The Donor and

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					ICU Management of the
    Organ Donor

    Bradley J. Phillips, MD
      Burn-Trauma-ICU
      Adults & Pediatrics
                       Case
•   19 yof unrestrained MVC
•   Unresponsive at scene
•   P 120, SBP 70, agonal breathing
•   Intubated at scene, IV’s
•   Transported to BMC
                         Case
• Primary exam
  –   ET in place with CO2
  –   BS bilaterally
  –   BP 80
  –   Neuro - pupil dilated/fixed, unresponsive
• Secondary exam
  – significant head soft tissue/bony trauma
  – distended abdomen
                         Case
•   IVF/Blood
•   NGT/Foley
•   Labs drawn
•   Xrays
    – CXR/pelvis/lat cspine - negative
    – CTH - open skull fracture, massive swelling, loss of
      ventricular space, frontal SDH
    – CTA - negative
                 Issues
• Brain Death
• Organ Donation
• Management of the Donor
                  Brain Death
• Brain death = Death
• General criteria
  – cerebral and brain stem functions absent
     • do NOT include spinal reflexes
  – condition is irreversible
  – cessation of all brain function persists after an
    appropriated period of observation and adequate
    trial of therapy
                 Brain Death
• Guidelines
  – detailed neurologic exam
     • off any sedative drugs
     • normothermic
  – confirmatory neuro exam 6-12 hours later
  – ? Confirmatory test
     •   apnea test
     •   radionuclide cerebral imaging
     •   Xe-CT cerebral blood flow
     •   4-vessel angiogram
                Brain Death
• Pronounced as soon as brain death occurs
• Cardiac arrest usually 72 hours after brain death
          Organ Donation

• Consideration of patients as organ donors should in
  no way interfere with treatment
• Required by law to report patients to Organ Bank
• “Presumed Consent”
• Patients failing criteria for whole organ donation
  frequently meet tissue donation criteria
• Heart Beating vs Non-beating donors
                 Donor Criteria
• General                      • Specific
  – no cancer except skin or      –   Cr < 1.8, BUN < 20
    brain                         –   No hypertension (K)
  – no systemic infection         –   No UTI (K)
  – no hepatitis                  –   No diabetes (P)
  – no h/o TB/syphilis            –   No visible lung damage by CXR
  – no h/o IVDA                       (Lu)
  – no prolonged                  –   PaO2 > 250 on <=100%
    hypotension or asystole       –   Nl EKG/no CAD (H)
  – no ARF/CRF                    –   Sputum clear on Bronch (Lu)
  – ? Age < 70                    –   Nl liver function tests (Li)
           Donor Management
• Concerns
  –   Temperature
  –   Hemodynamics/perfusion
  –   Oxygenation
  –   Urine output
                    Case

• Initial neuro exam no brain stem function
• VS: HR 100 SBP 120 RR 12 UOP 300 cc/hr
• Labs
  –   Hct 38
  –   ABG pH 7.48/32/112/24 (SIMV 14/600/40%)
  –   Na 147/K 3.0/Cl 108/Cr 0.4/BUN 18
  –   Tox + opiates
                      Case
• 12 hours later
  – VS: HR 120 SBP 90 RR 12 UOP 400 cc/hr
  – Neuro exam: no brain stem function
  – LABS
     • HCT 45
     • NA 167/K 4.5/Cl 118
     • pH 7.50/30/100/28 (SIMV 14/700/40%)
         Donor Management

• Maintain core temperature > 35 C
• Restore normal circulatory volume
• Support blood pressure
   – Hydration
   – Pressors (norepi or dopamine)
      • minimal dose possible
   – Treat hyperglycemia (>180)
      • insulin qtt
• Treat cardiac arrest agressively
          Donor Management
• Monitor electrolytes closely
  – if hypernatremia = D5 1/4 NS
  – if UOP > 500 cc/hr lower D5 and no KCL
• Maintain brisk diuresis
  – UOP 1-2 cc/kg
  – IVF
     • UOP 1-2 cc/kg use D5 1/2 NS c 20 meq KCL
     • UOP > 2 cc/kg use replacement IVF cc for cc
       Diabetes Insipidus (DI)

• Impairment of water conservation (pure water)
• Suspect Diabetes Insipidus
  –   Trauma involving hypothalamus/pituitary
  –   UOP > 500 cc/hr ( 7 cc/kg/hr)
  –   Na > 150 mEq/L
  –   Serum Osm > 310
  –   Low urine sodium
       Diabetes Insipidus
• Management
  – Replace free water (D5W or D5 1/4 NS)
  – Drugs
     • DDAVP
         – SQ or nasal
         – SQ 0.03 mg/kg
     • Pitressin
         – IV or SQ
         – IV 0.4 to 2.5 units/hr
     • Adjust UOP to 100-200 cc/hr
  – Follow serum Na
End Points of Therapy

