Transcript Donation in the UK - ODT Clinical Site

Donation after Brain-Stem Death
DBD
Jerome McCann
Arpan Guha
21st May 2013
Organ Donation Past, Present and Future
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Session Objectives
• Present regional data for DBD
• Understand that DBD gives better organs than DCD
• Increase rate of neurological confirmation of death
by increasing confidence in the Diagnosis of Death
• Increase quality of DBD organs
– adoption of extended care bundle and compliance
with the six early interventions in donor
optimisation
– collaboration in Scout pilot
Organ Donation Past, Present and Future
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NORTH
WEST
Regional Data
Jerome McCann
Organ Donation Past, Present and Future
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Donation after Brain Death
(DBD)
NORTH
WEST
Mechanically ventilated patient
where death has been confirmed
using neurological criteria.
74 donors
-5.1% increase
Lungs
Heart
Small Intestine
Organ Donation Past, Present and Future
Kidneys
Liver
Pancreas
Donations over time: North West Team
NORTH
WEST
140
26.6%
120
100
80
-5.1%
Donation after Brain
Death
60
40
20
Total Deceased
Donation
181.3%
Donation after
Circulatory Death
0
Organ Donation Past, Present and Future
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DCD
DBD
kidneys
intestine
lungs
pancreas
liver
Organ Donation Past, Present and Future
heart
DBD- Neurological death testing rate
NORTH 100
WEST
ND tested (%)
80
87
82
Tied 9th
with 3
others 86
76
78
74
73
76
76
74
76
74
60
40
20
0
Team
-------- National rate
1 April 2012 to 31 March 2013, data as at 4 April 2013
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DBD- North West Neurological
death testing rate
100
10 33
14
19
25
3 8
29
17 31
24
20
12
13
32
1 9
80
ND tested (%)
1 Barrow-In-Furness, Furness General Hospital
2 Douglas, Nobles I-O-M Hospital
3 Chester, Countess Of Chester Hospital
4 Crewe, Leighton Hospital
5 Macclesfield, Macclesfield District General Hospita
6 Warrington, Warrington Hospital
7 Liverpool, Royal Liverpool University Hospital
8 Liverpool, Alder Hey Children's Hospital
9 Prescot, Whiston Hospital
10 Southport, Southport District General Hospital
11 Liverpool, University Hospital Aintree
12 Liverpool, Walton Centre For Neurology And Neuro
13 Wirral, Arrowe Park Hospital
14 Lancaster, Royal Lancaster Infirmary
15 Blackpool, Blackpool Victoria Hospital
16 Preston, Royal Preston Hospital
17 Blackburn, Royal Blackburn Hospital
18 Chorley, Chorley And South Ribble District Genera
19 Bolton, Royal Bolton Hospital
20 Bury, Fairfield General Hospital
21 Manchester, North Manchester General Hospital
22 Manchester, Manchester Royal Infirmary
23 Manchester, Royal Manchester Children's Hospital
24 Manchester, Wythenshawe Hospital
25 Oldham, Royal Oldham Hospital(Rochdale Road)
26 Salford, Salford Royal
27 Stockport, Stepping Hill Hospital
28 Ashton-Under-Lyne, Tameside General Hospital
29 Manchester, Trafford General Hospital
30 Wigan, Royal Albert Edward Infirmary
31 Bodelwyddan, Glan Clwyd District General Hospita
32 Wrexham, Maelor General Hospital
33 Bangor, Ysbyty Gwynedd District General Hospital
11
22
28
60
15
16
26
7
6
2
4
40
30
20
23
0 18 21 5
0
27
5
10
15
20
25
30
Number of neurological death suspected patients
Hospital
95% Upper CL
National rate
99.8% Lower CL
95% Lower CL
99.8% Upper CL
1 April 2012 to 31 March 2013, data as at 4 April 2013
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Mean no. of organs donated per donor
NORTH
WEST
4.3
4.2
4.1
4.0
3.9
3.8
3.7
3.6
3.5
3.4
3.3
1 April 2012 to 31 March 2013, data as at 4 April 2013
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Diagnosis of brain-stem death
1976
2008
37 years on
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Organ Donation Past, Present and Future
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Harvey Cushing
describes increased
brain pressure
provoking respiratory
arrest with preserved
heartbeat.
