Transcript Brain Death - Gift of Hope

A Priority Approach to Maximizing the
Gift from Donation After Cardiac Death
Martin D. Jendrisak, MD, FACS
Medical Director
Gift of Hope Organ and Tissue Donor Network
SRTR Data
Donation Stats as of July 15, 2011
National Organ Waiting List
111,827
Illinois Organ Waiting List
4,912
Indiana Organ Waiting List
1,513
Illinois Organ Waiting List By Organ
Kidney
4,111
Liver
495
Heart
141
Kidney/Pancreas
110
Pancreas
100
Lung
69
Intestine
10
Heart/Lung
1
Transplant Partners
180 Donor Hospitals
DSA of 12 Million
Referral
9 Transplant Centers
Transplant
Consent
Management
Recovery
Allocation
Catastrophic Neurologic Injury
Evaluation and Treatment in the Critical Care Setting
Clinical Trigger to donation Referral
•Donation option is part of end of life care planning
•Ensures this option is not denied to families
•Timely notification of OPO is critical to process
Futility of Continuation of Care
•Establish by health care providers
•Family understanding and acceptance
Death Determination
Death Determination
• By Neurologic Criteria (DBD)
– Cessation of all brain activity (brain death)
– Clinically established
– Confirmatory testing when indicated
• By Circulatory – Respiratory Criteria (DCD)
– Permanent absence of circulation and
respiration
– Hospital DCD policy followed
IOM Committee Recommendation: 2006
DNDD – Donation after a neurological
determination of death
DCDD – Donation after a circulatory
determination of death
Brain Death Determination
Yes
No
Decision & Planning for
Withdrawal of Care
ME/Coroner
Notification Hospital
Consent for Donation
Consent for Donation
Yes
ME/Coroner
Release - GOH
ME/Coroner
Release - GOH
Yes
1.
2.
3.
4.
5.
No
Implement donor management protocols
Donor Testing
Organ Evaluation
Organ Allocation
Coordinate Surgical Recovery OR Access
No
Withdrawal of Care
Death
Pronouncement
Implement DCD
Protocol: Time
Critical
ME/Coroner
Notification Hospital
Protein S-100 Brain Injury Biomarker Study
Donor
N
s-100b
p Value
Injury-> Sample
BD-> Sample
SCD
34
6.54 +/- 7.29
.0004
89.0 +/- 93.0
8.7 +/- 2.5
ECD
38
9.14 +/- 11.0
.0003
63.6 +/- 75.2
4.9 +/-3.0
DCD
30
4.18 +/- 6.40
.0243
81.2 +/- 66.5
N/A
DCD-A
30
1.37 +/- 1.83
-------
136.3 +/- 114.9
N/A
Donor Management Requires a
Collaborative Approach between OPO and
Donor Hospital Staff
Phases:
•Identification
•Referral & Initial Evaluation
•Management of the Potential Donor
•Brain Death and Consent
•Donor Management
•Special Interventions
•Organ Specific Testing and Assessment
De-escalation of Care
Definition: Strategic reduction in the level of care in the setting of patient
non-recovery
Examples: Withhold or reduce vasopressor support, transfusions, fluid and
electrolyte resuscitation, pulmonary care, laboratory monitoring, etc.
Consequence on Donation: Renders organs not transplantable
Per CMS and Contractual Obligation: Hospitals and providers must
provide adequate medical support to give families the option for organ
donation.
Best Practice: (1) Early contact with GOH and (2) Provide full medical care
until GOH determines non-donor status.
Donor Management - Goals
• Optimize Organ Viability
• Proper Assessment of Organ Quality
• Maximize Organ Utilization
• Optimize Outcomes of Transplantation
Consequences of the Pathophysiology
of Brain Death
• Myocardial Dysfunction
• Hemodynamic Instability
• Neurogenic Pulmonary Edema
• Diabetes Insipidus
• Organ Dysfunction
Detrimental Physiological Effects of
Brain Death
• Hemodynamic:
• “Catecholamine storm”
• Cardiac dysfunction
• Increase SVR
• Capillary alveolar membrane damage
• Hormonal
• Endocrinopathy
• Pituitary – ADH, TSH, ACTH
• Immunologic
• Activation of inflammatory mediators
• IL-6, IL-10, ???
