ADVANCED PRACTICE: INTENSIVIST INVOLVEMENT

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ADVANCED PRACTICEINTENSIVIST INVOLVEMENT

• Michael Sedrak, M.D.
• Medical Director - OneLegacy Physician Group

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Question to Run On

• What steps can intensivists, other critical care
  leaders, and OPOs take to strengthen their
  working relationship to achieve the goals of
  increased donation and transplantation?
• What resources are available at the OPO, donor
  and/or transplant hospitals to support the
  donation process?

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Why Is Organ Donation Important?

• Over 6,000 people in the U.S. with end-stage
  organ failure die every year while waiting for an
  organ transplant
• On average, 30.8 additional life-years are gained
  with each organ donation
• The Life-Years Saved by a Deceased Organ Donor MA
  Schnitzler, JF Whiting,
• et al American Journal of Transplantation Volume
  5 Issue 9 Page 2289 - September2005

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Goals

• Conversion rate ? 75
• Organs transplanted per donor ? 3.75

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Two Different Models

• Procurement Transplant Coordinator (PTC) makes
  organ donor management decisions
• Medical Director (OPO) determines final medical
  suitability for donation
• Intensivist takes organ donor management calls

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Strategies for Success

• Take the Time Required to Get The Best Outcome
• Actively Involve Critical Care Specialists in
  Donor Management
• Treat Every Donor As a Lung Donor

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ICU Management

• Ongoing Critical Care management
• Increases the number of organs recovered per
  donor
• Improves performance of organs once transplanted
• Collaborative practice is paramount for best
  outcome
• Wheeldon DR, et al, Transforming the
  "unacceptable" donor J Heart Lung Transplant,
  1995.

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Organs Transplanted per Donor
Moncure, Organ Donation and transplant alliance,
San Francisco November 2006
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At OneLegacy
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Increasing Organs per Donor

• Get critical care involved early!
• Physiologic Management
• Individualize care to which organs will be donated

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Increasing Organs per Donor

• Achieve physiologic endpoints
• Provision of technical support
• Provision of knowledge skill to collaborate

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Cardiac Management

• Hemodynamic monitoring
• Assist with invasive monitoring when indicated
• Blood pressure support
• Adequate hydration
• Vasopressor support
• Treat hypotension and hypovolemia
• H/H Coagulation factors
• Maintain Hgb gt 10 g/dL

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Pulmonary Strategies

• Chest PT and tracheobronchial toilet
• Adequate oxygenation
• Ventilator management
• Aggressive respiratory hygiene
• Bronchodilators
• Bronchoscopy

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Other Areas of Concern

• Thermic resuscitation
• Treat hyper/hypothermia
• Volume, endocrine, substrate resuscitation
• Correction of electrolyte abnormalities
• Monitoring urine output
• Treating DI
• Adequate hydration

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Other Areas of Concern

• Hormone replacement therapy
• Maintain normoglycemia
• Continuation of antibiotics

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Increasing Organ Availability

• Aggressive management increases lung recovery and
  eventual performance
• Small volume resuscitation track CVP (lt8mmHg)
• Narcan protocols for improved graft performance
  in recipient
• Cummings et al Positive effect of aggressive
  resuscitative J Transplant Co, 1995 .

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Increasing Organ Availability

• Aggressive management increases lung recovery and
  eventual performance (cont)
• Early and aggressive bronchoscopy for secretion
  management
• (removal of foreign bodies, assessment of degree
  of aspiration, assessment of microbiology)
• Cummings et al Positive effect of aggressive
  resuscitative J Transplant Co, 1995 .

