The Role Of RT’s & RN’s In Organ Procurement

An Opportunity For Us All Michael J Hewitt, RRT, ACCS, NPS, RCP, FAARC, FCCM Clinical Manager, Respiratory Care Services Rhode Island Hospital & Hasbro Children’s Hospital Principal Teaching Hospital, The Warren Alpert Medical School of Brown University Providence, Rhode Island Chair; Respiratory Section, Society of Critical Care Medicine Secretary, Rhode Island Society for Respiratory Care

Conflict of Interest Disclosures

I wish to disclose the following potential conflicts of interest: Type of Potential Conflict Grant/Research Support Consultant Speakers’ Bureaus Financial support Other Details of Potential Conflict Monaghan Medical, Hollister The material presented in this lecture has no relationship with any of these potential conflicts

The Facts

Transplant waiting list candidates today: * 123,228 Active waiting list candidates today: 77,909 (1,648 are for lungs) Transplants January - November 2013 27,036 Donors January - November 2014 13,125

* Data From Health Resources and Services Administration & Organ Procurement Network

Everyday Challenges To Organ Donation

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Demand always exceeds supply Many patients are not eligible to be donor * Even in the face of preset decision to be a donor, can be overridden by family member(s) Prolonged decision processes by families decrease organ availability, especially lungs * Only 5 in 1,000 are medically eligible to donate

Traditional Pathway To Organ Procurement

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Patient suffers injury/illness resulting in real or potential brain death

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Patient admitted to ICU

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Appropriate OPO is notified of the potential for organ procurement

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The process begins

Types Of Donation

1. Brain Dead Donors- Most Common

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Well regimented procedures and documentation

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Requires second independent physician pronouncement 2. Donation After Circulatory Death- Less Common

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Patient is NOT brain dead

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Occurs when family decides to withdraw care Patient pronounced in OR Organ recovery begins once cardiac death is declared Can be emotionally challenging for caregivers 3. Living Donation

Let’s Talk Lungs

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Classification Upon Evaluation:

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Stellar : PF ratio >450, clear film, minimal secretions

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Good-Great: PF ratio>300, near normal film & minimal secretions

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Decent: PF ratio> 200, some film abnormalities

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Poor: PF ratio 100-200, film abnormalities

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Unlikely: PF <100, major film abnormalities

The Transplant Surgeon’s Dream Patient

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PaO 2 at least 150 on 40% with a PEEP of 5

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Clear CXR: no infiltrates or atelectasis

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Normal bronch with no lesions, thick secretions, edema

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Absence of organisms on C&S, gram stain

Who Is Best Suited To Determine How The Lungs Are Classified?

Us: But Only If We Change Our Traditional Practice We Must Avoid These Patients Becoming Just a Task

Traditional RN Role In Patient Care

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Receive the patient in the ICU

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Institute typical ICU order sets

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Deliver care of the highest level

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Adjust once OPO is on site and implements their protocols

Traditional RT Role In Vent Management

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Receive the patient in the ICU & place on vent

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Typical institutionally specific settings & therapies

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Probably do albuterol & mucomyst treatments

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Some (far too few) provide aggressive recruitment/maintenance breaths

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Fewer provide vibratory therapy prophylactically

Traditional RT Role (cont’d)

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Receive orders from OPO once they get involved

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Institute OPO therapies, ABG’s, aerosols/MDI’s, etc

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Wait for the long process of H&P, organ identification & potential placement

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Meanwhile……

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The Process Continues…….

Why Is Our Traditional Vent Approach Problematic?

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Patients with brain death are apneic Apnea results in repeated, static tidal volumes Apnea results in no sigh breaths Static V t ’s and no sigh breaths result in atelectasis Atelectasis leads to secretion issues/pneumonia More times than not, the above causes lungs to be rejected by the OPO team Is this acceptable?

Who better than us to change this tradition?

How Do We Change That Tradition?

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Develop protocols & algorithms for this specific patient subset Initiate those P&A’s upon admission when patient identified as a potential donor Get aggressive and stay aggressive Initiating these P&A’s while the OPO notification and response occurs Much time (and more lungs) will be saved by this approach

Specifics:

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Aggressive Vent Modes: PCV, APRV, PRVC, HFOV Aggressive lung recruitment: Higher V t , higher PEEP, recruitment maneuvers Vibratory therapy, lowest FIO 2 as possible

The Key:

If you do not lose the lungs, you do not have to get them back

Let’s Make This More Personal

Today In Nevada

Active waiting list candidates today: * 123 All are for Kidneys BUT, in the states that touch Nevada, today we see: All Organs: 27,512 Lungs: 220 Heart/Lungs: 14 * Data From Health Resources and Services Administration & Organ Procurement Network

Summary:

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Organs are in high demand with a very limited supply Lungs are even more in demand and in very low supply Lungs are fragile and need to be kept in tune from the very start Is there anyone more suited to accomplish this than us?

In this day of RT Departments needing to bring much more value to the table, isn’t this a no brainer?

Partnering with our nursing colleagues we can have a profound impact on organ procurement

Questions?

Michael J Hewitt, RRT, ACCS, NPS, RCP, FAARC, FCCM [email protected]