1. 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

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

3. The Facts Transplant waiting list candidates today:* 123,228
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

4. Everyday Challenges To Organ Donation
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

5. Traditional Pathway To Organ Procurement
Patient suffers injury/illness resulting in real or potential brain death
Patient admitted to ICU
Appropriate OPO is notified of the potential for organ procurement
The process begins

6. Types Of Donation Brain Dead Donors- Most Common
Well regimented procedures and documentation
Requires second independent physician pronouncement
Donation After Circulatory Death- Less Common
Patient is NOT brain dead
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

7. Let’s Talk Lungs Classification Upon Evaluation:
Stellar: PF ratio >450, clear film, minimal secretions
Good-Great: PF ratio>300, near normal film & minimal secretions
Decent: PF ratio> 200, some film abnormalities
Poor: PF ratio , film abnormalities
Unlikely: PF <100, major film abnormalities

8. The Transplant Surgeon’s Dream Patient
PaO2 at least 150 on 40% with a PEEP of 5
Clear CXR: no infiltrates or atelectasis
Normal bronch with no lesions, thick secretions, edema
Absence of organisms on C&S, gram stain

9. 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

10. Traditional RN Role In Patient Care
Receive the patient in the ICU
Institute typical ICU order sets
Deliver care of the highest level
Adjust once OPO is on site and implements their protocols

11. Traditional RT Role In Vent Management
Receive the patient in the ICU & place on vent
Typical institutionally specific settings & therapies
Probably do albuterol & mucomyst treatments
Some (far too few) provide aggressive recruitment/maintenance breaths
Fewer provide vibratory therapy prophylactically

12. Traditional RT Role (cont’d)
Receive orders from OPO once they get involved
Institute OPO therapies, ABG’s, aerosols/MDI’s, etc
Wait for the long process of H&P, organ identification & potential placement
Meanwhile……
The Process Continues…….

13. Why Is Our Traditional Vent Approach Problematic?
Patients with brain death are apneic
Apnea results in repeated, static tidal volumes
Apnea results in no sigh breaths
Static Vt’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?

14. How Do We Change That Tradition?
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

15. If you do not lose the lungs, you do not have to get them back
Specifics:
Aggressive Vent Modes: PCV, APRV, PRVC, HFOV
Aggressive lung recruitment: Higher Vt, higher PEEP, recruitment maneuvers
Vibratory therapy, lowest FIO2 as possible
The Key:
If you do not lose the lungs,
you do not have to get them back

16. Let’s Make This More Personal

17. Today In Nevada 123 Active waiting list candidates today:*
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

18. Summary: 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

19. Michael J Hewitt, RRT, ACCS, NPS, RCP, FAARC, FCCM
Questions?
Michael J Hewitt, RRT, ACCS, NPS, RCP, FAARC, FCCM