1. Breakout Session C: Preserving the Opportunity – Before and After Consent
Moderator:
Adam Teller, OneLegacy
Presenters:
Lydia Lam, MD, LAC + USC Medical Center
Keith Markillie, RN, OneLegacy

2. Preserving the Opportunity: Before and After Consent
Moderator:
Adam Teller, Procurement Transplant Coordinator
OneLegacy

3. “How To Be” Being in Action! The Answers Are In the Room
“Report out” on Questions to Run-on:
Scribe
Spokesperson
All Teach / All Learn
Add this slide as Slide #2, after the Title Slide and before the Question to Run-on Slide.

4. Question to Run-On
How do your standards of care preserve the opportunity for the gift of life?

5. Objectives
By the end of this presentation, the attendee will be able to:
Understand the impact of a DNR and donation
Recognize pathophysiology of traumatic brain injury
Anticipate common interventions for optimal donor management

6. Preserving the Opportunity: Before and After Consent
Lydia Lam, MD
Division of Acute Care Surgery and Surgical Critical Care
Los Angeles County + USC Medical Center
Los Angeles, CA

7. “Do not harm?” or “Do not treat?”
DNR Decision
What does the DNR decision mean to the family?
No Chest Compressions?
No Shock?
No Medications?
No Labs?
No Fluids?
No Diagnostic Tests?
Allow natural death?
“Do not harm?” or “Do not treat?”

8. “Do not harm?” or “Do not treat?”
DNR Decision
What does the DNR decision mean to the healthcare team?
Routine decision in the Critical Care Unit
Stop all treatment immediately or no aggressive treatment after cardiac arrest?
DNR decision has its own “culture of understanding” that varies by hospital, unit, physician and nurse
“Do not harm?” or “Do not treat?”

9. Donation Decision Understanding the donation option clinically:
Maintaining blood pressure
Normalizing electrolytes
Managing oxygenation and organ perfusion
Balancing Intake and Output
Assessing brain death accurately
How can a family give the gift of life when the organs are not preserved for transplantation?

10. Balancing DNR and Donation
Traumatic Brain Injury (TBI)
Overall Clinical Deterioration
+ DNR Decision by Next-of-Kin
+ Fatal Diagnosis (Brain Death?)
How is this interpreted in your ICU?
What can be expected from your team?
How can we be proactive for this family?
Fly each line in individually to build clinical “equation”.

11. Pathophysiology of Traumatic Brain Injury
Physiologic collapse frequently accompanies TBI:
Hypotension
Endocrine Dysfunction
Pulmonary Dysfunction
Hematologic Dysfunction

12. Pathophysiology of Traumatic Brain Injury
Hypotension:
“Autonomic storms”
Smooth muscle ATP depleted = vasomotor hypotension
Anticipate BP spike followed by BP drop
Titrate Vasopressors
Diuretics
Consider Fluid Resuscitation
Closely monitor Intake and Output – DI?

13. Pathophysiology of Traumatic Brain Injury
Endocrine Dysfunction:
Hypothalamic injury -> pituitary dysfunction
Thyroid dysfunction = T4 Infusion
Reduction of Antidiuretic Hormone / DI
ADH = Vasopressin Infusion
Glycemic control disrupted
Insulin infusion
Relative deficiency of corticosteroids
Solumedrol Infusion

14. Pathophysiology of Traumatic Brain Injury
Pulmonary Dysfunction:
Neurogenic pulmonary edema
Systemic hypertension + LV dysfunction
Primary pneumatocyte dysfunction
Iatrogenic injury due to aggressive resuscitation
Exacerbated by intubation, aspiration &atelectasis
Concurrent blunt lung injury common
Parenchymal injury problematic in immunosuppressed recipients

15. Pathophysiology of Traumatic Brain Injury
Hematologic Dysfunction:
Thrombocytopenia
Platelets as needed
Coagulopathy/DIC
FFP / Cryo as needed
Hypothermia
Keep them warm!

