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ICU Management of the Organ Donor

ICU Management of the Organ Donor. Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics. Case. 19 yof unrestrained MVC Unresponsive at scene P 120, SBP 70, agonal breathing Intubated at scene, IV’s Transported to BMC. Case. Primary exam ET in place with CO2 BS bilaterally

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ICU Management of the Organ Donor

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  1. ICU Management of the Organ Donor Bradley J. Phillips, MD Burn-Trauma-ICU Adults & Pediatrics

  2. Case • 19 yof unrestrained MVC • Unresponsive at scene • P 120, SBP 70, agonal breathing • Intubated at scene, IV’s • Transported to BMC

  3. Case • Primary exam • ET in place with CO2 • BS bilaterally • BP 80 • Neuro - pupil dilated/fixed, unresponsive • Secondary exam • significant head soft tissue/bony trauma • distended abdomen

  4. Case • IVF/Blood • NGT/Foley • Labs drawn • Xrays • CXR/pelvis/lat cspine - negative • CTH - open skull fracture, massive swelling, loss of ventricular space, frontal SDH • CTA - negative

  5. Issues • Brain Death • Organ Donation • Management of the Donor

  6. Brain Death • Brain death = Death • General criteria • cerebral and brain stem functions absent • do NOT include spinal reflexes • condition is irreversible • cessation of all brain function persists after an appropriated period of observation and adequate trial of therapy

  7. Brain Death • Guidelines • detailed neurologic exam • off any sedative drugs • normothermic • confirmatory neuro exam 6-12 hours later • ? Confirmatory test • apnea test • radionuclide cerebral imaging • Xe-CT cerebral blood flow • 4-vessel angiogram

  8. Brain Death • Pronounced as soon as brain death occurs • Cardiac arrest usually 72 hours after brain death

  9. Organ Donation • Consideration of patients as organ donors should in no way interfere with treatment • Required by law to report patients to Organ Bank • “Presumed Consent” • Patients failing criteria for whole organ donation frequently meet tissue donation criteria • Heart Beating vs Non-beating donors

  10. General no cancer except skin or brain no systemic infection no hepatitis no h/o TB/syphilis no h/o IVDA no prolonged hypotension or asystole no ARF/CRF ? Age < 70 Specific Cr < 1.8, BUN < 20 No hypertension (K) No UTI (K) No diabetes (P) No visible lung damage by CXR (Lu) PaO2 > 250 on <=100% Nl EKG/no CAD (H) Sputum clear on Bronch (Lu) Nl liver function tests (Li) Donor Criteria

  11. Donor Management • Concerns • Temperature • Hemodynamics/perfusion • Oxygenation • Urine output

  12. Case • Initial neuro exam no brain stem function • VS: HR 100 SBP 120 RR 12 UOP 300 cc/hr • Labs • Hct 38 • ABG pH 7.48/32/112/24 (SIMV 14/600/40%) • Na 147/K 3.0/Cl 108/Cr 0.4/BUN 18 • Tox + opiates

  13. Case • 12 hours later • VS: HR 120 SBP 90 RR 12 UOP 400 cc/hr • Neuro exam: no brain stem function • LABS • HCT 45 • NA 167/K 4.5/Cl 118 • pH 7.50/30/100/28 (SIMV 14/700/40%)

  14. Donor Management • Maintain core temperature > 35 C • Restore normal circulatory volume • Support blood pressure • Hydration • Pressors (norepi or dopamine) • minimal dose possible • Treat hyperglycemia (>180) • insulin qtt • Treat cardiac arrest agressively

  15. Donor Management • Monitor electrolytes closely • if hypernatremia = D5 1/4 NS • if UOP > 500 cc/hr lower D5 and no KCL • Maintain brisk diuresis • UOP 1-2 cc/kg • IVF • UOP 1-2 cc/kg use D5 1/2 NS c 20 meq KCL • UOP > 2 cc/kg use replacement IVF cc for cc

  16. Diabetes Insipidus (DI) • Impairment of water conservation (pure water) • Suspect Diabetes Insipidus • Trauma involving hypothalamus/pituitary • UOP > 500 cc/hr ( 7 cc/kg/hr) • Na > 150 mEq/L • Serum Osm > 310 • Low urine sodium

