Title: THE ROLE OF THE INTENSIVIST IN ORGAN DONATION The University of California, Irvine Devastating Brain
1THE 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
2Question To Run On
- How can the working relationship between critical
care specialists and the OPO achieve the goals of
increased donation and transplantation?
3The Problem
Waiting list
17 deaths/day gt6000/year
Transplants
4How 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
5What 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
6Organ 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
7Aggressive Donor Management
Brain Death
Organ Procurement
8arrhythmias
hypotension
Brain Death
DI
DIC
acidosis
hypothermia
pulmonary edema
cardiovascular collapse
9Complications of Brain Death
10Why?
- 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?
11Fixing the problem
- A hormonal problem
- A fluid problem
- Oxygen delivery
- An attention problem
12Instituting a User-Friendly Protocol - 1998
Aggressive Donor Management
(ADM The Roth Protocol)
Dedicated team fluids, pressors, T4
Early identification
ICU admission
13Hormone 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
14The 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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16ADM Works!!!!!!
17Moncure, Organ Donation and transplant alliance,
San Francisco November 2006
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27Education / Public Awareness
28THANK YOU