16. What are Traumatic Brain Injury Guidelines?
Hospital approved guidelines for treating patients with Traumatic Brain Injury

17. What are Traumatic Brain Injury Guidelines?
Prevent secondary injury, even with grave prognosis
Secondary injury includes other organs, as well as the brain
Maintain Organ Perfusion
Volume Load
Maintain adequate CVP & MAP
Oxygenation
Correct electrolyte abnormalities

18. Why Implement Traumatic Brain Injury Guidelines?
Ensure consistent management of the critically ill patient
Maintain homeostasis for accurate brain death assessment
Prevent “secondary injury” to organs, even with grave prognosis
Provide a clinical bridge between determination of brain death and family’s decision on donation

19. LAC + USC Standardized organ donor management protocol
Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: )
LAC + USC Standardized organ donor management protocol
Before-after study (January 1998) of ADM institution
January 1995-December 2002

20. Vasopressors if MAP <70
Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: )
Vasopressors if MAP <70
Dopamine
Levophed
Vasopressin
Hormones for maximal vasopressors.
Insulin
Solumedrol T4

21. # patients referred increased 57% # of potential donors increased 19%
Aggressive Organ Donor Management Significantly Increases the Number of Organs Available for Transplantation (Salim et al. J Trauma 2005; 58: )
878 patients referred, 460 (53.4%) patients potential organ donors and 161 (34.3%) actual donors.
# patients referred increased 57%
# of potential donors increased 19%
# of actual donors increased 82%
# of patients lost to cardiovascular collapse decreased 87%
# of organs recovered increased 71%

22. How to Implement TBI Guidelines in your Hospital?
Clinical Educator
Critical Practice Committee
Critical Care Leadership
Critical Care Physicians or Medical Director
Sample Guidelines available at:

23. “Do not harm?” or “Do not treat?”
DNR Decision
What does the DNR decision mean to the family?
No Chest Compressions?
No Shock?
No Medications?
No Labs?
No Fluids?
No Diagnostic Tests?
Allow natural death?
“Do not harm?” or “Do not treat?”

24. Summary
Critical care teams can honor the DNR decision while preserving the option of donation.
Pathophysiology of Traumatic Brain Injury can be anticipated and treated.
TBI Guidelines can be implemented to prevent “step down” in clinical management and preserve the family’s donation option.

25. The Care and Management of Consented Brain Dead Organ Donors
Keith Markillie PTC, RN, BSN
OneLegacy

26. Best Practices Approach to Saving Lives &
Preserving the Opportunity for Organ Donation

27. Organ Donor Management
Similar to Traumatic Brain Injury Guidelines: “What’s good for the patient is good for the donor”
Treatment of Brain Death
Standardizes donor management within OneLegacy
Maximize the organs recovered per donor

28. Organ Donor Management
MAP 60 – 110 mmHg
CVP mmHg
EF > 50%
</= 1 pressor used AND:
Dopamine </= 10 mcg/kg/min
Neosynephrine </= 100 mcg/min
Norepinephrine </= 10 mcg/min
Vasopressin </= 2.4 units/hour (0.04 units/min)
ABG pH
PaO2:FiO2 ratio  >300 on PEEP = 5
Serum Sodium <155
Urine output 1-3 mL/kg/hour
Glucose < 150
Hemoglobin > 10
Track hormone replacement usage

29. Hormonal Replacement Post brain death endocrine changes
There is a sharp decrease in T3 and T4 to 50% of normal within one hour of brain death & down to Zero after 16 hours
Cortisol levels decrease to 50% after one hour and continue to decrease
Antidiuretic Hormone decrease significantly and completely disappear after 6 hours
Insulin decreased to 20% of baseline by 13 hours
>>Transplantation, Vol 83, pp , no 11, December 15, 2006

30. Hormonal Imbalances
Research findings suggest that after brain death aerobic metabolism changes to anaerobic cellular metabolism
ATP and creatinine phosphate deplete & lactate increases which leads to decreased cardiac function
After T4 infusion, lactate decreases, glucose utilization increases and the mitochondria resume aerobic energy generation
>>Transplantation, Vol 83, pp , no 11, December 15, 2006