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Brain death: Discovered not Invented (by intensive care)
1940s
Danish medical
students hand
ventilate polio
victims
Mouth to Mouth
Resuscitation gains
prominence &
Mechanical Ventilation
becomes possible
1954
1stsuccessful
kidney
transplant between
identical twins
1959, doctors discover empirical
proof by the identification of
mechanically ventilated patients
in coma dépassé.
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1963
1962
1st successful
deceased donor
kidney Tx
Proposed that the
EEG can
demonstrate death
of the Central
Nervous System.
1st
successful
deceased
donor liver &
lung Tx
1966
1968
1st successful
deceased donor
pancreas Tx
1st successful
deceased donor
heart Tx
1964, Keith Simpson
“there is life so long as
circulation of oxygenated
blood is maintained to live
brainstem centres”
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Modern
intensive care
practice
grows.
Organ Donation
from Brain Dead
donors increases
worldwide.
1976 (clarified 1979)
UK Criteria for
Diagnosing Death
using Neurological
Criteria Published.
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Growing use of ECMO
and other techniques to
support the circulation,
establish that it is
possible to be alive,
without a heart-beat.
Rene´ Laennec
1819
Eugene Bouchut
1846
2008
UK Criteria for
Circulatory Criteria
published for the 1st
time. 5 minutes.
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UK Definition of Death
“The definition of death should be
regarded as the irreversible loss of
the capacity for consciousness,
combined with irreversible loss of
the capacity to breathe…
therefore irreversible cessation of
the integrative function of the
brain-stem equates with the death
of the individual.”
Organ Donation Past, Present and Future
All human death is
anatomically located
to the brain.
17
A medical concept of death
Neurological Criteria
DEATH
Circulatory Criteria
Irreversible loss of the
capacity for consciousness
Irreversible loss of the
capacity to breathe
Organ Donation Past, Present and Future
Somatic Criteria
Dx Death using Neurological Criteria
1.
An established
aetiology capable of
causing structural
damage to the brain
which has led to the
irreversible loss of
the capacity for
consciousness
combined with the
irreversible loss of
the capacity to
breathe.
•
•
DEATH
Irreversible loss of the
capacity for consciousness
Cause tells you
irreversibility, based on
the natural history of
the disease
Cause tells you how long
you should observe
before testing:
• SAH
6 hours
• Hypoxia 24 hours
Irreversible loss of the
capacity to breathe
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Dx Death using Neurological Criteria
2.
1.
An established
aetiology capable of
causing structural
damage to the brain
which has led to the
irreversible loss of
the capacity for
consciousness
combined with the
irreversible loss of
the capacity to
breathe.
An exclusion of
reversible conditions
capable of mimicking
or confounding the
diagnosis of death
using neurological
criteria.
DEATH
Irreversible loss of the
capacity for consciousness
Irreversible loss of the
capacity to breathe
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Dx Death using Neurological Criteria
•
Clinical judgement essential
•
Impossible to create rules covering
2.
every situation
•
Difficulties mainly with
An exclusion of
reversible conditions
capable of mimicking
or confounding the
diagnosis of death
using neurological
criteria.
thiopentone and midazolam
•
Plasma concentrations not good
predictors of effect
•
DEATH
Irreversible loss of the
Use of antagonists may help capacity for consciousness
Irreversible loss of the
capacity to breathe
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Dx Death using Neurological Criteria
2.
1.
An established
aetiology capable of
causing structural
damage to the brain
which has led to the
irreversible loss of
the capacity for
consciousness
combined with the
irreversible loss of
the capacity to
breathe.
DEATH
Irreversible loss of the
capacity for consciousness
Irreversible loss of the
capacity to breathe
Organ Donation Past, Present and Future
An exclusion of
reversible conditions
capable of mimicking
or confounding the
diagnosis of death
using neurological
criteria.
98.5%
Death confirmed
in 1220 of
1238 tests
(2012 data)
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Dx Death using Neurological Criteria
1.
An established
aetiology capable of
causing structural
damage to the brain
which has led to the
irreversible loss of
the capacity for
consciousness
combined with the
irreversible loss of
the capacity to
breathe.
2.
An exclusion of
reversible conditions
capable of mimicking
or confounding the
diagnosis of death
using neurological
criteria.
3.
A clinical examination
of the patient, which
demonstrates
profound coma,
apnoea and absent
brainstem reflexes.
