Transcript Donor Case Studies

Donor Case Studies
Optimal Management
Harbor-UCLA Critical Care – Organ Donation Symposium
April 12, 2010
Brant Putnam, MD FACS
Trauma / Acute Care Surgery / Surgical Critical Care
Harbor-UCLA Medical Center
What is OPTIMAL donor
management?
= GOOD CRITICAL CARE
OPTIMAL donor management
begins PRIOR to proclamation of
brain death.
The ICU nurses and physicians are
jointly responsible for optimal
donor management, not just the
OPO.
If the patient has not been
formally pronounced brain dead,
then the patient is alive.
Who is not willing to provide good
critical care to a live patient?
NO ONE
Case #1
 63yo
male found lying against a wall
 Possible
fall vs. assault
 Large laceration to occipital area
 GCS 1-4-1
 Pupils sluggish
Case #1
 Called
as a “Tier II” (high acuity) trauma
A
- Patent, but not protected
 B - Spontaneous, clear bilaterally
 C - P = 86 BP – 150
 D - Unresponsive
GCS = 1-4-1
Pupils 32, sluggish
Blood from left ear
Case #1

Intubated in the ED for airway
protection

Taken for CT scan for suspected
severe traumatic brain injury
Multiple intraparenchymal
hemorrhages
Large left
subdural
hematoma
(w/ midline shift)
Case #1

Neurosurgery consultation 
 To OR immediately for bilateral craniectomy +
evacuation ICH and SDH
 GCS 1-1-1
 Coagulopathic
and HD unstable intra-op
 Prognosis deemed poor leaving the OR
Case #1

Patient transported to ICU
Time
BP
P
0400
2200
140/70 140/70
90
85
2300
160/80
110
0000
80/60
60
0100
100/70
100
Labetalol given Levophed started
What do you think happened here?
Case #1: So to review…
Time
2200
2300
0000
0100
BP
140/70
160/80
80/60
100/70
P
85
110
60
100
Pupils
4, sluggish
4 mm,NR
6 mm, NR
6 mm, NR
Motor
Flexor pos
Flexor pos
No
movement
No movement
Cough
+
+
-
-
Herniation
Brain Herniation

Often accompanied by
catecholamine storm



Hypertension
Tachycardia
Avoid anti-hypertensives
Management Goal #1

Appropriate hemodynamic resuscitation to
maintain perfusion to potential organs for
donation
 Maintain
MAP 65-100 mmHg
 Place central venous line; fluid resuscitation to
CVP 4-10 cm H20
 Use of < 1 vasopressor
 Dopamine
< 10 mcg/kg/min
 Levophed < 10 mcg/min
 Neosynephrine < 60 mcg/min
 Consider
hormonal resuscitation with T4 protocol
What should happen next??

Begin testing for brain death

One Legacy notification (actually should have
already been notified!!!)

Clinical optimization
When to notify One Legacy…
Case #1: What did happen….

Next morning… 1200 noon

One Legacy notified

Physician to hold family conference to
discuss poor prognosis

No new orders written…
No new orders written…
Time
0800 1200
1800
2400
24 hr total
UOP
300
250
300
100
- 1000 cc
Na
153
158
164
165
165
What do you think is going on here? Management?
Diabetes Insipidus
Excretion of large amounts of severely dilute
urine
 “Central” – no ADH release from brain
 Kidney can not concentrate urine


Therapy
 DDAVP
(desmopressin acetate)
 Synthetic
 Free
analogue of ADH
water replacement
 Frequent monitoring of serum Na
What was done…

DDAVP given at 1900
Time
UOP
Na


0800
300
153
1200
250
158
1800
300
164
2400
100
165
Free water replacement started next morning
(POD #2)…
M.D. “brain death evaluation when electrolytes
correct”
Management Goal #2
Maintain perfusion to all organs
 Goal urine output 1-3 cc/kg/hr

 Suspect
DI if U/O > 200 cc/hr x 2 hrs
 Treat with DDAVP and fluid (free H2O)

Keep serum Na 135-155
Meanwhile…

POD #3
Time
0000
0600
1200
1800
2400
Glucose
219
160
406
465
398
Management?
Insulin drip finally started next morning at 0900
Management Goal #3
 Potential
donors are critically ill patients
 Tight glucose control applies
 Increase
frequency of Accu-checks
 Increase sliding scale
 Insulin drip as needed
 Goal
is to keep serum glucose < 150
As time passes . . .

Multiple ventilator alarms
 PIPs
45-50
 Low exhaled tidal volumes
O2 sats 85%
 Increase TVs to 1 L to maintain sats 88-90%

Is this the best
ventilator
management?
Management Goal #4

Maintain good oxygenation
 PaO2/FiO2
ratio > 300
 Reduce
FiO2 to reduce oxygen toxicity
 Avoid high PEEP effects on hemodynamics

Maintain adequate ventilation
 ABG

pH 7.30-7.45
Avoid barotrauma to lungs
 PIPs
< 32 cm H20
Case #1: POD #4
0300 1st Brain Death Note written
(Note: 75 hours after herniation event)
1000 2nd Brain Death Note written
1455 One Legacy obtains consent for all organs
and tissue
Case #1: Outcome
HD deterioration to near-code
 Poor organ function
 Crashed donor to OR because of instability
 Kidneys recovered
 Kidney biopsy results poor
 No organs suitable for transplant

Case #2 – Getting it right . . .

22yo male S/P pedestrian struck by auto x 2
 GCS
1-1-1
 Lost pulses on arrival; CPR x 12 min
 Devastating brain injury
 One Legacy notified within 4 hours of arrival
Case #2
Case #2

Ongoing resuscitation
 IV
fluid to CVP 8
 Blood products to keep Hb near 10
 Correction of coagulopathy
 Use of Levophed to maintain MAP > 65
 Addition of T4 within 4 hours

Adequate oxygenation / ventilation
 ABG
7.39 / 40 / 118 / 24 / -2 / 99%
 PaO2 / FiO2 = 350
 PIPs 22-24
Case #2

Early treatment of DI
 DDAVP
 Free
water replacement
 Na 150-154

Tight glycemic control with insulin drip
Loss of brainstem functions
 First BD note < 12 hours after arrival

Case #2

Outcome - 7 organs transplanted at local
centers:
 Right
lung
 Left lung
 Heart
 Liver
 Right kidney
 Left kidney
 Pancreas
Case #3: Steven
 17yo
male S/P skateboarding accident
GCS 1-1-1
Severe DAI, small SDH on CT scan
Devastating brain injury
Case #3: Steven
Donor Management Goals

Appropriate hemodynamic resuscitation
 MAP 65-100
ALL organs
 CVP 4-10
Lungs, ALL
 EF 50-70%
Heart, ALL
 Use of < 1 vasopressor
Heart, ALL
 Hormonal
resuscitation
with T4 protocol
ALL
Donor Management Goals
Good oxygenation / ventilation
 PaO2/FiO2 ratio
Lungs
 ABG pH 7.30-7.45
Lungs, ALL
 PIPs < 32 cm H20
Lungs
 Urine output 1-3 cc/kg/hr
Kidney
 Serum Na 135-155
Liver
Pancreas
 Glucose < 150
