2/20/2018. Organ Donation after Cardiac Death. STA Introduction. Disclosure. The Need

Transcription

1 STA Introduction Organ Donation after Cardiac Death Geoffrey Funk, MD, FACS Associate Medical Director Southwest Transplant Alliance Disclosure Canadian by birth Three degrees from Texas A&M Trauma and acute care surgeon by training The Need 140, , ,000 80,000 60,000 40,000 20,000 0 Patients Waiting Organs Transplanted Donors

2 Statistics In 2016 more than 33,500 organs were transplanted Every 10 minutes someone is added to the waiting list On average, 22 people die each day while waiting One organ donor can save eight lives Objectives Understand the differences between donation after brain death and donation after cardiac death Professional obligation and best practices Medical management to increase organs transplanted per donor Identify challenges in the process of donation after cardiac death Conflicts of Interest None 2

3 Donation after Brain Death (DBD) Definition Brain stem death (AKA heart-beating donation) Meets criteria for brain death as defined by the Uniform Determination of Death Act and the American Academy of Neurology Cardiorespiratory support continues, allowing for optimization of conditions for donation Donation after Brain Death (DBD) Uniform Declaration of Death Act (UDDA) An individual who has sustained either 1) irreversible cessation of circulatory and respiratory functions, or 2) irreversible cessation of all functions of the entire brain, including the brainstem is dead. A determination of death must be made with acceptable medical standards. Donation after Brain Death (DBD) American Academy of Neurology Clinical evaluation (prerequisites) Establish irreversible and proximate cause of coma Achieve normal core temperature (>36 o ) Achieve normal systolic blood pressure Perform one neurologic exam 3

4 Donation after Brain Death (DBD) American Academy of Neurology Clinical evaluation (neurologic assessment) Coma Absence of brainstem reflexes Pupillary response Ocular movements Oculocephalic/oculovestibular Corneal reflex Facial muscle movement to noxious stimuli Pharyngeal and tracheal reflexes Donation after Brain Death (DBD) American Academy of Neurology Clinical evaluation (neurologic assessment) Apnea Absence of breathing drive Normotension Normothermia Euvolemia Eucapnia Absence of hypoxia No prior evidence of CO 2 retention Donation after Brain Death (DBD) American Academy of Neurology Ancillary tests EEG Cerebral angiography Nuclear scan TCD CTA MRI/MRA 4

5 Donation after Cardiac Death (DCD) Definition Non-heart beating donation, defined at the First International Workshop on DCD in Maastricht (1995) Sole source of organs prior to 1968 Uncontrolled DCD Dead on arrival Unsuccessful resuscitaiton Controlled DCD Requires the clinical assessment that death is inevitable or that recovery is functionally impossible Donation after Cardiac Death (DCD) Controlled DCD Management of the donor for the benefit of the recipient Ethical dilemmas: What invasive procedures are acceptable? How aggressively can the potential donor be managed? Donation after Cardiac Death (DCD) Controlled DCD Volk et al. (2010) study public attitudes: Slightly higher willingness to donate a family member s organs after cardiac death than after brain death the public may prefer donation after cardiac death because it resonates more closely with popular conceptions of the dying process 5

6 Donation after Cardiac Death (DCD) Controlled DCD Lack of knowledge amongst healthcare providers is a huge problem Wolf et al. (1994) evaluated nursing opinions and understanding Uncertain of whether or or not the DCD donors could feel pain Unconvinced that the donors were dead Increased knowledge of the process significantly correlates with support for DCD (D Alessandro et al. 2008) More positive feelings about the donation process Increased positive perception of the process s value for family members Decreased personal barriers to DCD Donation after Cardiac Death (DCD) Controlled DCD The Dead Donor Rule Donation after Cardiac Death (DCD) Controlled DCD Potential for conflict of interest Separation of patient care team and those approaching regarding donation DCD could give the impression that patients would be killed for their organs uncomfortable similarity between euthanasia and DCD (Mandell et al. 2006) 24% of surveyed transplant personnel believed the practice of retrieving organs causes physicians to view some persons as suppliers of body parts, rather than as people who themselves need the best treatment possible (Dubois et al. 1999) 6

7 What is donor management? Stabilization of the potential donor to allow for brain death testing or DCD efforts Optimization of the function and viability of all transplantable organs Implementation of a collaborative process between the OPO and hospital staff to increase the chances of life-saving transplantation How can we optimize the process? Remove unnecessary orders for the patient s chart (e.g., sedatives, anticonvulsants, etc.) Make sure necessary orders exist and are available for ideal patient care Design orders to allow bedside providers to recognize physiologic goals and notify appropriate personnel if issues arise The pathophysiology of brain death Systemic physiologic instability secondary to loss of brain stem function Hyperdynamic state secondary to loss of vasomotor control Loss of respiratory function Cardiac arrhythmias Loss of thermoregulation Loss of hormonal regulation 7