DEATH
Irreversible loss of the
capacity for consciousness
Irreversible loss of the
capacity to breathe
Organ Donation Past, Present and Future
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Brain-stem reflexes








Pupils (II, III)
Corneal (V, VII)
Pain (V, VII)
Gag (IX, X)
Cough (IX, X)
Oculovestibular (III, VI, VIII)
Oculocephalic
Suck
Paediatric
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Apnoea Test
Starting paCO2 > 6.0 KPa
StartingpH<7.4
5 minutes with paCO2> 0.5 KPa
Recommended method: After pre-oxygenation, disconnect the patient
from the ventilator and administer oxygen via a suction catheter in the
endotracheal tube at a rate of >6 L/minute. If oxygenation is a problem,
consider the use of a CPAP circuit (egMapleson B).
The apnoea test is performed only twice in total.
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Testing for Brain-stem Death
“This form is consistent with and should be used in conjunction with, the
AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of Death
and has been endorsed for use by the following institutions: Faculty of
Intensive Care Medicine, Intensive Care Society and the National Organ
Donation Committee.”
Abbreviated
Organ Donation Past, Present and Future
Full
26
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WHY TEST?
Organ Donation Past, Present and Future
A guiding dignity consistent approach
to declaring death
• Dying, is a process, which effects different
functions and cells of the body at different
rates of decay.
• Doctors must decide at what moment along
this process there is permanence and death
can be appropriately declared.
Organ Donation Past, Present and Future
A doctors duty
Diagnose the dead
1. Safe – no coming back to life after death declared
2. Timely – no unnecessary delay
Organ Donation Past, Present and Future
WHY TEST?
Where Brain Stem Death (BSD) is suspected, it is
highly desirable to confirm this by Brain Stem
Testing:
• To eliminate all possible doubt regarding
survivability
• To confirm diagnosis for families
• In cases subject to medico-legal scrutiny
• To provide choice regarding organ donation
Organ Donation Past, Present and Future
diagnosis
Organ Donation Past, Present and Future
decision
TWO TESTS or ONE?
• National professional guidance mandates two
tests to be performed regardless of organ
donation (Bolam&Bolithio).
• Same two doctors carry out the second set of
tests immediately after the first set (update
family and stabilise patient).
• Death is retrospectively confirmed at the
conclusion of the second test. Until then, as a
matter of law and ethics, it is necessary to treat
the patient as alive.
Organ Donation Past, Present and Future
1976
2008
Lesson 1
Organ Donation Past, Present and Future
Lesson 2
Organ Donation Past, Present and Future
Lesson 3
Take your time
•Atypical
presentation
•Hypoxic brain
injury
>24 hours
Organ Donation Past, Present and Future
Lesson 4
Induced
hypothermia has
unpredictable
consequences
See Lesson 3
Organ Donation Past, Present and Future
Lesson 5
NO EEG
Organ Donation Past, Present and Future
Lesson 6
Start with Lesson 2 =
use your brain and examine
your patient
1. Clinical brain death + NO flow
2. Clinical brain death + flow
= Death
= Wait
See Lesson 3 =
take your time and ask
‘Is reversibility possible?’
Organ Donation Past, Present and Future
Optimising the
brainstem dead
donor
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Donor optimisation
• Ameliorate ‘systemic’ effects of brain
stem death
• Why?
•
•
•
Increase number of donors
Increase number of organs per donor
Increase quality of organs
• Who takes responsibility?
•
•
•
ICU staff: medical and nursing
SN-ODs
Retrieval teams
•
•
Organ Donation Past, Present and Future
‘Scout’
Cardio-thoracic teams
43
‘Collateral damage’
• Hormonal
• Diabetes insipidus
• Hypovolaemia
• Hypernatraemia
• T3 / T4 reduces
• ACTH
• Blood glucose
• Hypothermia
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Incidence of organ involvement
• Hypotension
81%
• Diabetes insipidus65%
• DIC
28%
• Cardiac dysrrhythmias
25%
• Pulmonary oedema
18%
• Metabolic acidosis
11%
J Heart Lung Transplantation 2004 (suppl)
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Organ Donation Past, Present and Future
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Evidence
• Totsuka Transplant Proc. 2000; 32;322-326
• High sodium in liver donor doubles graft loss
• Rosendale Transplantation 2003. 75 (4): 482-487
• Protocol increased organs per donor 3.1 to 3.8. Increased probability of
transplant.