• Upregulated HLA Class II Expression
• Upregulated Expression of Adhesion Molecules
GIK Study
Cardiac Output Stroke Volume
SVR
Case
Age
Sex
Weight
Pre-
GIK
Pre-
GIK
Pre-
GIK
Organs
Transplanted
1
19
M
70kg
8.8
6.8
81
64
727
672
lu/li/k/p
2
45
M
78kg
4.5
4.6
52
65
1228
1236
li/k/p
3
33
F
139kg
4.6
7.2
38
61
1549
768
lu/li/k/p
4
17
M
64kg
2.5
9.2
28
74
5
47
M
72kg
4.0
12.9
46
91
740
1045
li/k
6
34
M
68kg
5.8
11.5
65
108
997
482
h/lu/li/k/p
li/k/p
SVR = Systemic Vascular Resistance; lu= lungs; li= liver, k= kidneys; p = pancreas; h = heart
Plexmark Study
IP - 10
MIG
OPG
SCD
125.3+/-182.9
45.5+/-85.3
877.0+/985.5
ECD
275.9+/-519.7
32.2+/-48.9
801.6+/-662.4
DCD
8.7+/-11.6
2.0+/-4.5
280.4+/431.6
Cytokine Response to Steroids in DBD
Time
IP - 10
MIG
OPG
0
180.8+/-340.7
40.6+/-72.7
849.2+/-860.9
6
35.0+/-33.4
13.0+/23.9
434.3+/-382.9
12
20.6+/23.0
5.93+/-13.8
494.9+/-360.7
24
48.5+/-63.4
0
283.5+/-243.6
DCD PROCESS
• OPO evaluates donation candidacy
• OPO coordinates organ procurement/allocation
• Patient care team withdraws support, provides comfort
measures and pronounces death
• Organ recovery initiated after death – time critical
• Adherence to “Dead Donor Rule”
– Organ can be recovered only after death
– Organ recovery process does not hasten death
DCD
• 90 minute time limit
• Warm ischemia limits transplant opportunity
– Kidneys – generally transplanted
– Liver, lungs, pancreas maybe transplanted if
organ flush within 20 minutes and donor
age<40
• DCD evaluation tool
Donation After Cardiac Death Tool
Criteria
Assigned Points
Patient Age
0-30
1
31-50
2
51+
3
BMI Calculation*
BMI <25
1
BMI 25 - 29
2
BMI >30
3
Intubation
Endotracheal Tube
3
Tracheostomy
1
Vasopressors/Inotropes
No Vasopressors/Inotropes
1
Single Vasopressor/Inotropes
2
Muliple Vasopressors/Inotropes
3
Spontaneous Respirations after 10 minutes
Rate >12
1
Rate <12
3
TV>200cc
1
TV<200cc
3
NIF>20
1
NIF<20
3
No Spontaneous Respirations
9
Oxygen Saturation After 10 minutes
02 Sat >90%
1
02 Sat 80-89%
2
02 Sat <79%
3
Final Score
Point Score
Donation After Cardiac Death Tool
Final Score
% Probability of Expiration
In <60 minutes
% Probability of Expiration
in <120 minutes
10
8
26
11
13
34
12
20
42
13
28
51
14
38
59
15
50
68
16
62
75
17
72
81
18
81
86
19
87
90
20
92
95
21
95
95
22
97
96
23
96
97
DCD TOOL LIMITATIONS
• 80% positive predictive value
• 20% donors missed
• Focused on uncertainty of the DCD
process
• Clinician input may add complexity to
the decision process
DCD PRACTICE CHANGE
•
•
•
•
Started 3/1/2010
Omit DCD tool
Omit reliance on clinician prediction ability
Pursue all opportunities
– Potential for transplantable organs
– Maximize the gift
– Family driven
• Monitor practice through data analysis
Impact of the DCD Evaluation Tool on Organ Procurement
∆
With Tool
Without Tool
214
74
Exclusions
82 (38%)
16 (22%)
Pursued Cases
132 (62%)
58 (78%)
Expired
117 (89%)
38 (66%)
DNE
15 (11%)
20 (34%)
23%
Missed Donors
15 (18%)
0
18%
Potential Cases
16%
Donation Patterns of DCD Expired Cases
With Tool
Without Tool
<90 min
117
38
<60 min
111 (95%)
38 (100%)
<30 min
98 (84%)
32 (84%)
<20 min
85(73%)
28(74%)
Total
118 (89%)
29 (89%)
Extra-renal
39 (40%)
11 (40%)
Time to CPA
Positive Donors
Conclusions
• New DCD Practice Paradigm Maximizes The
Gift
– No missed donor opportunity
– 20% increase in donation with transplantable
organs
– Meet donor/family wishes 100% of time
• Demand On Donation Resources Acceptable
– Identifies/excludes futile efforts (age>60)
Conclusions (Cont’d)
• Adds Clarity About DCD Process/Manages
Expectations
– 2 out of 3 attempts (on average),
transplantable organs are recovered
– 3 out of 4 actual donors expire under 20
minutes to permit extra-renal organ
recover/transplantation
– Clarity of message benefits family/staff