Engaging ICU Teams

1. Engaging ICU Teams Randy Janczyk, MD, FACS William Beaumont Hospital Royal Oak, Michigan

2. Case 1 • 41 year old white female, history of 48 hour severe headache. EMS called when patient experienced seizure and became unresponsive. Pinpoint pupils which were fixed and dilated upon arrival to EC. Head CT demonstrated very large Intraparenchymal hemorrhage with uncal herniation. Patients clinical exam consistent with brain death. • PMH unremarkable

3. Case 1 • EC arrival 1500 • ICU arrival 2100 • OPO Referral 2200 • OPO Evaluation 2300 Overnight Condition • BP 80 - 90’s Max. dose: Dopa, Neo Uo: > 900/hr • Labs: CVP: • Donation Consent 0800 • Na 170 • Medical Management Started 1100

4. Major Concerns • Marginal Blood Pressure • High Dose Pressors • No Central Venous Access • Complications with peripheral administration of vasoactive drips • Unable to assess adequacy of resuscitation / direct therapy • No Arterial Line • Additional vasopressors added • High Urine Output • Concerning in Brain injured patient • DI • Osmotic diuresis • No Labs • Risk of significant electrolyte abnormalities • Large volume diuresis / IV Fluid replacement

5. Quality Improvement Did the ICU team manage this patient well? NO Why NOT? Patient Identified as: “NOT Salvageable/ Treatable” Treatment initiated only after consent to donate

6. Catastrophic Brain Injury “Not a surgical candidate” “Prognosis Poor” “Vegetable” “Family probably won’t donate” “Waste of Time” Therefore NO REASON TO TREAT PATIENT

7. Cultural Change Treat every patient as if they are your loved one There are NO rule outs There is always the potential of Organ Donation Sometimes patients actually get better and go home Avoid Premature judgement and closure

8. Missed Opportunities • EC arrival 1500 • ICU arrival 2100 • OPO Referral 2200 • OPO Evaluation 2300 • Donation Consent 0800 • Medical Management Started 1100 • 12 hours inadequately treated BP • 12 hours inadequately treated DI • Na 170 Timely referral Optimal medical management HUDDLE Donor Death, ATN,  graft survival Delay in Brain Death Exam,  Incidence 1 graft non function,  graft survival

9. Congratulations !!! Successful Procurement and Transplantation 2 Kidneys 1 Liver

10. …No Harm No Foul … • Shock 15 - 24 hours • Severe metabolic acidosis and electrolyte imbalance • May preclude timely brain death determination • End Organ dysfunction • Levophed - “leav-em-ded” - Mortality • Donor Death • Poor quality grafts - unable to donate • Graft “looks” ok • Primary Graft Dysfunction

11. Brain Death Effects • 53% of donors suffered sustained hypotension • More common in those treated with inotropic agents in the presence of a low CVP and in patients with DI not treated with ADH replacement

12. Dopamine • Does not • Improve renal function • Alter outcome of renal failure • Improve hepatosplanchnic circulation • Does • Suppress secretion and function of anterior pitutary • TSH and Growth hormone • Levophed • Increased mean perfusion pressures without adverse effect on renal and splanchnic blood flow as compared to dopamine in septic patients (Low SVR, similar to brain death physiology)

13. Vasopressin • Undetectable levels of vasopressin in up to 87% donors • Warsaw • 20% developed DI • 31% had hemodynamic instability • Yoshioka ( low dose vasopressin and epinephrine ) • Hemodynamic stability average 23 days after brain death • Vasopressin decreased amount of epinephrine required • Preservation of renal function for mean of 14 days • Pennefather • Decrease in Urine output ( Rx DI, prevent Over-diuresis ) • Decrease in plasma osmolality • Increase in Mean Arterial Pressure and SVR • Decrease in Dopamine dose • Kinoshita • Increase MAP 17 mmHg • Discontinue vasopressors in 40%, Decrease in additional 40%

14. Kidneys • Hemodynamically Unstable Donors • Increased Renal graft failure and ATN • Increased early graft non-function • Dopamine • Reduced graft survival in patients on high dose dopamine • Increased incidence of ATN • Hypernatremia • Increased incidence of ATN and primary graft non-function

15. Age Sex ABO Blood Type Cause of Death Macrosteatosis Endotoxins and Cytokines ICU LOS Ischemia Times Hypernatremia Nutrition and Liver Glycogen Hypotension/Vasoactive Drugs Preconditioning for I/R Donor Factors Affecting Liver Transplant Outcome Not Amenable to Change Amenable to Change Powner Prog Transplantation 2004;14:241-249

16. Clinical Variables Affecting Short-term Graft Function Odds Ratio Totsuka Txp Proceed 2004; 36: 2215-2218

17. Influence of High Donor Sodium on Post-Operative Graft Function: Effect of Correction Na > 155peak Na < 155final #36 Na < 155 #118 Na > 155 #27 Totsuka Liver Txp Surg 1995; 5: 421-428

18. In Regards to Patient Care…. • We already know how to properly care for the majority of conditions. • We often overlook the simple interventions or fail to implement interventions in a timely manner. • Only a small portion of patients will fail to respond to timely therapy or have conditions not amenable to typical treatments.

19. Donor Management Pearls • Good Old Fashioned Critical Care • Treat every patient as if they are going to survive • Prevent Iatrogenic Complications • Easier to prevent than to fix (salvage) • Autonomic Storm (Heart) • Neurogenic Pulmonary Edema (Lungs) • Treat every patient as if they are going to survive • Start appropriate ICU therapies as early as possible • Via OPO in a consented brain dead patient • Via OPO in a consented pending brain dead patient • Via ICU upon OPO recommendations of “Best Practices” • Remind and continually educate hospital colleagues • This is not just “a dead guy” • This potential donor may save 8 lives • Optimal care is good for brain injury survivors and potential organs • Next time they will start appropriate therapies before you arrive • Work with your hospitals to develop catastrophic brain injury guidelines

20. Donor Management Pearls • Vasopressin • Stabilize BP • Treat DI • Prevent fluid and electrolyte abnormalities • Goal directed fluid therapy • Wean Pressors • Avoid overload (esp. lungs) • Pressure Control Ventilation (APRV)(IRV)(PEEP) • Maximize Mean Airway Pressure • Prevent alveolar collapse and atelectasis • Avoid shear injury • PREVENT NEUROGENIC PULMONARY EDEMA • NARCAN alone won’t cut it • All organs benefit from oxygen, All organs suffer from a lack of it