Advanced Practice Intensivist Involvement and Donor Mangement Goals DMGs The University of Californi

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Advanced Practice Intensivist Involvement and
Donor Mangement Goals (DMGs)The University of
California, Irvine Devastating Brain Injury
Clinical Pathway and Data from the UNOS Region
5 DMG Workgroup

• Darren Malinoski, MD
• Assistant Professor of Surgery
• Director, Surgical Intensive Care Unit
• Chair, UC Irvine Organ Donor Council
• Division of Trauma/Critical Care/Burns
• UC Irvine Medical Center

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Thomas Guide to Organ Donor Management - the
abridged version

• Case Presentation
• National Statistics
• Proposed Solutions
• Donor Management Goals

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Case Presentation

• 22 year old male with self-inflicted GSW to the
  face.
• Before arriving at UCI, the patient was taken to
  a nearby hospital for airway stabilization.
• Asystole upon arrival, which responded to
  intubation, correction of hypoxia, epinephrine,
  atropine, and CPR
• No medications required no gag or spontaneous
  movements
• Transferred to UCI
• Upon arrival to UCI
• Endotracheal tube placement was confirmed
• Equal breath sounds bilaterally
• HR 152, BP 50/palp
• Pupils fixed and dilated, no spontaneous
  movement/reflexes
• Active hemorrhage noted from the mouth with a
  defect in the posterior hard and soft palate with
  no exit wound.

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Resuscitation

• The oropharynx was packed
• Foley catheters were inserted into bilateral
  nares and pulled to create tamponade.
• A nearly continuous infusion of blood and blood
  products was required to help maintain blood
  pressure
• PRBCs 11 units
• FFP 10 units
• Cryoprecipitate 10 units
• Platelets 2 units
• Novo-7 1 dose
• Normal saline 3 liters
• 3 saline 500 cc
• Hormone Replacement protocol instituted
• Bleeding from oropharynx continued

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Control of Hemorrhage

• In the face of uncontrollable posterior
  oropharyngeal bleeding, balloon tamponade is a
  well described technique.
• Insert a foley catheter down each nostril and
  incompletely inflate.
• Pull until taut and clamp at the septum with a
  hemostat.
• This is only a temporary measure, as continued
  pressure on the septum will eventually cause
  necrosis.

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Control of Hemorrhage

• After the balloon tamponade, there was still
  considerable hemorrhage from the face
• Plastic surgery fellow in ED
• Bilateral external carotid artery ligation was
  performed.
• Bleeding slowed, however ?

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Abdominal Compartment Syndrome

• Pulse oximetry fell from the 90s to the low
  80s.
• Peak airway pressures went from normal to 40mm
  Hg.
• Bladder pressure was gt40 cmH20.
• Systolic blood pressure was in the 50s.
• Decompressive laparotomy was performed with an
  immediate improvement in vital signs and
  ventilation.

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Outcome

• The patients blood pressure stabilized and he
  was transferred to the ICU.
• The patients family was informed of his
  condition and they initiated a discussion about
  organ donation.
• Brain death was declared 2 hours later in the ICU
  and One-Legacy was contacted.
• He went on to donate 18 hours after arrival.

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The Problem
Waiting list
19 deaths/day gt7000/year
Transplants
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How do we solve the problem?

• Make donation a priority
• Aggressive donor management
• Donation after Cardiac Death
• Education Public Awareness
• Extended criteria organ donors
• Living Donors
• Public Health
• Xenotransplantation
• RESEARCH

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What are we doing at UCI?

• Organ Donor Council created in 2006
• GOALS
• Aggressive Management of Brain Dead Donors
• Donation after brain death
• Achieve gt 4 organs per donor
• Re-institute policies of Donation after Cardiac
  Death - DCD
• Donation after somatic death
• Donation after elective withdrawal of support
• Conversion rate gt75

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Organ Donor Council

• Multi-disciplinary
• Transplant Surgeons
• Intensivists
• Nurses
• Palliative Care
• Ethics
• OPO
• Administration
• Chaplain
• PI
• Risk Management

• Determination of Death Guidelines
• Clinical Practice Guideline
• Donation After Cardiac Death (DCD) Policy
• Education

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The Problem
Waiting list
19 deaths/day gt7000/year
Transplants
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Aggressive Donor Management
Brain Death
Organ Procurement
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arrhythmias
hypotension
Brain Death
DI
DIC
acidosis
hypothermia
pulmonary edema
cardiovascular collapse
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Complications of Brain Death
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Why?