31. T-4 Protocol Give IV boluses of the following:
20 mcg T-4 IV push
20 units regular insulin
50 mL dextrose 50%
30 mg/kg Solumedrol (2 grams max)
After initial bolus start T-4 drip
200 mcg in 500mL NS at 25mL/hour initially (10 mcg/hour)
Titrate as needed to maintain BP
Continue drip to procurement

32. Solumedrol Used in conjunction with T-4
Corticosteroid replacement for lowered cortisol levels in brain dead patients
Used routinely throughout care of the donor

33. Vasopressin/Pitressin
Used as hormone replacement of ADH from posterior pituitary gland in brain dead patient
Very effective in treating DI related hypotension
May or may not give 1 unit IV bolus of vasopressin before starting drip
Drip rate is 0.5 – 2.4 units/ hour
Closely observe Urine Output—don’t make the donor anuric

34. Insulin Monitor glucose every 2 hours
Treat with insulin drip rather than SQ
Keep
Utilize hospital or OneLegacy protocol

35. Treatment beyond Hormones
Organ Perfusion
Balance electrolytes
Correct coagulopathy
Correct metabolic acidosis
Optimize oxygenation and ventilation
Antibiotic usage

36. Organ Perfusion Maintain MAP 60 – 110mmHg
1. Consider invasive hemodynamic monitoring
Adequate hydration to maintain euvolemia
Crystalloids, colloids, blood products
Free water
Vasopressor support
Dopamine
Vasopressin
Neosynephrine
Levophed
2D Echo to evaluate function once resuscitated & pressors low dose

37. Monitor and treat electrolytes maintaining:
Balance Electrolytes
Monitor and treat electrolytes maintaining:
Sodium: 134 – 145 mMol/L
Potassium: 3.5 – 5.0 mMol/L
Magnesium: 1.8 – 2.4 mEq/L
Phosphorus: 2.0 – 4.5 mg/dL
Ionized Calcium: – 1.3 mmol/L

38. Correct Coagulopathy
Maintain normothermia 36 – 37.5 degrees Celsius (96.8 – 99.5 degrees Fahrenheit)
Maintain hemoglobin > 10.0 g/dL & hematocrit > 30%
If PT > 2.0, consider transfusion of FFP
If Fibrinogen is , consider FFP. If < 70, consider cryoprecipitate
If platelets < 50, consider platelet transfusion

39. Metabolic Acidosis Adequate perfusion Volume resuscitation
Sodium Bicarbonate
Use judiciously with high sodium
Find other reasons for acidosis (respiratory, kidney failure, electrolytes)
Use potassium and sodium acetate to supplement electrolytes

40. Oxygenation/Ventilation
Early bronchoscopy to clear secretions
Routine use of Solumedrol
Good pulmonary toileting
Breathing treatments/MDI
Narcan early
Lung recruitment
PEEP maneuvers
I:E ratio manipulation

41. Antibiotic Usage
ALL patients get antibiotics! Dosages can be adjusted to size and kidney clearance
Less than 5 days = Zosyn
Greater than 5 days = Vancomycin + Levaquin
May need other coverage, depending on pre-donor condition
ID consult? Never a bad idea with “strange circumstances”

42. Organ Donor Management
MAP 60 – 110 mmHg
CVP mmHg
EF > 50%
</= 1 pressor used AND:
Dopamine </= 10 mcg/kg/min
Neosynephrine </= 100 mcg/min
Norepinephrine </= 10 mcg/min
Vasopressin </= 2.4 units/hour (0.04 units/min)
ABG pH
PaO2:FiO2 ratio  >300 on PEEP = 5
Serum Sodium <155
Urine output 1-3 mL/kg/hour
Glucose < 150
Hemoglobin > 10
Track hormone replacement usage

43. Final Thoughts
“Everyone of us can help make this difference …Because that truly is the Right Thing to Do.”
Dr. Kenneth Moritsugu, MD
US Deputy Surgeon General

44. Question to Run-On
How do your standards of care preserve the opportunity for the gift of life?