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The Role of the Respiratory Therapist in Organ Donation The

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					     The Role of the Respiratory
     Therapist in Organ Donation

                        Presented by

           Oscar Colon, RN CPTC
          In-house Clinical Donation Specialist III




          The Sharing Network
 Private non-profit service organization
 Federal designation to provide recovery
  services
 State licensed
 Available 24 hours/7 days a week
 Arrange for the recovery of all organs and
  tissues




                                    Organ Transplant
                                     Waiting Lists
                                     January 2010

105,000Total Waiting in U.S.
                                    3,100 Total Waiting In NJ




                                                                1
                              Hospitals
                Conditions of Participation
    1.   Refer all deaths to the          4.   All request for donation
         OPO. Referral must be                 must be a collaborative
         “timely” and                          effort between OPO and
         “imminent.”                           hospital.
    2.   Hospitals must
         participate with their           5.   Develop cooperative
         approved OPO in                       relationships with eye
         Medical Reviews.                      and tissue banks.
    3.   Only staff trained or            6.   The OPO must
         employed by an OPO                    determine donor
         may offer families the                suitability.
         options of donation




                   Current Clinical Triggers:
                        When to Refer
                     Imminent Death Referrals
   Regardless of age, diagnosis, cause of death, sedation or religious beliefs
                          call on all vented patients
       within 1 hour of meeting any of the following clinical triggers:

• Glasgow coma scale (GCS) 5 or less
• Absence of 2 or more of the following reflexes:
      Cough Reflex                         Gag Reflex
      Pupillary response to light          Corneal Reflex
      Response to Pain                     Loss of Respirations
• Call when contemplating discussions of the following:
Before withdrawal of life support, making End of Life Decisions -
while organs for transplant are still viable




                How the staff sees us:




                                                                                 2
           Incidence of Brain Death

   About 75,000 deaths per year in N.J.

   32,000 – 34,000 of those deaths in hospitals

   Only 275-325 are brain dead and medically
    suitable

   That is less than .01% of all deaths




                   Organ Donation
    One organ donor can save up to 8 lives
•    Heart
•    Lungs
•    Liver
•    Kidneys
•    Pancreas
•    Small Intestine




             Tissue Donation
     (50 or more potential recipients)
•    Bone - orthopedic surgeries such as spinal, knee
     replacements, hip revisions and dental procedures.
•    Soft tissue – for sport injuries such as Achilles tendon
     replacement
•    Corneas – restores sight
•    Heart valves – used for heart valve replacement
     surgery
•    Blood vessels – for bypass surgery
•    Skin – used for wound and burn grafting




                                                                3
       Steps in the Donation Process
 1. Referral
 2. Evaluation
 3. Consent
 4. Maintenance
 5. Recovery
 6. Follow-up




                The Referral
•   Report all deaths –mandated by COP
•   Cardiac deaths – Call within 1 hour after the
    patient expires
•   Potential organ donor – Call within 1 hour
    when the patient meets clinical triggers at or
    initiation of brain death protocol, Glasgow
    Coma Scale of 5 or less




               The Evaluation
• Response –on sight transplant
  coordinator
• Donor suitability-lab data, current
  status
• Requirements for declaration of death
• Medical and social history thru chart
  review




                                                     4
                The Consent
•   Family assessment-legal NOK and decision
    makers
•   Decoupling information
•   Presentation of donation options by
    “Effective Requestor”
•   Legal consent
•   Testing -infectious disease screening
•   Medical examiner




               Maintenance
•   Maintain optimal organ function

•   Maximize on number of recipients

•   Maintain hemodynamic stability

•   Adequate oxygenation




              Organ Sharing
•   All recipients listed with UNOS (United
    Network for Organ Sharing)
•   Match run lists from donor information
•   Each organ has separate list
•   OPO mandated to share organs by list
•   Local centers get greatest priority




                                               5
               The Recovery
•   Use of operating room at donor hospital
•   Surgical recovery and preservation of
    organs
•   Tissue recovery after organs recovered
•   Reconstruction of body
•   Body released – to medical examiner or
    funeral home




                  Follow up
•   Family - provide follow up letter
•   Hospital staff - outcomes and appreciation
•   Family aftercare support
•   Communication - donor family and
    recipient(s)




           When are you dead?