• Hypovolemia, hypothermia, coagulopathy, acidosis
• Endocrine Crisis
• Low levels of T3, T4, cortisol, insulin, ADH
• Cellular changes
• Mitochondrial shift from aerobic to anaerobic
  metabolism
• Alteration in the intracellular metabolism of T3
• Inflammatory response to brain death
• ? Reversal with hormonal replacement?

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Instituting a User-Friendly Protocol - 1998
Aggressive Donor Management
(ADM The Roth Protocol)
Dedicated team fluids, pressors, T4
Early identification
ICU admission
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Hormone Therapy

• Rapid IV boluses of
• 1 amp 50 dextrose
• 20 units insulin
• 2 g Solumedrol
• 20 mcg T4
• Continuous T4 infusion at 10 mcg/h

T4 only used in hemodynamically unstable donors
-combined vasopresssor dose gt 15mcg/kg/min
after establishing adequate intravascular volume
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The Role of thyroid hormoneSalim et al Arch Surg
20011361377-1380
T4 administration
Total Vasopressor Dose (mcg/kg/min)
Time interval in hours Time 0 is start of T4
Due to limited numbers, only a trend in the
number of OTPD was found.
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ADM Works!!!!!!
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Moncure, Organ Donation and transplant alliance,
San Francisco November 2006
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How Can I Adopt this at My Institution?
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OTPD and DMGs
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Background

• Transplant Growth and Management Collaborative
• Three estates OPO, donor hospital, transplant
  center
• Donor Management Goals (DMGs)
• Every OPO Different
• Results generally good, but not specific

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DMGs and OTPD
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OTPD and DMGs
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PARTICIPATING OPO REPRESENTATIVES

• Tamra Grote, Jim Trisch, and Chrystal Graybill
• CTDN Rick Elizondo
• DNAZ Jennifer Treece
• Golden State Chris Good
• Intermountain Mike Ingraham
• Lifesharing Jill Stinebring
• Nevada Donor Network Galyn Ashikawa
• New Mexico Ann Roberson
• OneLegacy Sherry Watson

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PROPOSED DMGS for REGION

• 1. MAP 60-100 2.      CVP 4-10 3.      EF
  gt 50 4.      lt/ 1 pressor used AND
  a.      Dopamine lt/ 10 mcg/kg/min
• b.      Neosynephrine lt/ 100 mcg/kg/min
  c.      Norepinephrine lt/ 10 mcg/kg/min
  d.      Vasopressin lt/ 2.4 units/hour (0.04
  units/min)
• 5.      ABG pH 7.3-7.45
• 6.      Pao2Fio2 ratio  gt300 on PEEP 5
  7.      Serum Sodium 135-160 8.      Urine
  output 1-3 cc/kg/hour 9.      Glucose lt 150
  10. Hemoglobin gt 10
• Track hormone replacement usage

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CURRENT PROJECT

• Universal template
• 40 SCDs from each OPO
• Retrospective collection of data regarding
  proposed DMGs (prior to procurement) and organ
  disposition information
• Statistical analyses
• 80 DMGs goal met
• gt/ 4 OTPD primary outcome measure
• DMG-specific results
• Other notable findings

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Number of DMGs and OTPD
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Multivariate analysis - gt/ 4 OTPD
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DMG and Organ-Specific Data
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Moving Forward

• The Region has adopted 9 DMGs for prospective
  implementation
• Will collect data prospectively for 6 months
  organ disposition and function
• DMGs will be measured at 3 time points

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So, what happened to our donor?
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THANK YOU