8 Management of the potential donor Stabilize hemodynamics Support homeostasis Optimize donor organ perfusion Autonomic/sympathetic storm Catecholamine release Tachycardia Elevated cardiac output Vasoconstriction Hypertension Pituitary failure Diabetes insipidus with loss of ADH production Resultant hypovolemia and electrolyte imbalances 8

9 Thyroid failure Cardiac instability Hemodynamic instability Coagulopathy Intensive care management Rule of 100s SBP > 100 mm Hg HR < 100 UOP > 100 ml/hr PaO2 > 100 mm Hg Aggressive resuscitative therapy to restore and maintain intravascular volume SBP > 90 mm Hg (MAP > 60 mm Hg) CVP ~ 10 mm Hg Intensive care management Neurogenic pulmonary edema Catecholamine storm Left-sided heart pressures exceed pulmonary pressure Interstitial edema/alveolar hemorrhage Release of tissue plasminogen activator Coagulopathy and possibly DIC 9

10 Intensive care management Hypotension Crystalloids vs. colloids Dopamine/neosynephrine Vasopressin Thyroxine (T4) Intensive care management T4 protocol Sudden reduction of pituitary hormones May impact myocardial cell metabolism and contractility Severe dysfunction can lead to extreme hypotension and potential organ loss T4 protocol Pre-medication (in rapid succession): 1 amp 50% Dextrose in Water 2 grams Solumedrol IV 20 units Regular Insulin 20 micrograms (mcg) Levothyroxine IV Infusion: Levothyroxine 400 mcg/500 ml NS Start infusion at 10 mcg/hr Double infusion rate if no response Titrate to wean off pressors 10

11 Intensive care management Impaired gas exchange Maintain PaO2 >100 and an oxygen saturation >95% PEEP 5cm, increase PRN HOB >30 degrees Increase ET cuff pressure Aggressive pulmonary toilet CT and bronchoscopy sometimes necessary Intensive care management Impaired gas exchange Avoid over-hydration Lung protective strategies Avoid oxygen toxicity Electrolyte management Hypokalemia Hypernatremia Hypocalcemia Hypomagnesemia Hypophosphatemia Intensive care management Hypothermia Continuous temperature monitoring and correction Anemia Prefer a hematocrit >30% Transfuse and reassess Identify source of blood loss and treat 11

12 Clinical Triggers Ventilator Neurological insult Missing 2 more reflexes Age, medical condition, or Medical Examiner involvement does not preclude organ donation Brain Death vs Donation after Circulatory Death Brain Death Irreversible cessation of all brain function including the brain stem. Brain dead donors remain on the vent and vital signs and heartbeat are maintained until organ recovery begins. Donation after Circulatory Death (DCD) Option for those with non-recoverable illness/injury with neurological devastation resulting in ventilator dependency Condition is irreversible but patient does not meet brain death criteria If cardiopulmonary death is likely to occur within 60 minutes following withdrawal of ventilator support Donor Registry / UAGA* Patient who are registered are considered First Person Consent Texas Health and Safety Code (chapter 692A) also states: Review of medical records and examinations Measures to ensure suitability may not be withdrawn *Uniform Anatomical Gift Act 12

13 UAGA / TAGA- 692A.021(b) Before resolution of the conflict, measures necessary to ensure the medical suitability of the part may not be withheld or withdrawn from the prospective donor. Family Family s worst day Brain death pronouncement removes burden from family Organ donation helps families through their grieving process Families who decline to donate frequently regret the decision later Families experience a secondary loss when donation does not come to fruition Obstacles Family decisions Advanced directive Can t do this anymore Withdrawal of treatment Confusion Meaning of DNR Didn t know to call STA This will cost the family money 13

14 Collaborative Approach Move to private, quiet setting Explain brain death from a medical standpoint Spend time and listen to the family Answer the family s questions; What s the next step? Collaborative Approach Best introduction of the STA coordinator: Your family has some important decisions to make at this difficult time. This is Laura, and she will help support your family and answer any questions you might have regarding end-of-life decisions for your son. Collaborative Approach According to CMS Guidelines, only a trained, designated requestor can mention donation to the family For a physician, or other healthcare provider currently caring for the potential donor, to mention donation can be perceived by the family as a conflict of interest. 14