• SnellJ Heart Lung Transplant 2008;27:662-7
• 54% of Australian lung donations used for transplant vs. 13% in UK
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Principles
• Ameliorate ‘systemic’ effects of brain stem death
• Why?
• Increase number of donors
• Increase number of organs per donor
• Increase quality of organs
• Who takes responsibility?
• ICU staff: medical and nursing
• SN-ODs
• Retrieval teams
• ‘Scout’: who are they attached to?
• Cardio-thoracic teams
• Abdominal teams
• Free standing
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What do we aim for ?
• General stability
• Examples of target values
• MAP: 60 – 80 mm Hg
• Heart rate: 60 – 100 / min SR
• CI: > 2.1 l/min/m2
• Guidelines
•
•
•
•
•
Australian
Canadian
Map of Medicine
ICS
NHSBT
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Cardiovascular management
• Summary of cardio vascular target values
•
•
•
•
•
MAP: 60 – 80 mm Hg
CVP: 4 – 10 mm Hg
Heart rate: 60 – 100/min SR
CI: > 2.1 l/min/m2 (can be higher, be aware of myocardial stunning)
Filling targets: no good evidence for any specific targets, depends on
device
• SvO2> 60%
• SVRI target
• Secondary target
• Dehydration  temptation to maintain MAP with vasopressors rather than filling
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Respiratory management
• Recruitment manoeuvre
• Post BSD testing: apnoea test resulting in atelectasis
• After suctioning / disconnection
• When SpO2 drops / FiO2 increases
•
•
•
•
•
•
•
Lung protective ventilation: 4 – 8 ml/kg ideal body weight
Permissive hypercapnia with pH > 7.25
Optimum PEEP (5 – 10 cm H2O) and FiO2 (aim for < 0.4 as able)
Head–up positioning (30 - 45°)
Suctioning, physiotherapy as required
Antibiotics for purulent secretions: local microbiology surveillance
Avoid over-hydration
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Managing Diabetes insipidus
• Very common occurrence
• Pathophysiology
• Posterior pituitary failure
• Polyuria: output > 4ml/kg/h
• Dehydration with  Na+
• Usually at least partially addressed with stabilisation for BSD testing
• Treatment:
• Fluids
• Vasopressin
• DDAVP
• Aim for u-output 0.5 – 2.0 ml / kg / h
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Hormonal treatment
• Vasopressin
• Reduction in other vaso-active drugs
• Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time)
• Liothyronine (T3)
• No clear evidence yet for either use or not
• May add haemodynamic stability in very unstable donor
• Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team
• Methylprednisolone in all cases
• Dose: 15 mg/kg up to 1g
• Insulin
• At least 1 unit/h (Occasionally may need to add glucose infusion)
• ‘Tight’ glycaemic control (4 - 10 mmol/l)
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Haematological management
• DIC seen occasionally as direct consequence of BSD
• May require correcting prior to BSD testing if bleeding
• Hb> 8 g/dl (~ 10 g/dl traditionally advocated) (even > 7g/dl ?)
• No evidence on harm with lower Hb, but some evidence of harm with
blood transfusions and organ function post transplant
• Where Hb borderline, ensure blood available for retrieval procedure: local
protocols and antibodies will determine whether G&S only, or units to be
cross matched
• Use of clotting factors
•
•
•
•
Only where bleeding is an issue
Monitor clotting status
Use local hospital protocol
Retrieval procedure may require additional products
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General measures
• Maintain normothermia (active warming may be required)
• Thrombo-embolism prophylaxis
• Stockings
• Sequential compression devices
• LMWH
• Positioning
• Head-up
• Side to side
• Attention to cuff pressures and leaks to prevent aspiration
• Continue NG feeding (may be reduced/ stopped for bowel
transplant)
• Antibiotics according to sensitivities or empirical according to Trust
guidelines
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Monitoring optimisation
• Implementation: use of care bundle
• Adherence easy to monitor
• Audit first 5 priorities
• Results of optimisation evaluated
• Number of organs retrieved
• Increase in cardiothoracic organs retrieved
• Quality of organs: organ function in recipients
• Delayed graft function
• Quality: biomarkers
• Duration of graft function: long term project
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