Organ DonationOrgan DonationEnd of Life care in the Operating RoomEnd of Life care in the Operating Room

Matthew BockMatthew BockSurgical recovery coordinatorSurgical recovery coordinator

University of Wisconsin University of Wisconsin

Organ Procurement OrganizationOrgan Procurement Organization

1-866-UWHC OPO1-866-UWHC OPO

(1-866-894-2676)(1-866-894-2676)

PerspectivePerspective

Remembering why we’re hereRemembering why we’re here

Save lives through transplantationSave lives through transplantation

Supporting the family’s choiceSupporting the family’s choice

Honoring the patient’s wishesHonoring the patient’s wishes

Donation after Cardiac Death Donation after Cardiac Death (DCD)(DCD)

Uniform Determination of Death Uniform Determination of Death ActAct, 1980, 1980

Irreversible cessation of circulatory and Irreversible cessation of circulatory and respiratory function respiratory function - OR-- OR-

Irreversible cessation of all functions of Irreversible cessation of all functions of the entire brain, including the brain stemthe entire brain, including the brain stem

Two ways to donateTwo ways to donateDeceased Organ DonationDeceased Organ Donation

Donation After Donation After

Brain DeathBrain Death

Donation After Donation After

Cardiac Death Cardiac Death (DCD)(DCD)

Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:

-Clinical exam-Clinical exam-Apnea test-Apnea test

DCDDCD

Severe neurological Severe neurological injuryinjury

Does not meet criteria Does not meet criteria for brain deathfor brain death

Family has elected to Family has elected to withdraw supportwithdraw support

Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:

-Clinical exam-Clinical exam-Apnea test-Apnea test

DCDDCD

Severe neurological Severe neurological injuryinjury

Does not meet criteria Does not meet criteria for brain deathfor brain death

Family has elected to Family has elected to withdraw supportwithdraw support

Clinical Diagnosis of Clinical Diagnosis of Brain DeathBrain Death

Unresponsive to all stimuli Unresponsive to all stimuli No spontaneous respiratory activity No spontaneous respiratory activity All brain stem reflexes are absent:All brain stem reflexes are absent:– Pupillary response to lightPupillary response to light– Corneal reflexesCorneal reflexes– Oculo-vestibular reflex (caloric response)Oculo-vestibular reflex (caloric response)– Oculocephalic reflex (doll’s eye Oculocephalic reflex (doll’s eye

phenomenon)phenomenon)– Gag reflex Gag reflex

Apnea TestApnea Test

Make sure patient has normal body temp, blood pressure, Make sure patient has normal body temp, blood pressure, volume status, ABG’svolume status, ABG’sDisconnect from ventilatorDisconnect from ventilatorMonitor continuous pulse oximetryMonitor continuous pulse oximetryAdminister 100% O2 at 6 L/min into the tracheaAdminister 100% O2 at 6 L/min into the tracheaMonitor closely for respiratory movementsMonitor closely for respiratory movementsCheck serial ABG’s, or at approx. 8 minutesCheck serial ABG’s, or at approx. 8 minutesIf no respiratory movement and arterial PCO2 is > 60 mm Hg, If no respiratory movement and arterial PCO2 is > 60 mm Hg, the apnea test supports the clinical diagnosis of brain deaththe apnea test supports the clinical diagnosis of brain death

Apnea TestApnea Test

Make sure patient has normal body temp, blood pressure, Make sure patient has normal body temp, blood pressure, volume status, ABG’svolume status, ABG’sDisconnect from ventilatorDisconnect from ventilatorMonitor continuous pulse oximetryMonitor continuous pulse oximetryAdminister 100% O2 at 6 L/min into the tracheaAdminister 100% O2 at 6 L/min into the tracheaMonitor closely for respiratory movementsMonitor closely for respiratory movementsCheck serial ABG’s, or at approx. 8 minutesCheck serial ABG’s, or at approx. 8 minutesIf no respiratory movement and arterial PCO2 is > 60 mm Hg, If no respiratory movement and arterial PCO2 is > 60 mm Hg, the apnea test supports the clinical diagnosis of brain deaththe apnea test supports the clinical diagnosis of brain death

Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:

-Clinical exam-Clinical exam-Apnea test-Apnea test

DCDDCD

Severe neurological Severe neurological injuryinjury

Does not meet criteria Does not meet criteria for brain deathfor brain death

Family has elected to Family has elected to withdraw supportwithdraw support

Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:

