Pediatric Donation After Cardiac Death: The PICU Perspective

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Pediatric Donation After Cardiac Death The PICU
Perspective

• Patty Schriver, RN, BSN, CCRN, CHOC
• Marilyn Begin, CST, Surgical Recovery
  Coordinator, OneLegacy

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Question

• What does your Donation after Cardiac Death
  program look like in your hospital?

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History of Donation after Cardiac Death

• Prior to the acceptance of the brain death
  criteria in the mid-1970s, all organ donations
  were performed after cessation of cardiopulmonary
  function (DCD).
• In 1999, 68 Donation After Cardiac Death (DCD)
  cases were accomplished across the United States.
• In 2006, 559 DCD cases were accomplished

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Number of DCD DonorsJan 2000-Oct 2006
(Nationally)

• 2000 118
• 2001 169
• 2002 189
• 2003 269
• 2004 391
• 2005 560
• 2006 559
• TOTAL 2255

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Definition

• The surgical recovery of organs that occurs
  after the cessation of cardiopulmonary function

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Re-Invention of a Forgotten Procedure

• DCD practice abandoned with acceptance of
  Harvard Brain Death Criteria
• Brain Dead donors allow for a higher donor yield
• So why go back to the future?

Heart , Lungs, Liver, Pancreas, Kidneys, Small
Bowel
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Institute of Medicine Conclusions

• The recovery of organs from DCD donors
• is an important, medically effective and
• ethically acceptable approach to reducing
• the gap between the demand for and the
• available supply of organs for
• transplantation.
• Institute of Medicine. National Academy of
  Sciences, 2006

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Donation after Cardiac Death vs. Brain Death

• Hospital remains in charge of patient care
• Hospital Physician to order comfort care
  medications to be given for withdrawal of
  life-sustaining measures
• Preliminary Release for donation (from coroner)
  needs to be given BEFORE death

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Suitable Candidates for DCD

• Meets one of the following
• Non recoverable, Irreversible Brain injury
• End stage musculoskeletal or pulmonary disease
• High spinal cord injury
• Ventilator dependent
• Family has made patient DNR or plans to withdraw
  all hemodynamic ventilator support, must be
  documented in patient chart
• Family inquired or initiated discussion about
  organ donation

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Consent/Approval

• No donor related medications or procedures can be
  performed without consent.
• Clearance from medical examiner/coroner must be
  obtained when applicable.
• There should be a plan if death does not occur
  within the 60 minute timeframe, including
  immediate notification of the family.
• The legal next of kin shall also include the
  patient, a designated health care representative,
  legal next of kin, or appropriate surrogate.

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Organ Recovery

• Policy
• Following the declaration of death by the
  hospital patient care team, the organ recovery
  may be initiated.
• UNOS
• Current Practice
• Organ recovery begins after 5 minutes of
  asystole.

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Important Points to Remember

• The family will make the decision to withdraw
  life sustaining measures independent of the
  decision to donate organs.
• This procedure should not be viewed as a way to
  circumvent brain death criteria but as a means to
  provide families with an additional option of
  donation that complies with the patient or
  authorized family directives.
• Like all care at the end of life, donation after
  cardiac death (DCD) should focus on the patient
  and family

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Childrens Hospital of Orange County(CHOC)

• 208 bed free-standing Childrens hospital.
• Orange County, California
• 30 bed PICU
• Neurosurgery
• Cardiac surgery
• Many sub-specialties
• Not a Trauma Center

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Shared Services

• St. Josephs Hospital of Orange
• 300 bed Catholic adult facility with no
  pediatric inpatient services except newborn
  nursery
• Emergency services
• Laboratory services
• Radiology

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Shared Services

• Surgical Services
• Staff
• Equipment
• PACU
• Anesthesia

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Donation After Cardiac Death

• First case for the hospitals
• St. Joseph patient
• 25 year old Retts Syndrome
• Opened the door for CHOC to start DCD
• Policies
• Mirror each other
• Meet the needs of both facilities

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Case 1

• L.R. 3 year old female
• Found face down in the swimming pool
• Unknown time since last seen
• No bystander CPR
• Asystolic when EMS arrived
• CPR started by EMS
• Asystolic upon arrival to ED

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Case 1 continued

• 45 minutes of CPR and multiple doses of
  Epinephrine before return of spontaneous
  circulation
• ABG in ED
• pH 6.8
• PCO2 21
• PO2 669
• HCO3 3.2
• Base deficit -30.4

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Case 1 continued

• Transported from outside ED to our PICU
• Parents informed of grave prognosis
• After 3 days, parents requested to discontinue
  support and inquired about organ donation
• OneLegacy was contacted

