Barb NelsonAgnew, Hospital Liaison

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Donation After Cardiac Death

• Barb Nelson-Agnew, Hospital Liaison
• Andrea Tighe, RN, CPTC
• LifeSource

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We believe that lifeis a gift to
shareLifeSource
We pledge to provide the bridge between the loss
of life and the gift of life Through organ
tissue donation transplantation.
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LifeSource
Federally designated organ procurement
organization for MN, ND, SD, and portions of WI.
Provides the link between donor hospitals and
transplant centers.
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2007 UNOS Waiting List

• As of August, 2007 there were 96,697 people
  waiting to receive an organ transplant.
• 2,616 reside in North Dakota, Minnesota, and
  South Dakota.
• There were 28,931 organs transplanted in the US
  in 2006.
• Patient Survival Rates One Year After Transplant
• Kidney 96
• Pancreas 94
• Liver 88
• Heart 88
• Heart-Lung 67
• Lung 84

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Transplantation WorksPre-liver transplant, 6
months post-liver transplant. 88 success rate.
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The Growing NeedFor Transplantable
OrgansOrgan Donors vs. Wait Listed Patients

Based on OPTN data through May 31, 2007
www.OPTN.org
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HHS - Organ Donation Transplantation
Breakthrough Collaboratives

• Organ Donation Breakthrough Collaborative (ODBC),
  2003
• Based on best practices
• Goal increase donation/conversion rates in US
• Organ Transplantation Breakthrough Collaborative
  (OTBC), 2005
• Built on success of ODBC
• Goal save more lives through transplantation

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Collaboratives

• ODBC
• 75 donation/conversion rate
• Achieved by adopting/adapting best practices
• Monitored by CMS and JCAHO
• OTBC
• 3.75 organs transplanted per donor

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Initiatives are working!

• Conversion/Donation Rates
• 2004 2005 2006 2007
• National 55 59 63 69
• LifeSource 65 67 73 80 (thru
  July)
• Lives saved through transplantation
• 2004 2005 2006 2007
• 20,044 21,211 22,201 9,222 (thru May)

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HRSA Medal of Honor

• In 2006 and 2007, 12 hospitals in the LifeSource
  DSA qualified to receive the HRSA Medal of Honor
  for maintaining a 75 conversion rate over a
  12-month period.

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LifeSource Donation Activity

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LifeSource Experience 2004-2007

• 33 DCD Cases in the LifeSource region from 2004
  July, 2007
• 70 Organs Transplanted
• - 51 kidneys
• - 17 livers
• - 2 pancreas
• Donor age range 13 years 59 years

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Donation after Cardiac Death Donor Profile

• Maintained on a ventilator
• Devastating neurological injury
• Head trauma
• Anoxic injury
• Cerebral vascular accident
• Does not meet brain death criteria
• Family desires withdrawal of support
• Likely to die within 60-90 min. following the
  withdraw of support

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DCD Activity Nationwide

• JCAHO and CMS recommend every hospital with a
  ventilator have a DCD policy in place.
• Yearly Number of DCD Donors in the United States
• Source UNOS

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Potential Organ Donor Devastating Brain Injury /
Ventilator Dependent
Donation after Cardiac Death
Donation after Brain Death
BRAIN DEATH EXAMINATION
Exam c/w brain death Death determined by neuro
criteria
Exam Not c/w brain death
Donation discussed with family (LifeSource)

• Family/MD initiate topic W/D med treatment
• LifeSource Coord discussion with family
• Family supportive of donation

Patient supported during organ evaluation
allocation
Patient evaluated as potential DCD candidate

• Withdrawal of medical treatment
• Pronouncement of death
• Surgical Recovery

Surgical recovery
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Patient Evaluation for DCD Suitability

• Age
• Weight
• ABO
• Past Medical History
• History of Present Illness
• Current Clinical Condition
• Organ Function

• Respiratory Drive Assessment
• Respiratory Rate
• Tidal Volume
• Minute Ventilation
• Negative Inspiratory Force (NIF)
• Changes in Hemodynamics Oxygen Saturation
• Length of Time off Ventilator

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Operating RoomSet-up and Instrumentation
If family chooses to be present All
instrumentation will be covered Room
warmed Windows draped Lights dimmed Soft
music turned on prior to family arrival

• Major Abdominal
• Thoracic
• Vascular
• Sternal saw

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Operating RoomWithdrawal of Treatment / Roles