-Clinical exam-Clinical exam-Apnea test-Apnea test

DCDDCD

Severe neurological Severe neurological injuryinjury

Does not meet criteria Does not meet criteria for brain deathfor brain death

Family has elected to Family has elected to withdraw supportwithdraw support

Severe Neurologic InjurySevere Neurologic Injury

TraumaTrauma– MVA, FallMVA, Fall

SDHSDH

AnoxiaAnoxia– Cardiac Arrest, Cardiac Arrest,

near drowningnear drowning

Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:

-Clinical exam-Clinical exam-Apnea test-Apnea test

DCDDCD

Severe neurological Severe neurological injuryinjury

Does not meet criteria Does not meet criteria for brain deathfor brain death

Family has elected to Family has elected to withdraw supportwithdraw support

Two ways to donateTwo ways to donate

Donation After Brain DeathDonation After Brain Death

Patient is maintained on Patient is maintained on ventilator for organ ventilator for organ recoveryrecovery

Organs dissected insituOrgans dissected insitu

3-4 hour surgery3-4 hour surgery

Donation After Cardiac DeathDonation After Cardiac Death

(DCD)(DCD)

Patient is extubated in the Patient is extubated in the Operating Room or ICUOperating Room or ICU

Surgery begins 5 minutes Surgery begins 5 minutes after cessation of cardiac after cessation of cardiac function and declaration by function and declaration by patient’s physicianpatient’s physician

Rapid recovery with organs Rapid recovery with organs procured en bloc. procured en bloc.

Two ways to donateTwo ways to donate

Donation After Brain DeathDonation After Brain Death

Patient is maintained on Patient is maintained on ventilator for organ ventilator for organ recoveryrecovery

Organs dissected insituOrgans dissected insitu

3-4 hour surgery3-4 hour surgery

Donation After Cardiac DeathDonation After Cardiac Death

(DCD)(DCD)

Patient is extubated in the Patient is extubated in the Operating Room or ICUOperating Room or ICU

Surgery begins 5 minutes Surgery begins 5 minutes after cessation of cardiac after cessation of cardiac function and declaration by function and declaration by patient’s physicianpatient’s physician

Rapid recovery with organs Rapid recovery with organs procured en bloc.procured en bloc.

Two ways to donateTwo ways to donate

Donation After Brain DeathDonation After Brain Death

Patient is maintained on Patient is maintained on ventilator for organ ventilator for organ recoveryrecovery

Organs dissected insituOrgans dissected insitu

3-4 hour surgery3-4 hour surgery

Donation After Cardiac DeathDonation After Cardiac Death

(DCD)(DCD)

Patient is extubated in the Patient is extubated in the Operating Room or ICUOperating Room or ICU

Surgery begins 5 minutes Surgery begins 5 minutes after cessation of cardiac after cessation of cardiac function and declaration by function and declaration by patient’s physicianpatient’s physician

Rapid recovery with Rapid recovery with organs procured en bloc. organs procured en bloc.

““We don’t do that here”We don’t do that here”

ICU nurseICU nurseRTRT

OPO staffOPO staffNo family yetNo family yet

Who is involved?Hospital-Anesthesia Anesthesia -Surgical Technician/Scrub NurseSurgical Technician/Scrub Nurse-Circulating NurseCirculating Nurse

Abdominal Transplant Team- Surgeon- Surgeon- Physician Assistant- Physician Assistant- Surgical Recovery Coordinator- Surgical Recovery Coordinator

Cardiothoracic Team- Surgeon- Surgeon- Surgical Fellow- Surgical Fellow- Surgical Recovery Coordinator- Surgical Recovery Coordinator

PaperworkPaperwork

Consent x2Consent x2Time outTime outPost Op Post Op dispositiondispositionDeath packetDeath packet

Prep & drapePrep & drape

Femoral cutdownFemoral cutdown

Cover patient and Cover patient and back tableback table

Unnecessary staff Unnecessary staff exits the roomexits the room

DCD Withdrawal in the ORDCD Withdrawal in the OR

Accommodating the FamilyAccommodating the Family

Meds, Withdrawal & DeclarationMeds, Withdrawal & Declaration

How long can we wait?How long can we wait?

Rapid En-bloc recoveryRapid En-bloc recovery

Organ Preservation TimeOrgan Preservation Time

Heart: 4-6 hrsHeart: 4-6 hrs

Lungs: 4-6 hrsLungs: 4-6 hrs

Liver: 12 hrsLiver: 12 hrs

Pancreas: 18 hrsPancreas: 18 hrs

Kidneys: 24 hrsKidneys: 24 hrs

A wedding storyA wedding story