Donation after Brain-Stem Death DBD

Transcription

1 Donation after Brain-Stem Death DBD Dr Peter Hall Dr Dale Gardiner Dr Gerlinde Mandersloot 22 nd May

2 YORKSHIRE Regional Data Dr Peter Hall CLOD Calderdale and Huddersfield NHS Trust 2

3 Session Objectives Present regional data for DBD Understand that DBD gives better organs than DCD Increase rate of neurological confirmation of death by increasing confidence in the Diagnosis of Death Increase quality of DBD organs adoption of extended care bundle and compliance with the six early interventions in donor optimisation collaboration in Scout pilot 3

4 Donation after Brain Death YORKSHIRE (DBD) Mechanically ventilated patient where death has been confirmed using neurological criteria. 52 donors -1.9% (from 5 years ago) Lungs Heart Small Intestine Kidneys Liver Pancreas

5 YORKSHIRE Donation in Yorkshire % 1.9% 137.5% 5

6 YORKSHIRE Donation in Yorkshire

7 DCD DBD kidneys intestine lungs pancreas liver heart

8 YORKSHIRE DBD- Neurological death testing rate Tied 9th with 3 others 74 ND tested (%) 20 0 Eastern London Midlands North West Northern Northern Ireland Scotland South Central South East South Wales South West Yorkshire 1 April 2012 to 31 March 2013, data as at 4 April 2013 Team National rate 8

9 DBD- Yorkshire Neurological death testing rate ND tested (%) Number of neurological death suspected patients Bradford 2 York 3 Harrogate (with 6) 4 Airedale 5 Sheffield Children s 6 Barnsley (with 3) 7 Rotherham 8 Chesterfield 9 Sheffield 10 Nth Lincolnshire & Goole 11 Doncaster and Bassetlaw 12 Leeds 13 Hull and East Yorkshire 14 United Lincolnshire Hospitals 15 Calderdale and Huddersfield 16 Mid Yorkshire Hospitals Trust National rate 95% Lower CL 95% Upper CL 99.8% Lower CL 99.8% Upper CL 1 April 2012 to 31 March 2013, data as at 4 April

10 YORKSHIRE Mean no. of organs donated per donor Tied 6 th Northern (1 st ) : Every 10 donors save 3 more lives than we do 1 April 2012 to 31 March 2013, data as at 4 April

11 Diagnosis of brain stem death years on 2008 Dr Dale Gardiner Adult Intensive Care Consultant, Nottingham Midlands, Clinical Lead for Organ Donation Member of the UK Donation Ethics Committee 11

12 not inventors. We are explorers

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15 Brain death: Discovered not Invented (by intensive care) 15

16 1964, Keith Simpson there is life so long as circulation of oxygenated blood is maintained to live brainstem centres 16

17 1976 (clarified 1979) UK Criteria for Diagnosing Death using Neurological Criteria Published. 17

18 Rene Laennec 1819 Eugene Bouchut UK Criteria for Circulatory Criteria published for the 1 st time. 5 minutes. 18

19 UK Definition of Death irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe 2008 therefore irreversible cessation of the integrative function of the brain stem equates with the death of the individual. 19

20 UK Definition of Death irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe All human death is anatomically located to the brain therefore irreversible cessation of the integrative function of the brain stem equates with the death of the individual. 20

21 1 death : 3 sets of criteria Neurological Criteria Circulatory Criteria DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe Somatic Criteria

22 Dx Death using Neurological 1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. Criteria DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe Cause tells you irreversibility, based on the natural history of the disease Cause tells you how long you should observe before testing: Typical > 6 hours Hypoxia 24 hours Atypical? longer 22

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24 > patients 10 years 37 years

25 D. Alan Shewmon, MD

26 Although we were unable to restore his consciousness or spontaneous breathing, the boy lived several more years. (page 195)

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28 Dx Death using Neurological 1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. Criteria DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 2. An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. 28

