Organ Donation End of Life care in the Operating Room Matthew Bock Surgical recovery coordinator

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Organ DonationEnd of Life care in the Operating
RoomMatthew BockSurgical recovery
coordinator

• University of Wisconsin
• Organ Procurement Organization
• 1-866-UWHC OPO
• (1-866-894-2676)

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Perspective
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Remembering why were here

• Save lives through transplantation
• Supporting the familys choice
• Honoring the patients wishes

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Donation after Cardiac Death (DCD)
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Uniform Determination of Death Act, 1980

• Irreversible cessation of circulatory and
  respiratory function
  
  - OR-
• Irreversible cessation of all functions of the
  entire brain, including the brain stem

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Two ways to donateDeceased Organ Donation

• Donation After
• Cardiac Death (DCD)

• Donation After
• Brain Death

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• DCD
• Severe neurological injury
• Does not meet criteria for brain death
• Family has elected to withdraw support

• Brain Death
• Severe neurological injury
• Meets Brain death criteria
• -Clinical exam
• -Apnea test

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• DCD
• Severe neurological injury
• Does not meet criteria for brain death
• Family has elected to withdraw support

• Brain Death
• Severe neurological injury
• Meets Brain death criteria
• -Clinical exam
• -Apnea test

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Clinical Diagnosis of Brain Death

• Unresponsive to all stimuli
• No spontaneous respiratory activity
• All brain stem reflexes are absent
• Pupillary response to light
• Corneal reflexes
• Oculo-vestibular reflex (caloric response)
• Oculocephalic reflex (dolls eye phenomenon)
• Gag reflex

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Apnea Test

• Make sure patient has normal body temp, blood
  pressure, volume status, ABGs
• Disconnect from ventilator
• Monitor continuous pulse oximetry
• Administer 100 O2 at 6 L/min into the trachea
• Monitor closely for respiratory movements
• Check serial ABGs, or at approx. 8 minutes
• If no respiratory movement and arterial PCO2 is gt
  60 mm Hg, the apnea test supports the clinical
  diagnosis of brain death

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Apnea Test

• Make sure patient has normal body temp, blood
  pressure, volume status, ABGs
• Disconnect from ventilator
• Monitor continuous pulse oximetry
• Administer 100 O2 at 6 L/min into the trachea
• Monitor closely for respiratory movements
• Check serial ABGs, or at approx. 8 minutes
• If no respiratory movement and arterial PCO2 is gt
  60 mm Hg, the apnea test supports the clinical
  diagnosis of brain death

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• Brain Death
• Severe neurological injury
• Meets Brain death criteria
• -Clinical exam
• -Apnea test

• DCD
• Severe neurological injury
• Does not meet criteria for brain death
• Family has elected to withdraw support

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• DCD
• Severe neurological injury
• Does not meet criteria for brain death
• Family has elected to withdraw support

• Brain Death
• Severe neurological injury
• Meets Brain death criteria
• -Clinical exam
• -Apnea test

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Severe Neurologic Injury

• Trauma
• MVA, Fall
• SDH
• Anoxia
• Cardiac Arrest, near drowning

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• Brain Death
• Severe neurological injury
• Meets Brain death criteria
• -Clinical exam
• -Apnea test

• DCD
• Severe neurological injury
• Does not meet criteria for brain death
• Family has elected to withdraw support

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Two ways to donate

• Donation After Brain Death
• Patient is maintained on ventilator for organ
  recovery
• Organs dissected insitu
• 3-4 hour surgery

• Donation After Cardiac Death
• (DCD)
• Patient is extubated in the Operating Room or ICU
• Surgery begins 5 minutes after cessation of
  cardiac function and declaration by patients
  physician
• Rapid recovery with organs procured en bloc.

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Two ways to donate

• Donation After Brain Death
• Patient is maintained on ventilator for organ
  recovery
• Organs dissected insitu
• 3-4 hour surgery

• Donation After Cardiac Death
• (DCD)
• Patient is extubated in the Operating Room or ICU
• Surgery begins 5 minutes after cessation of
  cardiac function and declaration by patients
  physician
• Rapid recovery with organs procured en bloc.

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Two ways to donate

• Donation After Brain Death
• Patient is maintained on ventilator for organ
  recovery
• Organs dissected insitu
• 3-4 hour surgery

• Donation After Cardiac Death
• (DCD)
• Patient is extubated in the Operating Room or ICU
• Surgery begins 5 minutes after cessation of
  cardiac function and declaration by patients
  physician
• Rapid recovery with organs procured en bloc.

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• We dont do that here

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• ICU nurse
• RT

• OPO staff
• No family yet

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Who is involved?

• Hospital
• Anesthesia
• Surgical Technician/Scrub Nurse
• Circulating Nurse
• Abdominal Transplant Team
• - Surgeon
• - Physician Assistant
• - Surgical Recovery Coordinator
• Cardiothoracic Team
• - Surgeon
• - Surgical Fellow
• - Surgical Recovery Coordinator

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Paperwork

• Consent x2
• Time out
• Post Op disposition
• Death packet

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• Prep drape
• Femoral cutdown
• Cover patient and back table
• Unnecessary staff exits the room

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DCD Withdrawal in the OR

• Accommodating the Family

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Meds, Withdrawal Declaration
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How long can we wait?
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Rapid En-bloc recovery

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Organ Preservation Time

• Heart 4-6 hrs
• Lungs 4-6 hrs
• Liver 12 hrs
• Pancreas 18 hrs
• Kidneys 24 hrs

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A wedding story