1. Organ Donation End of Life care in the Operating Room Matthew Bock Surgical recovery coordinator University of Wisconsin Organ Procurement Organization 1-866-UWHC OPO (1-866-894-2676)

2. Perspective

3. Remembering why we’re here Save lives through transplantation Supporting the family’s choice Honoring the patient’s wishes

4. Donation after Cardiac Death (DCD)

5. Uniform Determination of Death Act, 1980 Irreversible cessation of circulatory and respiratory function - OR- Irreversible cessation of all functions of the entire brain, including the brain stem

6. Two ways to donate Deceased Organ Donation Donation After Brain Death Brain Death Donation After Cardiac Death (DCD) Cardiac Death (DCD)

7. Brain Death Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

8. Brain Death Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

9. Clinical Diagnosis of Brain Death Unresponsive to all stimuli No spontaneous respiratory activity All brain stem reflexes are absent: –Pupillary response to light –Corneal reflexes –Oculo-vestibular reflex (caloric response) –Oculocephalic reflex (doll’s eye phenomenon) –Gag reflex

10. Apnea Test Make sure patient has normal body temp, blood pressure, volume status, ABG’s Disconnect from ventilator Monitor continuous pulse oximetry Administer 100% O2 at 6 L/min into the trachea Monitor closely for respiratory movements Check serial ABG’s, or at approx. 8 minutes If no respiratory movement and arterial PCO2 is > 60 mm Hg, the apnea test supports the clinical diagnosis of brain death

11. Apnea Test Make sure patient has normal body temp, blood pressure, volume status, ABG’s Disconnect from ventilator Monitor continuous pulse oximetry Administer 100% O2 at 6 L/min into the trachea Monitor closely for respiratory movements Check serial ABG’s, or at approx. 8 minutes If no respiratory movement and arterial PCO2 is > 60 mm Hg, the apnea test supports the clinical diagnosis of brain death

12. Brain Death Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

13. Brain Death Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

14. Severe Neurologic Injury Trauma –MVA, Fall SDHAnoxia –Cardiac Arrest, near drowning

15. Brain Death Brain Death Severe neurological injury Meets Brain death criteria: -Clinical exam -Apnea test DCD Severe neurological injury Does not meet criteria for brain death Family has elected to withdraw support

16. Two ways to donate Donation After Brain Death Patient is maintained on ventilator for organ recovery Organs dissected insitu 3-4 hour surgery Donation After Cardiac Death (DCD) Patient is extubated in the Operating Room or ICU Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician Rapid recovery with organs procured en bloc.

17. Two ways to donate Donation After Brain Death Patient is maintained on ventilator for organ recovery Organs dissected insitu 3-4 hour surgery Donation After Cardiac Death (DCD) Patient is extubated in the Operating Room or ICU Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician Rapid recovery with organs procured en bloc.

18. Two ways to donate Donation After Brain Death Patient is maintained on ventilator for organ recovery Organs dissected insitu 3-4 hour surgery Donation After Cardiac Death (DCD) Patient is extubated in the Operating Room or ICU Surgery begins 5 minutes after cessation of cardiac function and declaration by patient’s physician Rapid recovery with organs procured en bloc.

19. “We don’t do that here”

20. ICU nurse RT OPO staff No family yet

21. Who is involved? Hospital - Anesthesia - Surgical Technician/Scrub Nurse - Circulating Nurse Abdominal Transplant Team - Surgeon - Physician Assistant - Surgical Recovery Coordinator Cardiothoracic Team - Surgeon - Surgical Fellow - Surgical Recovery Coordinator

22. Paperwork Consent x2 Time out Post Op disposition Death packet

23. Prep & drape Femoral cutdown Cover patient and back table Unnecessary staff exits the room

24. DCD Withdrawal in the OR Accommodating the Family

25. Meds, Withdrawal & Declaration

26. How long can we wait?

27. Rapid En-bloc recovery

28. Organ Preservation Time Heart: 4-6 hrs Lungs: 4-6 hrs Liver: 12 hrs Pancreas: 18 hrs Kidneys: 24 hrs

29. A wedding story