  17. Diabetes Insipidus • Management • Replace free water (D5W or D5 1/4 NS) • Drugs • DDAVP • SQ or nasal • SQ 0.03 mg/kg • Pitressin • IV or SQ • IV 0.4 to 2.5 units/hr • Adjust UOP to 100-200 cc/hr • Follow serum Na

  18. End Points of Therapy • SBP: 100-120 mm Hg • CVP: 8-20 mm Hg • PAWP 12-15 mmHg • PaO2: 80-100 mm Hg • SaO2: > 95% • UOP: 100-200 ml/hr (1-2 cc/kg) • pH: 7.35-7.35 • Hgb: 10-12 g/dl

  19. Donor Labs • Common • Chemistry/CBC/ Coags • ABO blood group • CXR/EKG • Urinalysis • Uncommon • LFT/Amylase/lipase • Hepatitis/HIV/CMVscreen • Urine /blood/sputum cultures • Bronchoscopy/Echo/Catheterization

  20. Transplantation Facts • Maximum organ preservation times • heart/lung 4-6 hrs • pancreas 8-16 hrs • liver 12-24 hrs • kidney 24-36 hrs

  21. Waiting /yr Renal 35,253 Liver 7,995 Heart 3,797 Lung 2,368 Kidney/Panc 1488 Pancreas 339 Intestine 87 Transplants / yr Renal 10,891 Liver 3922 Heart 2361 Lung 871 Kidney/Panc 914 Pancreas 110 Intestine (recently restarted) Transplantation Facts

  22. On Death Row, China's Source of Transplants THE gruesome details of China's trade in human organs harvested from Death Row were revealed in detail for the first time in Washington last week by a young doctor from the People's Republic newly fled to the West. As horror stories, they compare with the experiments carried out in Nazi concentration camps. Prisoners are killed to order so that doctors can take their body parts, including - in at least one case - while a victim's heart was still beating. Wang Guoqi, 38, speaking to congressmen, confirmed that condemned men, and sometimes women, are executed to order so that their organs can be transplanted into wealthy recipients from the West and Far East. Dr Wang was a burns specialist at the Paramilitary Police Hospital in Tianjin, under the control of the People's Liberation Army, whose senior generals are believed to make large profits from the trade. He claims that after execution, bodies were taken to the hospital where every part that could be sold was stripped from the corpse

  23. Increasing Organ Donation • Identify key contact individuals • Develop hospital policy • Procurement agency visibility • Education hospital staff • Institute early on-site donor evaluation • Provision of feedback to hospital staff • Non-beating donors? O’Brien, et al. Arch Surg, 1996

  24. Average Cost 1st Year • Heart $253,200 • Liver $314,500 • Kidney $116,100 • Lung $265,900 • includes evaluation/candidacy/procurement/hospital/ physician/follow up/immunosuppression

  25. Transplant Facts • Every 27 minutes someone transplanted • Every 18 minutes name added to waiting list • Every 144 minutes potential recipient dies • Transplant centers: 279 • Kidney 251 Liver 118 • Heart 166 Lung 93 • Pancreas 121 Intestine 27

  26. Living related (20%) Perfect match 95% Half match 90% Zero match 92% Cadaveric (80%) Six antigen 90% all other 85% retransplant 70% Kidney Transplant Survival

  27. Transplant Survival • Heart 84% 77% (graft) • Liver 80% 69% (graft) • Lung 75% 55% (graft) • Intestines 50% 50% (patient) 1 - YR 3 -YR

  28. Healing of the biliary anastomosis after liver transplant most depends on A. Length of donor and recipient bile duct B. The amount of reperfusion injury induced C. Intact portal venous flow D. Intact hepatic arterial flow E. Adequate immunosuprression

  29. HLA matching is not necessary for liver transplant True. Only ABO compatibility is required.

  30. Wound healing is not significantly delayed in patients being treated with A. Cyclosporine A B. Prednisone C. Azathioprine D. Doxorubicin E. Radiation Therapy

  31. Initiation of steroids can be delayed for induction therapy or for oliguria after renal transplant. True.

  32. Major cause of graft loss in heart and kidney allografts is A. Acute rejection B. Hyperacute rejection C. Vascular thrombosis D. Chronic rejection E. Graft infection

  33. Incidence of acute rejection in liver transplantation? 50%

  34. Major cause of mortality after orthotopic liver transplant A. Primary nonfunction of graft B. Hyperacute rejection C. Acute rejection D. Chronic rejection E. Infection

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