optimising the brain-stem dead donor

Dr Gerlinde Mandersloot20th April 2012

Optimising the brain-stem dead

donorDr Gerlinde Mandersloot

National Clinical Lead - Donor Optimisation

Organ Donation Past, Present and Future 1

Challenges

4Organ Donation Past, Present and Future

• Physiological consequences of BSD

‘Collateral damage’

• Hormonal • Diabetes insipidus

• Hypovolaemia• Hypernatraemia

• T3 / T4 reduces• ACTH• Blood glucose

• Hypothermia

Organ Donation Past, Present and Future 5

Incidence of organ involvement

• Hypotension 81%

• Diabetes insipidus 65%

• DIC 28%

• Cardiac dysrhythmias 25%

• Pulmonary oedema 18%

• Metabolic acidosis 11%

J Heart Lung Transplantation 2004 (suppl)

Organ Donation Past, Present and Future 6

Challenges

7Organ Donation Past, Present and Future

• Physiological consequences of BSD• Stabilisation and brainstem death testing

Stabilisation of a patient to facilitate neurological examination

• Difficulties in defining futility, especially in survivors• Replace by concept of ‘Best Interests’

• Not only medical factors taken into account

• Stabilisation of patient prior to BSD testing• Brainstem death testing is part of a neurological examination of the patient

• Clinical in the majority of cases• Ancillary tests where required

• Active management may be necessary in order to examine accurately

• Continued care after BSD to explore possibility of donation

• Integral part of every End of Life Care Plan

Challenges

9Organ Donation Past, Present and Future

• Physiological consequences of BSD• Stabilisation and brainstem death testing• Consistent donor optimisation

• 65% of units have 2 or fewer donor per year• 23% of donors are from these units• Only 4% units have 10 or more donor per year, 28% of the total donor

population

Give me a CVP of 6-10

Too much-less than 6

I’d like 10-12

Just get on with it!! Make sure they aren’t hypovolaemic, please

Fluid overload is a problem for us-if we get goals withless that’s good

Lots of fluid please-better function

earlier

Decent perfusion, good gases and BP, it can only

get worse

Evidence

• Totsuka Transplant Proc. 2000; 32;322-326

• High sodium in liver donor doubles graft loss

• Rosendale Transplantation 2003. 75 (4): 482-487

• Protocol increased organs per donor 3.1 to 3.8. Increased probability of

transplant

• Snell J Heart Lung Transplant 2008;27:662-7

• 54% of Australian lung donations used for transplant vs. 13% in UK

Organ Donation Past, Present and Future 11

12Organ Donation Past, Present and Future

Organ Donation Past, Present and Future 13

Unifying practice across the UK• Optimisation tool

• Non-controversial (or not too controversial)• Not too complicated• One side of an A4 ?• Buy-in from retrieval / transplant community• Easy to audit

• Extended Care Bundle with two components• Prescription: medical staff • Implementation

• Critical care nurses• SN-ODs• ‘Scouts’

• Monitoring implementation

14Organ Donation Past, Present and Future

15Organ Donation Past, Present and Future

16Organ Donation Past, Present and Future

Priorities, if not already addressed

17Organ Donation Past, Present and Future

• Assess fluid status and correct hypovolaemia with fluid boluses as required

• Perform lung recruitment manoeuvre(s) as at risk of atelectasis following apnoea tests

• Identify, arrest and reverse effects of Diabetes insipidus

• Introduce vasopressin infusion: reduces Norepinephrine requirements and treats DI

• Methylprednisolone, 15 mg/kg to max of 1g, as soon as possible

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 for use• 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)

Organ Donation Past, Present and Future 18

19Organ Donation Past, Present and Future

Monitoring optimisation

20Organ Donation Past, Present and Future

• 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: graft function in recipients• Delayed graft function• Quality: biomarkers• Duration of graft function: long term project