how & when?)

Why is your PcO2 high or low?

Fluid management plan?

Why is your PA pressure high?

Why are other centers saying “No?”

If you’re going to cath anyway

Get R side pressures

Leave a SWAN in

Combine this with the CT road trip

If not traveling on a vent, use a PEEP valve

Transplant Center Challenges

Front line staff may lack autonomy

Lack of R/O criteria

Listed pts who aren’t local

(recipient transport times)

Surgeon availability

Time to set up flights

Willingness to spend $$ on flights (DCD, others recovering far away?)

Transplant Center Responsibilities

Search for any global R/O

Decline based on antigens to avoid

Decline based on size

Decline based on available organs and laterality

Create a list of ??s that need to be answered by OPO and testing requests

What does the list tell us?

Bypass impossible placements

Save time &let transplant center staff sleep.

Exhausting the list:Heroic or Wasteful?

830 isn’t a reason; it’s a vague code

STOP and ASK WHY !!

Innate vs. treatable issues

“Fix” your donor before making more offers

Consider stopping when efforts are clearly futile

Know when to fold ‘em

COPD

Pulm HTN refractory to diuresis

HCV

Aspiration of things you can’t remove

Severe aspiration of gastric contents, food, gravel, glass etc.

Bullets in LU parenchyma

Reaching Transplant Center Staff:Using the OPO Console

OPO staff contact info can be found in the Match Run

Real offer

Setting OR times

Do not set OR times prior to placing all organs, period

If you’ve ignored the above, stop making offers when OR timing will R/O those offers

In Summary

Thorough donor testing is essential to recipient safety

Both OPO and Transplant Center staff need to seek clear and open communication at all times

Offers need to be complete, and Transplant Center responses timely

Special Thanks To:

Cleveland Clinic

Lung Transplant Program Staff

…and

Thank YOU, for your daily dedication!!

Questions?

References & Sources

CDC.gov

optn.transplant.hrsa.gov

OPTN Policies

Unet

seemyradiolgy.com