THE ROLE OF THE INTENSIVIST IN ORGAN DONATION The University of California, Irvine Devastating Brain

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THE ROLE OF THE INTENSIVIST IN ORGAN
DONATIONThe University of California, Irvine
Devastating Brain Injury Clinical Pathway

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

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Question To Run On

• How can the working relationship between critical
  care specialists and the OPO achieve the goals of
  increased donation and transplantation?

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The Problem
Waiting list
17 deaths/day gt6000/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

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

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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
• ? Reversal with hormonal replacement?

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Fixing the problem

• A hormonal problem
• A fluid problem
• Oxygen delivery
• An attention problem

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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 bolus 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 10mcg/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 organs / donor 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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Education / Public Awareness
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THANK YOU