15 Collaborative Approach According to CMS Guidelines, only a trained, designated requestor can mention donation to the family For a physician, or other healthcare provider currently caring for the potential donor, to mention donation can be perceived by the family as a conflict of interest. Collaborative Approach STA coordinator offers support and explains opportunity to donate: Reinforce physician s explanation of brain death Potential timeline for organ recovery Directed Donation Donation-related hospital costs paid by STA Open casket funeral remains an option Conflict of Interest There is no conflict of interest. The transition from caring for a critically ill or dying patient to a potential organ donor can be a difficult process for health care providers. Treat all patients as though they will survive. What s good for the patient is good for organ donation. To avoid the perception of conflict of interest, the STA Family Services Coordinator often takes the lead during the approach process. 15

16 In charge and responsible Once patient is declared brain dead, the STA Medical Director and Coordinator assume responsibility for managing that patient The donation process sometimes requires physicians support for certain procedures (e.g., place central and arterial lines, bronchs, bedside liver biopsies, etc) STA Donation Coordinators are specially trained in donor management Progression to Brain Death Cell Death Edema and cytokine release ICP & CPP increase Sympathetic Nervous System Catecholamine release Tachycardia, HTN, SVR increase Cytokines cross BBB Anaerobic metabolism = acidosis Depressed organ function Hypotension, cardiac failure, pulmonary edema, interstitial fluid Pre-donor Management Goals Catastrophic Brain Injury Guidelines Blood Pressure SBP > 100 (MAP > 65) Adequate hydration Vasopressor support Blood Products Hgb > 8.0 g/dl Platelets > 50 INR < 1.5 Electrolytes Glucose mg/dl Normalize Na, K, Mg, Phos, Ca Oxygenation PO 2 > 100 ph PEEP 5 8 Urine Output > 0.5 ml/kg/hr Lasix < 300 ml/hr Vasopressin Temperature Normothermic 16

17 Questions? References Dixon, T., Malinoski, D., Devastating brain injuries: assessment and management part I: overview of brain death, Western Journal of Emergency Medicine, Volume X, No. 1. Fung, John, Management of the Deceased Organ Donor, Cleveland Clinic Transplant Center. Hagan, M., McClean, D., Falcone, C., Arrington, J., Matthews, D, Summe, C Attaining specific donor management goals increased number of organs transplanted per donor: a quality improvement project, Progress in Transplantation, Vol. 19, No. 3, September. Malinoski, D., Patel, M., Ahmed, O., Daly, M., Mooney, S., Graybill, C., Foster, C., Salim, A., The impact of meeting donor management goals on the development of delayed graft function in kidney transplant recipients, American Journal of Transplantation, December. Doi: /ajt Malinoski, D., Patel, M., Daly, M., Graybill, C., Salim, A., The impact of meeting donor management goals on the number of organs transplanted per donor: Results from the united network for organ sharing region 5 prospective donor management goals study, Critical Care Medicine, Vol. 40, No. 10. doi: /CCM.0b013e31825b252a Malinoski, D., Daly, M., Patel, M., Graybill, C., Foster, C, Salim, A Achieving donor management goals before deceased donor procurement is associated with more organs transplanted per donor. The Journal of Trauma, Volume XX, XXX. Doi: /TA.0b013e e5 Murthy, Col TVSP, Organ donation: intensive care issues in managing brain dead, Medical Journal Armed Forces India, Vol. 65, No. 2. How can you help? Advocate for CBIGs Catastrophic Brain Injury Guidelines Prevent uncontrolled cardiac arrests Facilitate smooth transition to brain death testing Patient already in physiologic homeostasis Fewer delays, less anxiety for family Assure certainty of proper brain death diagnosis Preserve organ function 17

18 Case Study #2: Importance of Donor Management Day 1: 52 yr female called EMS reporting inability to breathe EMS arrival, pt found down, no pulse, CPR initiated Intubated at the scene 22:34 Admitted anoxic injury s/p cardiac event Occasional posturing at time of admit Day 2: Case Study #2: Importance of Donor Management 15:00 Referral to STA HR 98 BP 102/62 Temp U/O 100cc/hr Dopamine drip Day 3: Case Study #2: Importance of Donor Management Not breathing over vent No cough or gag reflex No corneal reflex Apnea test attempt; did not tolerate Unable to do CBF Physician spoke to family about poor prognosis 18

19 Case Study #2: Importance of Donor Management Day 4: No change in condition Treatment decelerated Vasopressors discontinued NS Case Study #2: Importance of Donor Management Day 5: Serial EEGs recommended; only one performed Brain Death Note written Family approached regarding donation option Day 6: Case Study #2: Importance of Donor Management 13:20 Donation authorization obtained 16:03 Second EEG performed (OPO requirement in absence of adequate Apnea test or CBF) 22:10 Donor case shut down due to lab results indicating poor organ function 22:57 Withdrawal of ventilatory support; Cardiac time of death 19

20 Case Study #2: Importance of Donor Management Learning points: Case treatment not aggressive Donation opportunity lost 20