29 Dx Death using Neurological Clinical judgement essential Impossible to create rules covering every situation Difficulties mainly with thiopentone and midazolam Criteria 2. An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. Plasma concentrations not good predictors of effect Use of antagonists DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe 29

30 Dx Death using Neurological 1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. Criteria 2. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. 3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes. 30

31 Brain stem reflexes Pupils (II, III) Corneals (V, VII) Pain (V, VII) Gag (IX, X) Cough (IX, X) Oculovestibular (III, VI, VIII) Oculocephalic Paediatric Suck Consciousness Ascending reticular activity system Breathe Medulla Oblongata Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001;344: AoMRC (2008) 31

32 Apnoea Test Starting: paco 2 > 6.0 Kpa ph <7.4 Stopping: 5 minutes observation paco 2 rise > 0.5 KPa Recommended method: After pre oxygenation, disconnect the patient from the ventilator and administer oxygen via a suction catheter in the endotracheal tube at a rate of >6 L/minute. If oxygenation is a problem, consider the use of a CPAP circuit (eg Mapleson B). The apnoea test is performed only twice in total. 32

33 Dx Death using Neurological 1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe. Criteria 2. DEATH Irreversible loss of the capacity for consciousness Irreversible loss of the capacity to breathe An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria. 3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes. In 2012,1238 tests performed, death confirmed in 1220 = 98.5%

34 Testing for Brain stem Death This form is consistent with and should be used in conjunction with, the AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of Death and has been endorsed for use by the following institutions: Faculty of Intensive Care Medicine, Intensive Care Society and the National Organ Donation Committee. Abbreviated Full 34

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36 WHY TEST?

37 WHY TEST? 1. To eliminate all possible doubt regarding survivability 2. To confirm diagnosis for families 3. To protect doctors in cases subject to medico legal scrutiny 4. To provide choice regarding organ donation

38 diagnosis decision

39 Brainstem death in the

40 TWO TESTS or ONE? 2008 Dr A performs Dr B observes SWAP Dr B performs Dr A observes = 2 TESTS (regardless of organ donation) Legal support from case law & Bolam & Bolithio tests

41 TWO TESTS or ONE? 2008 Dr A performs Dr B observes SWAP Dr B performs Dr A observes = 2 TESTS (regardless of organ donation) Legal support from case law & Bolam & Bolithio tests

42 TWO TESTS or ONE? 2008 Dr A performs Dr B observes SWAP ALIVE Test 1 Time of Death Dr B performs Dr A observes ALIVE = 2 TESTS (regardless of organ donation) Legal support from case law & Bolam & Bolithio tests Test 2 DECEASED

43 Lesson 1

44 Lesson 2

45 Lesson 3 Take your time Slow down (minimum 6 hours) Don t over-read coning on CT Atypical presentation = wait Hypoxic brain injury >24 hours

46 Lesson 4 Induced hypothermia has unpredictable consequences See Lesson 3 Advice: warm to normothermia and then wait 24 hours

47 Lesson 5 NO EEG

48 Lesson 6 Start with Lesson 2 = use your brain and examine your patient 1. Clinical brain death + NO flow = Death 2. Clinical brain death + flow = Wait See Lesson 3 = take your time and ask Is reversibility possible?

49 Gardiner, Shemie, Manara & Opdam International Perspective on the Diagnosis of Death Br J Anaesthesia Supplement January 2012 Username: Password: Dale Gardiner

50 Optimising the brainstem dead donor Dr Gerlinde Mandersloot National Clinical Lead - Donor Optimisation Dr Gerlinde Mandersloot 20 th April

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53 Donor optimisation Ameliorate systemic effects of brain stem death Why? Increase number of donors Increase number of organs per donor Increase quality of organs Who takes responsibility? ICU staff: medical and nursing SN-ODs Retrieval teams Scout Cardio-thoracic teams 53

54 Collateral damage Hormonal Diabetes insipidus Hypovolaemia Hypernatraemia T3 / T4 reduces ACTH Blood glucose Hypothermia 54

