Donor Case StudiesOptimal Management

Harbor-UCLA Critical Care – Organ Donation SymposiumApril 12, 2010

Brant Putnam, MD FACSTrauma / Acute Care Surgery / Surgical Critical Care

Harbor-UCLA Medical Center

What is OPTIMAL donor management?

= GOOD CRITICAL CARE

OPTIMAL donor management begins PRIOR to proclamation of brain death.

The ICU nurses and physicians are jointly responsible for optimal donor management, not just the OPO.

If the patient has not been formally pronounced brain dead,

then the patient is alive.Who is not willing to provide good

critical care to a live patient?

NO ONE

Case #163yo male found lying against a wall

Possible fall vs. assaultLarge laceration to occipital areaGCS 1-4-1Pupils sluggish

Case #1Called as a “Tier II” (high acuity) trauma

A - Patent, but not protectedB - Spontaneous, clear bilaterallyC - P = 86 BP – 150D - Unresponsive

GCS = 1-4-1 Pupils 32, sluggish Blood from left ear

Case #1 Intubated in the ED for airway

protection

Taken for CT scan for suspected severe traumatic brain injury

Multiple intra-parenchymal hemorrhages

Large left subdural hematoma(w/ midline shift)

Case #1 Neurosurgery consultation

To OR immediately for bilateral craniectomy + evacuation ICH and SDH

GCS 1-1-1

Coagulopathic and HD unstable intra-opPrognosis deemed poor leaving the OR

Case #1 Patient transported to ICU

Time 0400 2200 2300 0000 0100BP 140/70 140/70 160/80 80/60 100/70P 90 85 110 60 100

Labetalol given Levophed started

What do you think happened here?

Case #1: So to review…

Time 2200 2300 0000 0100

BP 140/70 160/80 80/60 100/70

P 85 110 60 100

Pupils 4, sluggish 4 mm,NR 6 mm, NR 6 mm, NR

Motor Flexor pos Flexor pos No movement No movement

Cough + + - -

Herniation

Brain Herniation

Often accompanied by catecholamine storm Hypertension Tachycardia

Avoid anti-hypertensives

Management Goal #1 Appropriate hemodynamic resuscitation to

maintain perfusion to potential organs for donation Maintain MAP 65-100 mmHg Place central venous line; fluid resuscitation to

CVP 4-10 cm H20 Use of < 1 vasopressor

Dopamine < 10 mcg/kg/minLevophed < 10 mcg/minNeosynephrine < 60 mcg/min

Consider hormonal resuscitation with T4 protocol

What should happen next??

Begin testing for brain death

One Legacy notification (actually should have already been notified!!!)

Clinical optimization

When to notify One Legacy…

Case #1: What did happen….

Next morning… 1200 noon

One Legacy notified

Physician to hold family conference to discuss poor prognosis

No new orders written…

No new orders written…

Time 0800 1200 1800 2400

UOP 300 250 300 100

Na 153 158 164 165

24 hr total

- 1000 cc

165

What do you think is going on here? Management?

Diabetes Insipidus Excretion of large amounts of severely dilute

urine “Central” – no ADH release from brain Kidney can not concentrate urine

Therapy DDAVP (desmopressin acetate)

Synthetic analogue of ADH Free water replacement Frequent monitoring of serum Na

What was done… DDAVP given at 1900

Free water replacement started next morning (POD #2)…

M.D. “brain death evaluation when electrolytes correct”

Time 0800 1200 1800 2400UOP 300 250 300 100Na 153 158 164 165

Management Goal #2 Maintain perfusion to all organs Goal urine output 1-3 cc/kg/hr

Suspect DI if U/O > 200 cc/hr x 2 hrs Treat with DDAVP and fluid (free H2O)

Keep serum Na 135-155

Meanwhile…

POD #3

Time 0000 0600 1200 1800 2400

Glucose 219 160 406 465 398

Management?

Insulin drip finally started next morning at 0900

Management Goal #3Potential donors are critically ill patientsTight glucose control applies

Increase frequency of Accu-checksIncrease sliding scaleInsulin drip as needed

Goal is to keep serum glucose < 150

As time passes . . .

Multiple ventilator alarms PIPs 45-50 Low exhaled tidal volumes

O2 sats 85% Increase TVs to 1 L to maintain sats 88-90%

Is this the best ventilator

management?

Management Goal #4 Maintain good oxygenation

PaO2/FiO2 ratio > 300Reduce FiO2 to reduce oxygen toxicityAvoid high PEEP effects on hemodynamics

Maintain adequate ventilation ABG pH 7.30-7.45

Avoid barotrauma to lungs PIPs < 32 cm H20

Case #1: POD #4

0300 1st Brain Death Note written(Note: 75 hours after herniation event)

1000 2nd Brain Death Note written

1455 One Legacy obtains consent for all organs and tissue

Case #1: Outcome

HD deterioration to near-code Poor organ function Crashed donor to OR because of instability Kidneys recovered Kidney biopsy results poor No organs suitable for transplant

Case #2 – Getting it right . . .

22yo male S/P pedestrian struck by auto x 2 GCS 1-1-1 Lost pulses on arrival; CPR x 12 min Devastating brain injury One Legacy notified within 4 hours of arrival

Case #2

Case #2 Ongoing resuscitation

IV fluid to CVP 8 Blood products to keep Hb near 10 Correction of coagulopathy Use of Levophed to maintain MAP > 65 Addition of T4 within 4 hours

Adequate oxygenation / ventilation ABG 7.39 / 40 / 118 / 24 / -2 / 99% PaO2 / FiO2 = 350 PIPs 22-24

Case #2

Early treatment of DI DDAVP Free water replacement Na 150-154

Tight glycemic control with insulin drip

Loss of brainstem functions First BD note < 12 hours after arrival

Case #2

Outcome - 7 organs transplanted at local centers: Right lung Left lung Heart Liver Right kidney Left kidney Pancreas

Case #3: Steven

17yo male S/P skateboarding accidentGCS 1-1-1Severe DAI, small SDH on CT scanDevastating brain injury

Case #3: Steven

Donor Management Goals

Appropriate hemodynamic resuscitation MAP 65-100 CVP 4-10 EF 50-70% Use of < 1 vasopressor Hormonal resuscitation

with T4 protocol

ALL organsLungs, ALLHeart, ALL

Heart, ALL

ALL

Donor Management Goals

Good oxygenation / ventilation PaO2/FiO2 ratio ABG pH 7.30-7.45 PIPs < 32 cm H20

Urine output 1-3 cc/kg/hr Serum Na 135-155 Glucose < 150

LungsLungs, ALL

LungsKidney

LiverPancreas