• Donor
• Critical Care RN (Surgery Scrubs) Administers
  Comfort Care measures and declares patient
• Attending Physician Comfort Care orders and
  Declares patient
• (Surgery Scrubs) (may or may not be present)
• Family or Next-of Kin Family has option to be
  present with donor
• (May or may not wear until cardiac death occurs
• White Jump Suit and Head Cover)
• Donation Coordinators Monitors VS q 1 minute
  family support
• monitor
• (Surgery Scrubs)
• Pastoral Care (Surgery Scrubs) Family Support if
  famly present
• Respiratory Care Assist with respiratory
  support during

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When?
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Organ Recovery

• Recovery Team
• Operating Room Staff
• Donation Coordinators

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Case Review 1

• 26/M/C s/p trauma-ped vs. auto
• Family chose to withdraw support, LifeSource
  introduced DCD 5 days after admission.
• DCD Evaluation Score 14-15 (moderate risk for
  continuing to breathe after extubation). Rapidly
  de-saturated during DCD evaluation.

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Case Review 1, cont.

• Injuries included SAH, facial fx., Left
  pulmonary contusion, LLE fx.
• Intubated orally, PO2 174 on FIO2 50
• No vasopressor support
• Labs upon admit Bun 10, Cr. 0.7
• Labs prior OR Bun 14, Cr. 0.7, AST 81, ALT 52,
  Total Bilirubin 0.4

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Case Review 1, cont.

• OR Entrance time 0210
• Extubation 0224
• Declaration 0328
• Incision 0330
• Cross Clamp (CC) 0337
• Average BP 140/70, O2 sat poor signal ???
• Minute 50 BP ? 90/45
• Asystole minute 57
• Withdraw of support to Declaration 64 minutes
• Declaration to Cross Clamp 9 minutes
• Warm Ischemic Time (extubation to CC) 73
  minutes
• Using BP lt 90/45 WIT 23 minutes

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Outcome

• Right and left kidneys transplanted locally
• Heart valves, tissue and eyes recovered for
  transplant
• Pancreas, liver and R. lung placed for research

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Case Review 2

• 47/F/C s/p MVA with an anoxic injury/Closed Head
  Injury unknown amount of down time and 18
  minutes of CPR.
• Family chose to withdraw support, LifeSource
  introduced DCD 8 days after admission.
• DCD Evaluation Score 17 (moderate risk for
  continuing to breathe after extubation). Rapidly
  de-saturated during DCD evaluation.

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Case Review 2, cont.

• Injuries included CHI, left pneumothorax with
  chest tube, flail chest, rib fxs., pulmonary
  contusions, splenic laceration.
• Intubated orally, PO2 85 on an FIO2 of 40
• No vasopressor support
• Labs upon admit Bun 15, Cr. 0.8, AST 197, ALT
  79
• High Bun 30, Cr. 1.2, High AST 332, ALT 160,
  Total Bilirubin 1.7
• Labs prior to OR Bun 22, Cr. 0.7, AST 109, ALT
  121, Total Bilirubin 1.4

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Case Review 2, cont.

• OR Entrance time 0957
• Extubation 1040
• Declaration 1110
• Incision 1115
• Cross Clamp (CC) 1117
• Average BP 125/50, O2 sat unable to detect
• Minute 25 BP ? lt90/40
• Asystole minute 30
• Withdraw of support to Declaration 30 minutes
• Declaration to Cross Clamp 7 minutes
• Warm Ischemic Time (extubation to CC) 37
  minutes
• Using BP lt90/40 WIT 13 minutes

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Outcome

• Liver transplanted within region
• Both kidneys recovered for transplant-poor
  anatomy therefore discarded
• Heart valves transplanted

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Case Review 3

• 13/M/C s/p anoxic injury with 20-30 minutes down
  time and CPR
• Family interested in donation. LifeSource
  evaluated for DCD 5 days after admission.
• DCD Evaluation Score 11-12

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Case Review 3, cont.

• Anoxic Brain Injury
• Intubated orally, PO2 165 on FIO2 45
• Dopamine _at_ 7.5 mcg/kg
• Labs upon admit Bun 19, Cr. 0.8 (no liver labs
  drawn)
• Labs prior to OR Bun 8, Cr. 0.4, AST 49, ALT
  19, Total Bilirubin 0.3

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Case Review 3, cont.

• OR Entrance time 0115
• Extubation and vasopressor turned off 0129
• Declaration 0141
• Incision 0148
• Cross Clamp (CC) 0158
• Average BP 85/60, O2 sat ? rapidly
• Asystole minute 12
• Withdraw of support to Declaration 12 minutes
• Declaration to Cross Clamp 17 minutes
• Warm Ischemic Time (extubation to CC) 29
  minutes

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Outcome

• Liver, pancreas and kidneys recovered and
  transplanted
• Tissue and eyes recovered for transplant

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Your close collaboration and cooperation is
integral for effective family care, saving lives
and a successful donation program.
Thank You!