Faith Borunda, MSN-RN, CCRN, CPTC Senior Director of Regional Operations Southwest Transplant Alliance

Transcription

1 Faith Borunda, MSN-RN, CCRN, CPTC Senior Director of Regional Operations Southwest Transplant Alliance

2 The Never -Ending Need 114,401 in the U.S. wait for a lifesaving transplant * United Network for Organ Sharing (UNOS)

3 The Never -Ending Need 11,840 Texans need a lifesaving transplant * United Network for Organ Sharing (UNOS)

4 The Never -Ending Need Another person is added to the transplant wait list * United Network for Organ Sharing (UNOS)

5 The Never -Ending Need * United Network for Organ Sharing (UNOS) 22 people die everyday waiting for the organ that never comes

6 Problem St atement --Transplantation has become the standard treatment for many patients with organ failure, however, lack of viable organs for transplantation in the United States results in an increased number of deaths among potential donor recipients each year (UNOS, 2017). * United Network for Organ Sharing (UNOS)

7 Pathophysiology of Brain Death

8 What is pre-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

9 Management of a potential donor Stabilize hemodynamics Support homeostasis Optimize donor organ perfusion

10 How can you optimize the process? Continue to follow your Catastrophic Brain Injury Guidelines (CBIGS) or Traumatic Brain Injury Protocol (TBI) Make sure necessary orders exist and are available for ideal patient care Ex: dopamine and vasopressin Critical Care treatment to support the patient through the brain death process

11 Autonomic/Sympathetic Storm Catecholamine release Tachycardia Elevated cardiac output Vasoconstriction Hypertension

12 Results of Hypothalamus failure Impaired temperature regulation leading to most likely hypothermia Leads to vasodilation without the ability to vasoconstrict or shiver (loss of vasomotor tone) Which then leads to problems with the pituitary gland

13 Pituitary failure Diabetes insipidus with loss of ADH production Resultant hypovolemia and electrolyte imbalances

14 Thyroid failure Cardiac instability Hemodynamic instability Coagulopathy

15 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

16 Intensive Care Management Neurogenic pulmonary edema Catecholamine storm Left-sided heart pressures exceed pulmonary pressure Interstitial edema/alveolar hemorrhage

17 Intensive Care Management Release of tissue plasminogen activator Coagulopathy and possibly DIC

18 Intensive Care Management Hypotension Crystalloids vs. colloids Dopamine/Neosynephrine Vasopressin Thyroxine (T4)

19 Intensive Care Management T4 protocol Bolus: 2 grams Methylprednisone 20 mcg T 4 (Levothyroxine) IVP 20 units of Regular Insulin 1 amp D 50 W Infusion: 400 mcg T 4 in 500 cc NS Run at 25 cc/hr (20 mcg/hr) Titrate to keep SBP >100 Monitor Potassium levels closely!

20 Intensive Care Management Vasopressin Protocol May initiate with a 4 Unit Bolus 1-4 Units/hour titrate to keep SBP >100 or MAP >60 Replace Urine 1:1 for Diabetes Insipidus Inotropic Preference Dopamine and Neosynephrine

21 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 Avoid over-hydration Lung protective strategies Avoid oxygen toxicity CT and bronchoscopy sometimes necessary

22 Intensive Care Management Electrolyte management Hypokalemia Hypernatremia Hypocalcemia Hypomagnesemia Hypophosphatemia

23 Intensive Care Management Hypothermia Continuous temperature monitoring and correction

24 Intensive Care Management Anemia Prefer an H/H >10 & 30% Transfuse and reassess Identify source of blood loss and treat

25 The Heart of A Champion Stabilization is Key to saving Lives Normal Fluid Balance and Electrolytes to facilitate Brain Death Testing Pronouncement of Brian Death removes the burden from the family Organ Donation helps families through their grieving process

26 The Heart of A Champion STA s Common Goal is to Save Lives! Let s work together, as a TEAM to maximize the viability of donor organs for transplant

27 References Determining Optimal Threshold for Glucose Control in Organ Donors after Neurologic Determination of Death: A United Network for Organ Sharing Region 5 Donor Management Goals Workgroup Prospective Analysis Article Sally MB, Ewing T, Crutchfield M, et al. (2014), J Trauma Acute Care Surg, 76(1): 62-68, 69. doi: /TA.0b013e3182ab0d9b. ICU Management of the Potential Organ Donor: State of the Art Article (subscription) Maciel, C. and Greer, D. (2016). Current Neurology and Neuroscience Reports, 16(9). Management of the Heartbeating Brain-Dead Organ Donor Article McKeown, D., Bonser, R. and Kellum, J. (2012). British Journal of Anaesthesia, 108, pp.i96-i Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine / American College of Chest Physicians / Association of Organ Procurement Organizations Consensus Statement Article Kotloff RM, Blosser S, Fulda GJ, et al. (2015), Crit Care Med, 43(6): doi: /CCM Organ Donation in Adults: A Critical Care Perspective Article (subscription) Citerio, G., Cypel, M., Dobb, G., Dominguez-Gil, B., Frontera, J., Greer, D., Manara, A., Shemie, S., Smith, M., Valenza, F. and Wijdicks, E. (2016). Intensive Care Medicine, 42(3), pp The Impact of Meeting Donor Management Goals on the Development of Delayed Graft Function in Kidney Transplant Recipients Article Malinoski DJ, Patel MS, Ahmed O, et al. (2013), Am J Transplant, 13(4): doi: /ajt Epub 2013 Feb 13.

28 Questions?