55 Incidence of organ involvement Hypotension 81% Diabetes insipidus 65% DIC 28% Cardiac dysrrhythmias 25% Pulmonary oedema 18% Metabolic acidosis 11% J Heart Lung Transplantation 2004 (suppl) 55

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57 Evidence Totsuka Transplant Proc. 2000; 32; High sodium in liver donor doubles graft loss Rosendale Transplantation (4): Protocol increased organs per donor 3.1 to 3.8. Increased probability of transplant. Snell J Heart Lung Transplant 2008;27: % of Australian lung donations used for transplant vs. 13% in UK 57

58 Principles Ameliorate systemic effects of brain stem death Why? Increase number of donors Increase number of organs per donor Increase quality of organs Who takes responsibility? ICU staff: medical and nursing SN-ODs Retrieval teams Scout : who are they attached to? Cardio-thoracic teams Abdominal teams Free standing 58

59 What do we aim for? General stability Examples of target values MAP: mm Hg Heart rate: / min SR CI: > 2.1 l/min/m 2 Guidelines Australian Canadian Map of Medicine ICS NHSBT 59

60 Cardiovascular management Summary of cardio vascular target values MAP: mm Hg CVP: 4 10 mm Hg Heart rate: /min SR CI: > 2.1 l/min/m 2 (can be higher, be aware of myocardial stunning) Filling targets: no good evidence for any specific targets, depends on device SvO 2 > 60% SVRI target Secondary target Dehydration temptation to maintain MAP with vasopressors rather than filling 60

61 Respiratory management Recruitment manoeuvre Post BSD testing: apnoea test resulting in atelectasis After suctioning / disconnection When SpO 2 drops / FiO 2 increases Lung protective ventilation: 4 8 ml/kg ideal body weight Permissive hypercapnia with ph > 7.25 Optimum PEEP (5 10 cm H 2 O) and FiO 2 (aim for < 0.4 as able) Head up positioning (30-45 ) Suctioning, physiotherapy as required Antibiotics for purulent secretions: local microbiology surveillance Avoid over-hydration 61

62 Managing Diabetes insipidus Very common occurrence Pathophysiology Posterior pituitary failure Polyuria: output > 4ml/kg/h Dehydration with Na + Usually at least partially addressed with stabilisation for BSD testing Treatment: Fluids Vasopressin DDAVP Aim for u-output ml / kg / h 62

63 Hormonal treatment Vasopressin Reduction in other vaso-active drugs Dose: 1 4 units/h (can start with boluses of 1 unit at a time) Liothyronine (T3) No clear evidence yet for either use or not May add haemodynamic stability in very unstable donor Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team Methylprednisolone in all cases Dose: 15 mg/kg up to 1g Insulin At least 1 unit/h (Occasionally may need to add glucose infusion) Tight glycaemic control (4-10 mmol/l) 63

64 Haematological management DIC seen occasionally as direct consequence of BSD May require correcting prior to BSD testing if bleeding Hb > 8 g/dl (~ 10 g/dl traditionally advocated) (even > 7g/dl?) No evidence on harm with lower Hb, but some evidence of harm with blood transfusions and organ function post transplant Where Hb borderline, ensure blood available for retrieval procedure: local protocols and antibodies will determine whether G&S only, or units to be cross matched Use of clotting factors Only where bleeding is an issue Monitor clotting status Use local hospital protocol Retrieval procedure may require additional products 64

65 General measures Maintain normothermia (active warming may be required) Thrombo-embolism prophylaxis Stockings Sequential compression devices LMWH Positioning Head-up Side to side Attention to cuff pressures and leaks to prevent aspiration Continue NG feeding (may be reduced/ stopped for bowel transplant) Antibiotics according to sensitivities or empirical according to Trust guidelines 65

66 Monitoring optimisation Implementation: use of care bundle Adherence easy to monitor Audit first 5 priorities Results of optimisation evaluated Number of organs retrieved Increase in cardiothoracic organs retrieved Quality of organs: organ function in recipients Delayed graft function Quality: biomarkers Duration of graft function: long term project 66

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