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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
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Preserving the Opportunity:
Before and After ConsentModerator:
Adam Teller, Procurement Transplant CoordinatorOneLegacy
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“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
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Question to Run-On
How do your standards of care preserve the
opportunity for the gift of life?
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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
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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
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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?”
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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?”
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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?
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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?
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Pathophysiology of Traumatic Brain Injury
Physiologic collapse frequently accompanies TBI:
HypotensionEndocrine DysfunctionPulmonary DysfunctionHematologic Dysfunction
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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?
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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
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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
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Pathophysiology of Traumatic Brain InjuryHematologic Dysfunction:Thrombocytopenia
Platelets as neededCoagulopathy/DIC
FFP / Cryo as neededHypothermia
Keep them warm!
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What are Traumatic Brain Injury Guidelines?
Hospital approved guidelines for treating patients with Traumatic Brain Injury
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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
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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
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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
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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
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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%
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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
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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?”
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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.
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The Care and Management of Consented Brain Dead Organ Donors
Keith Markillie PTC, RN, BSNOneLegacy
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Best Practices Approach to Saving Lives
&Preserving the Opportunity for
Organ Donation
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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
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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
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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
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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
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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
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Solumedrol
Used in conjunction with T-4 Corticosteroid replacement for lowered cortisol
levels in brain dead patientsUsed routinely throughout care of the donor
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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
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Insulin
Monitor glucose every 2 hours
Treat with insulin drip rather than SQ
Keep 80-150Utilize hospital or
OneLegacy protocol
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Treatment beyond Hormones
Organ PerfusionBalance electrolytesCorrect coagulopathyCorrect metabolic acidosisOptimize oxygenation and ventilationAntibiotic usage
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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
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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
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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
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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
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Oxygenation/Ventilation
Early bronchoscopy to clear secretionsRoutine use of SolumedrolGood pulmonary toiletingBreathing treatments/MDINarcan earlyLung recruitment
– PEEP maneuvers– I:E ratio manipulation
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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”
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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
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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
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Question to Run-On
How do your standards of care preserve the opportunity for the gift
of life?