                                                 6
          New Jersey Legal Definition

          •       “An individual who has sustained either (1)
              IRREVERSIBLE cessation of circulatory and
              respiratory functions, or (2) IRREVERSIBLE
              cessation of ALL functions of the brain including
              the brain stem, is dead.
              A determination of death must be made in
              accordance with accepted medical standards.”




   State Regulations for Brain Death
    Board of Medical Examiners took law and
     passed regulations
    Assure consistent practice
    Create standard of care
    Provided level of authority to develop new
     standards as time progressed




                Brain Death: Board Of ME
              Appropriate Observation Period
                                  Clinical Exams:
                                  Minimum         Confirmatory
Age             Cause of Injury
                                  Period of       Test
                                  Observation
Any age         Any cause         One exam only   Yes
< 2 months      Any cause         48 hours        No
2 to 12
                Any cause         24 hrs          No
months
> 12 months Any cause             6 hrs           No




                                                                  7
        Ascertain Irreversibility
•   Known etiology
•   Rule out intoxication
•   Rule out abnormal metabolic states
•   Rule out profound hypothermia
•   Temporal space between exams




            Ascertain Totality
•   Unresponsiveness GCS of 3
•   Absence of brain stem reflexes
•   Apnea
•   Acceptance of spinal reflexes




           Confirmatory Tests
•   Cerebral Doppler

•   Nuclear Cerebral Blood Flow Study

•   Cerebral Vessel Angiography / MRI




                                         8
               The Apnea Test
 A method to determine absolute apnea
 Based on a finding that apnea cannot be
  reliably diagnosed unless it occurs in a
  setting of adequate hypercarbic stimulation
  of the brainstem.
 A PaCO2 of 60 mmHG or more is generally
  considered adequate hypercarbic
  stimulation of the respiratory centers.




      Performing the Apnea Test
   Obtain a baseline ABG
   Make necessary ventilator changes to achieve a
    PaCO2 of 40 mmHG and a pH <7.44
   Ventilate the patient with 100% oxygen for 30
    minutes
   Disconnect the ventilator and oxygenate with at
    least 8-10L of oxygen via T-piece or O2 tubing
    down the endotracheal tube




      Performing the Apnea Test
   Closely monitor the patient’s respiratory effort and
    hemodynamic status for 8-10 minutes
   If spontaneous breathing occurs; abort the test and
    place the patient back on the ventilator.
   If spontaneous breathing is absent and patient
    becomes hemodynamically unstable; draw an
    ABG and place the patient back on the ventilator




                                                           9
     Performing the Apnea Test
 If spontaneous breathing does not occur and
  patient is hemodynamically stable; after 10
  minutes draw an ABG
 If PaCO2 is greater than 60 mmHG or 20
  points above baseline PaCO2 and there
  have been no spontaneous respirations; the
  test is positive and the patient is considered
  to be apneic




        How can you help???
 Notify MD/RN of changes in patients
  ventilatory status
 Inquire if the referral has been made to
  NJSN – If not call us 1800-541-0075
 Please do not mention Donation!!!!
 Be an active part of the healthcare team;
  join in our huddles
 Provide aggressive pulmonary support




       Something to think about..


•   “What’s good for the Lungs is
    good for the Body”




                                                   10
               How can you help???
   Help overcome atelectasis
   Maintain HOB at 30 degrees
   Turn patient every 2 hours
   Frequent suctioning and good mouth care
   Chest PT every 4 hours
   Hyper inflate ETT cuff; which reduces aspiration
    and protects the lungs
   Bronchodilators every 4 hours
   Pulmonary toilet
   Lung Recruitment




          Pulmonary Management Goal
                     is to
           Ensure adequate ventilation
 Pressure - Control Ventilation
 TV 10-15ml/kg
 Peep 5-10cm
 ABG’s every 2-3 hours adjust settings accordingly to
  maintain optimal parameters
     –   pH 7.35 -7.45
     –   PaCO2 35-45
     –   PaO2 >100
     –   HCO3 22-26
     –   O2 Sat 95-100%
   PIP < 30 cm H2O




         Requirements for Lung offers

 O2 Challenge (pO2 > 300mmHg)
 Arterial Blood Gases
 Sputum Culture
 Chest X-rays
 Bronchoscopy
 Lung measurements
 Pulmonary Consult




                                                         11
                       O2 Challenge

 Place patient on 100% FIO2 with 5cm
  PEEP for 30 minutes
 After 30 minutes draw an ABG & switch
  FIO2 back to original setting
 Lung Transplant Surgeons are looking for
  PaO2 >300




                      What is DCD?
   Formerly called Non-Heart-Beating-Donation, Donation After
    Cardiac Death has been an end-of-life option for patients and
    families for than 30 years.