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Case 1 continued

• Parents spoke only Spanish
• OneLegacy sent Spanish speaking requestor
• Consent for donation was obtained and patient was
  stabilized for transport to OR

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First Case Scenario Hospital Staff Ready
Administration is on Board

• OR is set for 0900
• OR room prepared back table setup, slush
  available, perfusion lines flushed
• Parents are dressed in cover-alls, (bunny suits)
  hats and mask
• Parents will wait with the Family Care
  Coordinator and priest outside the OR Department
  until called to enter

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Team Assembled in the OR

• Surgical Recovery Team Liver and Assistant
  Surgeon, Perfusion Technologist, local Kidney
  Surgeon
• OR Staff Circulating RNs x 2, Surgical
  Technologist
• ICU Staff RNs x 2 or 3, Respiratory Therapist
• Attending Physician
• OneLegacy Staff Surgical Recovery Coordinator,
  Procurement Transplant Coordinator, Clinical
  Manager
• Anesthesia Care Provider may or may not be
  present, depending on Hospital policy (Not
  present in this case)

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Patient Enters the OR,Positioned on OR Bed at
0930

• Lead Surgeon calls a Huddle in the OR with all
  staff involved to review action plan, test
  mechanical equipment, check that all supplies are
  ready for immediate use
• Remind staff that this is a family-driven process
  and the parents can halt the procedure at any
  time

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Surgical Recovery Teams Not Present During
Withdrawal of Care Pronouncement

• Surgeons and Assistants will Scrub in, don
  sterile gown and gloves
• Surgical Team will then exit the OR room will
  wait in a sub-sterile room or adjoining OR room
• NOTE It is NEVER appropriate for the Surgical
  Recovery Team to give orders, directions or
  suggestions regarding the Withdrawal of Care
  Process

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ICU Team Initiates the Withdrawal of Care Protocol

• Room lights are dimmed to soften the harsh
  environment of the OR
• Parents Priest are escorted into OR, given
  chairs at the head of bed
• Thorough oral suctioning performed and ET tube is
  removed by the Attending Physician at 1049
• Death pronounced at 1120

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ICU Team Initiates the Withdrawal of Care
Protocol Continued

• Parents escorted from OR accompanied by Family
  Care Coordinator and Priest
• Organ recovery surgery commenced at 1130. Liver
  and both kidneys were successfully recovered and
  transplanted

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System Errors Identified

• Unavailability of scrubs for incoming teams
• Timing 0900 AM is a very busy time in the OR
  making it difficult to acquire needed equipment
• OR Staff is stressed not enough time to become
  comfortable with this procedure as Huddle time
  was limited
• OR room assigned was adjacent to the OR Control
  Desk
• JOINT COMMISSION WAS IN THE OR DEPARTMENT THAT
  DAY

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More Systems Errors(If that wasnt enough!)

• Patient did not have a functioning arterial line
• At the pronouncement of death, mom decompensated
• Once mom was composed enough to leave, dad
  decompensated
• Chosen exit route took the grieving entourage
  through the PACU

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Case 2

• R.S. 3 month old female twin
• Found unresponsive in crib, unknown downtime
• CPR initiated by parents EMS called
• Asystolic when EMS arrived
• CPR continued by EMS
• 30 minutes of ALS before return of spontaneous
  circulation

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Case 2 continued

• Non-accidental trauma work-up negative
• Metabolic work-up positive for fatty acid
  oxidative defect
• Parents informed of poor prognosis
• Family requested withdrawal of support and
  inquired about organ donation
• OneLegacy contacted
• Consent obtained for donation and patient
  prepared for transport to OR

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Second Case Scenario

• Again, Hospital Administration is on board with
  the DCD process
• Pt is only 4.2 kg there are no local potential
  recipients
• Stanford University accepts the liver same local
  kidney surgeon will recover kidneys
• OR is booked for 1600
• Flight plans set for team to fly from Palo Alto

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Case Set Up, continued

• Family is made aware of plans and will remain at
  the babys bedside until OR
• Parents do not want to be present in the OR when
  the heart stops instead they have requested the
  Family Care Coordinator keep them informed of the
  progress of the case
• Parents will be in a secluded area near a back
  exit to the OR
• Priest will remain with the parents

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OR Preparation

• OR booked a room in the back hall of the OR
• OR staff was all volunteer, no one felt coerced
  to participate
• Extensive Huddling took place with the OR staff
• Scrub apparel was acquired early for incoming
  surgical teams
• OR room is prepared prior to patients arrival
• All equipment is tested and ready