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Lung Management

• Awaiting Transplant

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Cause of Brain Death

• Traumatic
• Explosive brain death may have more circulatory
  impact
• Intubation may be in the field
• Can be associated with aspiration

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Cause of Brain Death

• Non-traumatic
• Non-explosive brain death may have fewer
  circulatory effects
• Intubation usually under controlled circumstances
• However, may spend more time on the ventilator
  prior to brain death

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Brain Death

• Labile blood pressure
• Increased preload on cardiac system
• Develop pulmonary edema
• Hormonal flux
• Increased pulmonary capillary reserve
• Enhanced PA blood flow
• Structural injury to endothelium, causing leak
• Increased back pressure from overloaded left
  atrium

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Brain Death

• Catecholamine changes result in
• Altered organ perfusion
• Increased vascular resistance
• Increased myocardial work
• Development of free radicals which damage tissue

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ISCHEMIA REPERFUSION Role of Improved Perfusion

• In brain dead pts, increased catecholamine levels
  lead to increased tissue level ischemia
• Cellular oxygen deficit may lead to global
  energetic failure
• Low ATP leads to activation cytosolic calcium
  leading to disruption of cell function and
  structure by intra-cellular enzyme pathways

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ISCHEMIA REPERFUSION Role of Improved Perfusion

• Oxygen free radicals participate in damaging cell
  membranes and vascular endothelium
• Utilize skills learned from Early Goal Directed
  Therapy

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ISCHEMIA REPERFUSION Role of Improved Perfusion

• Bx of kidneys from brain dead patients compared
  to controls increased non-soluble and soluble
  mediators of inflammation
• Animal models suggest that using T3 to limit
  pressor requirements decreases lactate production
  and serum FFA level (reflective of anaerobic
  metabolism)
• Novitzky D. Donor management state of the art.
  Transplant Proceedings 1997 293773-5,
• Depret J,et al. Global energetic failure in
  brain-dead patients. Transplantation 1995
  60966-71,
• Novitzky D. Detrimental effects of brain death
  on the potential organ donor. Transplant
  Proceedings 1997 293770-2

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Ischemia Reperfusion Immune Consequences of Shock

• Ischemia leads to cellular increase expression of
  MHC class II molecules (leads to increased T cell
  recognition in recipient)
• Severe episodes of hypotension in deceased renal
  donors increases rates of DGF/ATN
• DGF and ATN are associated with increased risk of
  acute cellular rejection and consequently,
  chronic rejection
• Nagano H, Tilney N. Chronic allograft failure
  the clinical problem. The American Journal of
  Medical Sciences 1997 313305-309

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Ischemia ReperfusionSummary

• One can infer from renal transplant data that
  limiting ischemia at a cellular level improves
  graft performance and longevity
• Better donor management restoration of normal
  physiology- modifies the immunological
  consequences of brain death

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Assessment

• Chest Xray
• Should be done early and repeated every 2-4 hours
  until donation ruled out
• Not sensitive for small changes
• AP supine films can be misleading
• Unilateral infiltrate does not rule out donation

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Assessment

• Oxygen challenge
• Have donor on lowest possible PEEP (lt5)
• Increase oxygen level to 100
• Wait 15-20 minutes to allow for equilibration
• PaO2 on 100 gt 400 makes for an acceptable donor
• Return FiO2 to baseline levels after test
• Repeat every 2-4 hours

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Assessment

• Bronchoscopy
• Provides best way to evaluate airways for
• Secretions/plugs
• Direct visualization for aspirated stomach
• Contents/blood
• Direct airway sampling for cultures

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Assessment

• Microbiological assessment
• Infection in the recipient associated with donor
  culture
• Tracheal cultures may not adequately reflect
• Lower respiratory tract flora
• Fungus/yeast may rule out lung donation

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Management

• Maximize ventilation through recruitment
  strategies
• Institute other strategies for lung recruitment
  and management
• Naloxone
• Solumedrol
• Hormone replacement (T4 protocols)
• Involve the respiratory therapist early and often

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Management

• Wait, wait and wait some more
• Do not rule out lungs until you are sure that the
  acute alterations due to brain death are over and
  under control
• Routine patient management
• Avoid fluid overload
• Aggressive pulmonary toilet
• Early and potentially repeated bronchoscopy

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Question to Run On

• What steps can intensivists, other critical care
  leaders, and OPOs take to strengthen their
  working relationship to achieve the goals of
  increased donation and transplantation?
• What resources are available at the OPO, donor
  and/or transplant hospitals to support the
  donation process?