 •   SBP: 100-120 mm Hg
 •   CVP: 8-20 mm Hg
 •   PAWP 12-15 mmHg
 •   PaO2: 80-100 mm Hg
 •   SaO2: > 95%
 •   UOP: 100-200 ml/hr (1-2 cc/kg)
 •   pH: 7.35-7.35
 •   Hgb: 10-12 g/dl
                Donor Labs
• Common
  –   Chemistry/CBC/ Coags
  –   ABO blood group
  –   CXR/EKG
  –   Urinalysis
• Uncommon
  –   LFT/Amylase/lipase
  –   Hepatitis/HIV/CMVscreen
  –   Urine /blood/sputum cultures
  –   Bronchoscopy/Echo/Catheterization
          Transplantation Facts
• Maximum organ preservation times
  –   heart/lung          4-6 hrs
  –   pancreas            8-16 hrs
  –   liver               12-24 hrs
  –   kidney              24-36 hrs
          Transplantation Facts
• Waiting /yr             • Transplants / yr
   –   Renal 35,253          –   Renal 10,891
   –   Liver 7,995           –   Liver 3922
   –   Heart 3,797           –   Heart 2361
   –   Lung 2,368            –   Lung 871
   –   Kidney/Panc 1488      –   Kidney/Panc 914
   –   Pancreas 339          –   Pancreas 110
   –   Intestine 87          –   Intestine (recently
                                 restarted)
              On Death Row, China's Source of Transplants
THE gruesome details of China's trade in human organs harvested from Death Row were
revealed in detail for the first time in Washington last week by a young doctor from the
People's Republic newly fled to the West.

As horror stories, they compare with the experiments carried out in Nazi concentration
camps. Prisoners are killed to order so that doctors can take their body parts, including - in at
least one case - while a victim's heart was still beating.

Wang Guoqi, 38, speaking to congressmen, confirmed that condemned men, and sometimes
women, are executed to order so that their organs can be transplanted into wealthy recipients
from the West and Far East.

Dr Wang was a burns specialist at the Paramilitary Police Hospital in Tianjin, under the
control of the People's Liberation Army, whose senior generals are believed to make large
profits from the trade. He claims that after execution, bodies were taken to the hospital
where every part that could be sold was stripped from the corpse
      Increasing Organ Donation
•   Identify key contact individuals
•   Develop hospital policy
•   Procurement agency visibility
•   Education hospital staff
•   Institute early on-site donor evaluation
•   Provision of feedback to hospital staff
•   Non-beating donors?

                              O’Brien, et al. Arch Surg, 1996
           Average Cost 1st Year
           •   Heart                    $253,200
           •   Liver                    $314,500
           •   Kidney                   $116,100
           •   Lung                     $265,900

• includes evaluation/candidacy/procurement/hospital/
  physician/follow up/immunosuppression
              Transplant Facts

•   Every 27 minutes someone transplanted
•   Every 18 minutes name added to waiting list
•   Every 144 minutes potential recipient dies
•   Transplant centers: 279
    – Kidney 251              Liver 118
    – Heart 166               Lung 93
    – Pancreas 121            Intestine 27
    Kidney Transplant Survival
• Living related (20%)
  – Perfect match 95%    • Cadaveric (80%)
  – Half match 90%         – Six antigen 90%
  – Zero match 92%         – all other 85%
                           – retransplant 70%
           Transplant Survival

                 1 - YR      3 -YR

•   Heart        84%      77% (graft)
•   Liver        80%      69% (graft)
•   Lung         75%      55% (graft)
•   Intestines   50%      50% (patient)
Healing of the biliary
anastomosis after liver
transplant most depends on


 A.   Length of donor and recipient bile duct
 B.   The amount of reperfusion injury induced
 C.   Intact portal venous flow
 D.   Intact hepatic arterial flow
 E.   Adequate immunosuprression
HLA matching is not necessary
for liver transplant



 True. Only ABO compatibility
          is required.
Wound healing is not
significantly delayed in patients
being treated with


    A.   Cyclosporine A
    B.   Prednisone
    C.   Azathioprine
    D.   Doxorubicin
    E.   Radiation Therapy
Initiation of steroids can be
delayed for induction therapy or
for oliguria after renal transplant.



           True.
Major cause of graft loss in
heart and kidney allografts is

    A.   Acute rejection
    B.   Hyperacute rejection
    C.   Vascular thrombosis
    D.   Chronic rejection
    E.   Graft infection
Incidence of acute rejection in
liver transplantation?



             50%
Major cause of mortality after
orthotopic liver transplant


     A.   Primary nonfunction of graft
     B.   Hyperacute rejection
     C.   Acute rejection
     D.   Chronic rejection
     E.   Infection

				
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