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Everything is on Track for a Successful Organ
RecoveryWhat could go Wrong??
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20 Minutes prior to OR time

• Liver team from Stanford have experienced an
  in-flight emergency
• Loss of electrical power forces the plane to
  return to ground immediately
• The departure air-field is now closed due to fog
  (San Francisco Bay area)
• Flight is diverted to Sacramento (opposite of OC)
• Family is informed of 3-4 hr delay they are
  willing to wait

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OR Delayed, continued

• OR staff will remain the same no need to
  re-orient relief staff
• OR staff is temporarily re-assigned to give
  dinner breaks, prepare other cases
• OR room remains Reserved for organ donation

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2000Stanford team has arrived.

• The (frazzled) surgeons are immediately scrubbed
  in, dressed in gowns and gloves, sequestered in
  the sub-sterile room
• Patient settled in the OR room Withdrawal of
  Care protocol is initiated by ICU staff
• OneLegacy PTC will record vital signs Q/min
• NOTE Considering that the parents are not
  present, it is not necessary to dim the OR room
  lights or play soft music. HOWEVER, out of
  respect for the patient, we will keep voices low
  and limit extraneous talk

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Pronouncement of Death

• Patient was pronounced dead 11 minutes after
  withdrawal of life support
• Parents are immediately informed babys blanket
  and toy are returned to parents
• Surgery starts after 5 minute pause
• Liver and kidneys successfully recovered

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What we learned

• Ethical considerations
• Who manages the patient in the PICU?
• Billing questions
• Going to the OR

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Ethical Considerations

• Staff Education
• Important to do up-front education
• Educate all staff not just nursing not just
  critical care
• DCD is not just confined to your PICU

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Ethical Issues

• Post-case Debriefing
• Dealing with the grieving staff
• Addressing issues right away
• Talking about DCD and the differences from Brain
  Death donation.

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Patient Management

• PICU MDs must manage the care of the DCD patient
  until they are declared dead.
• Medical management of DCD patient is very
  different from management of a brain death
  donation.

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The Operating Room

• Patient is managed by the PICU team in the OR
  until patient is pronounced.
• ICU staff should be oriented to the OR before
  starting a DCD program.
• Pronouncing the patient can either fall to the MD
  or RN.

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Operating Room

• Parents are present in the OR until the patient
  is pronounced.
• Parents are permitted to hold their child for a
  short period following the death.
• Dealing with parental grief.
• Exiting the parents from the OR.

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Conclusions/Lessons

• It is crucial to have a functional arterial line
  in place prior to OR
• This allows for precise observation and accurate
  documentation of the onset of asystole
• Timing of the OR is very important
• Best practiceplan OR for evening, night or early
  AM when there will be fewer cases going on in the
  department
• Take adequate time for all the huddles
• OR staff changes and rotates around for meals and
  breakshuddle everyone!
• Extensive huddles encourage ownership of the
  process

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Conclusion/Lessons Continued

• Anticipate the need for scrub apparel
• If your facility has a strict dress code that
  requires anyone from the outside to change to
  house scrub apparel, garner several sets of large
  sized scrubs from the linen department to
  accommodate anyone who may come in with the
  recovery teams
• Request an out of the way OR room
• Preferably one with an obscure point of egress to
  allow the family to exit privately
• Limits lookie-loos

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Conclusion/Lessons

• Expect that the parents will want to be with
  their child at the time of death
• Respect their wishes and their unique expressions
  of grief
• Expect that the OR staff will not be comfortable
  with the parents coming into the OR
• Acknowledge and validate their concerns
• Re-huddle!
• Encourage OR staff to come up with a solution
  that will relieve their discomfort

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Conclusions/Lessons

• Remember the ICU Bubble
• Patient is under the care of the ICU team up to
  and until death is pronounced
• Only then will the donor fall under the
  management of the OPO
• ICU staff will direct the withdrawal of care and
  pronouncement of death
• OPO staff will serve as consultant and staff
  support throughout the DCD process
• Take advantage of their expertise

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Finally

• Debriefing of all staff involved should occur
  within a week of the DCD donor
• Allows staff to organize their thoughts,
  questions
• Acknowledges the unique role played by each
  participant
• Brings closure and hopefully satisfaction to a
  tragic event
• Encourages the real-time incorporation of
  Lessons Learned into practice

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Where do we go from here?

• Recruit staff to be dedicated to donation cases.
• Develop policies around care of the patient from
  ICU to pronunciation of death.
• Establish protocols for care of the DCD patient.

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Questions??