• After the decision has been made that the patient has no chance of
    survival and the family has decided to withdraw life support, the
    Sharing Network is contacted and evaluates the patient for
    medical suitability. If patient is suitable, the family is offered the
    option of DCD.

   It is the recovery of organs from those patients who do not meet
    the criteria of brain death. Usually, these patients have suffered a
    severe, irreversible brain injury, but retain some brain stem
    activity




    DCD is Not a New Process……
 Kidney transplants began in the 1950s
 Early recoveries were from DCD donors
 Brain death criteria established in 1960s
 Recent renewed interest in DCD-the waiting
  list is ever growing!




                                                                             12
                                                      DCD TOOL
   Prior to the test record the BP, Pulse, O2 sat
   Disconnect the patient from the ventilator
   After 5 minutes and 10 minutes record the
    following:
    – BP, Pulse, O2 sat, respiratory effort (yes or no),
      respiratory rate, Tidal volume, NIF
   If patient becomes unstable (O2 sat <70%, systolic
    BP <80) abort the test and place the patient back
    on the ventilator




                                               The Leak Test

 Deflate  the cuff on the
  endotracheal tube
 Auscultate over the trachea to
  listen for an air leak around the
  endotracheal tube.




         Criteria                                                                                                                     Assigned Points   Patient Score


         1 - Spontaneous Respirations after 10 minutes

                  Rate > 12                                                                                                                  1
                  Rate < 12 or > 40                                                                                                          3

         2 – Tidal Volume
                  Tidal Volume > 200ml                                                                                                       1
                  Tidal Volume < 200ml                                                                                                       3

         3 – Negative Inspiratory Force (NIF)
                  NIF > -20cmH2O                                                                                                             1

                  NIF -1 to -20cmH2O                                                                                                         3

         ****No Spontaneous Respirations automatic 9

         5 - BMI
                  <25                                                                                                                        1
                  25-29                                                                                                                      2
                  >30                                                                                                                        3

         6 - Vasopressors
                  No Vasopressors                                                                                                            1

                  Single Vasopressor                                                                                                         2

                  Multiple Vasopressors                                                                                                      3

         7 - Patient Age
                    0-30                                                                                                                     1

                    31-50                                                                                                                    2

                    51 +                                                                                                                     3

         8 - Intubation
                    Endotracheal Tube                                                                                                        3

                    Tracheostomy                                                                                                             1

         9 - Oxygenation After 10 Minutes
                    O2 Sat. > 90%                                                                                                            1

                    O2 Sat. 80-89%                                                                                                           2

                    O2 Sat. < 79%                                                                                                            3

         10- Leak Test:               Present      Absent                                                                    Total Score →
         Date of Extubation:                                  Time of Extubation:
         Date of Expiration:                                  Time of Expiration:
                                                              Total Time:
                                                                                         Formula for Calculating BMI
                                                                              BMI =   (_________weight in pounds__________)       X 703
                                                                                        (Height in inches) X (Height in inches)
         SCORE:
         8-12  High Risk for continuing to breathe after extubation
         13-18 Moderate Risk for continuing to breathe after extubation
         19-24 Low Risk for continuing to breathe after extubation




                                                                                                                                                                        13
            Respiratory Therapist’s Role in
                        the OR
Brain Dead – pulmonary management, help transport the
           patient, preferably on a portable vent

            - hand off to anesthesia
DCD - help transport the patient, preferably on a portable
      vent
    - assist the attending physician and the
      ICU nurse with extubation in the O.R. as
      per standard ICU procedure (suction,
      extubate etc.)




  Families
  give the gift
  of life...
  if only we give
  them the
  opportunity.

               Thank You !!!




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                        Program Coordinator
                        shenfite@umdnj.edu
                           (973) 972-8825




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