The Physicians Role in Organ Donation

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The Physicians Role in Organ Donation

• Michael Moncure, MD
• Director of University of Kansas Hospital Trauma
  Center
• Associate Professor of Surgery Anesthesia

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Objectives

• Trauma Surgeons
• KU Initial Results
• Organ Donor Collaborative I
• Organ Donor Collaborative II
• Donor Management
• Catastrophic Brain Injury Guidelines
• Conclusion

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Trauma Centers ? Level I Level II
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Organ Donation

• Unlike other areas of Trauma no published
  guidelines
• Literature not replete with evidence-based
  methodology
• No course to take to bring you up to speed
• Hundreds of different practice models with
  disparity of results
• Important Model is the rapid cycle of change
  (PDSAs)

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Grieving

• Trauma situations are different than most
  tragedies
• Last time patient seen they were healthy
• Usual grief processes have occurred including
  denial..
• Requires constant communication with family to
  allow them to start to process the situation
• The more involvement possible with individuals
  familiar with grieving the better

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The Need
United Network of Organ Sharing reporting data,
2008
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The Problem

• Over 98,000 people on the national wait list
• Every day 17 people die waiting for an organ
• Every 10 minutes another name is added

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Before the Initiatives
ZERO donors in the 1st 7 months of 2002
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Before the Initiatives 2002

• Hospital wide consent rate 41
• Trauma consent rate 44
• Organ donation referral rates 88
• Timely referral rate lt 50
• 25 of requests were by untrained requestors
• Lack of accountability commitment

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Goals of Collaborative II

• Organs transplanted per Donor 3.75
• SCD 4.3
• ECD 2.5
• DCD 2.75
• Hearts transplanted 40
• Lungs transplanted 40
• DCD donations 10
• Kidneys in ATN lt10

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Collaborative II Initiatives

• Intensivist Involvement
• Catastrophic Brain Injury Guidelines
• Advanced Practice Techniques ( Narcan )

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Critical Care Involvement in the Management of
Organ Donors
Dr. Michael Moncure Director, Trauma
Services University of Kansas Hospital Lori
Markham, RN, MSN, CCRN, CPTC Manager of Organ
Procurement Services Midwest Transplant Network
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The Patient

• 16/m/ca
• MVC with ejection
• Found at scene unresponsive w/ agonal resp
• Intact circulation
• Intubated and transferred to trauma center

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ED Admission

• Arrived with stable VS, GCS3
• No cranial reflexes
• Occasional respiratory effort
• CT head multiple contusions, SAH, SDH, effaced
  cisterns, bilat skull fractures
• CT chest/abd bilat chest contusions/infiltrates,
  possible aspiration
• Large back hemotoma from interscapular region to
  lumbar level with probable active hemorrhage

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Hospital Course

• Admitted to SICU
• Throughout the night he lost his reflexes
• Sisters birthday so pronouncement was delayed
  until next day
• Managed by trauma service for next 24 hours
• Pronounced on day 2 at 1020
• Consent obtained for donation

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Donor Evaluation

• HR 130s
• BP 90/40 Dopamine 20mcg/kg/min
• Initial ABG 7.16, 46.3, 72, 22.6, BE -7
• PRVC 20, TV380-400, 100, 20PEEP
• CXR diffuse alveolar opacities, RUL
  atelectasis/collapse, small right pneumothorax
• Over last 24 hours gt27,000ml urine
• Multiple liters Albumin given
• Initial PAWP after swan placement 30

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Donor Evaluation

• Initial Labs
• Na 180
• K 1.6
• Phos lt1.0
• Mg 0.6
• INR 1.9
• H/H 5.2/14.7
• Plt 70

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Donor Management/Outcome

• Aggressive ventilator management/recruitment
  strategies
• Meticulous fluid and electrolyte administration
• DI management
• Blood products
• Continued donor management for 38 hours before
  proceeding to OR
• Heart, liver, pancreas, kidneys

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Catastrophic Brain Injury GuidelinesWhat is
good for the patient is good for the donor
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How do we tackle the overall collaborative goal
of 3.75?

• Reviewed recent cases in which donor stability
  was in question
• Identified that many issues stemmed from pre-OPO
  management
• Critical Care Task Force identified area of
  concern (Intensivists from major hospitals in MTN
  service area)
• Reviewed high risk physiologic areas

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Key Components of Early Intervention

• Get critical care involved early!
• Blood pressure support
• Hemodynamic monitoring
• Adequate hydration
• Vasopressor support
• Monitoring urine output
• Treating DI
• Adequate hydration

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Key Components cont

• Adequate oxygenation
• Ventilator management
• Aggressive respiratory hygiene
• Bronchodilators
• Other areas of concern
• Electrolyte management
• H/H Coagulation factors
• Temperature

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Additional Thoughts

• Simple, one page document
• Non-intimidating
• Help the non-intensivist physician or nurse
  identify and appropriately manage common
  derangements

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Feedback from nursing staff

• Easy to understand
• Gave them goals to shoot for
• Trigger for critical care consult
• Teaching for residents/med students

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Real Time Results

• Used on 7 different patients
• 3 went to rehab or home
• 1 family denied consent/pt stable
• 3 became organ donors resulting in 17 organs
  transplanted (5.66 O/D)

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CBIG Newest Data2008

• With CBIG vs. Without CBIG
• 36.4 vs. 8.3 Survival
• 2.6 vs. 1.4 GOS
• 36.4 vs. 20.3 Went on to Donate

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What has KU done?

• Presented to critical care commission
• Approved to become official order set
• To be utilized on all patients with an identified
  brain injury
• When implemented it will automatically trigger
  critical care consult

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Critical Care Involvement in the Management of
Organ Donors
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In the Old Days

• Once consent was obtained the OPO assumed care of
  the donor
• The critical care physician walked away
• The donor was managed by OPO medical director,
  who is a transplant surgeon with little critical
  care experience
• This resulted in sub-optimal outcomes

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It is dawning on the transplant community that
management of the organ donor is a critical care
function.
Paul W. Nelson, M.D. MTN Medical Director Kidney
Transplant Surgeon
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Rationale

• Current results were unacceptable
• National organs transplanted per donor 3.06
• Goal 3.75 OTPD
• MTN DSA 2.83 OTPD
• Wanted to impact the local national wait list
• Hypothesis Intensivist involvement would
  increase OTPD

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Methods

• Formal critical care consult obtained on donors
  occurring in collaborative hospitals
• Real time on-site consultation
• Hemodynamic monitoring
• Advanced ventilator management
• Guiding donor management throughout case
• Compared to donors during same time period where
  intensivist not involved

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End Points Analyzed

• Organs transplanted per donor
• of time met predetermined donor mgmt goals
• MAP, hemodynamic parameters, PFR, pressor dosage,
  met w/in 12 hours
• Thoracic recovery rates
• ATN rates in kidneys recovered transplanted

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Initial Results

• 12 cases of intensivist involvement compared to
  12 in which critical care not involved
• OTPD 4.16 vs 2.66 in comparison group
• 700 increase in lungs
• 366 increase in hearts
• DMG met 83 vs 33

No, this is NOT a typo
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Took it one step furtherIntensivist
involvement in ALL cases, either remotely or
primarily (via phone, on-site)
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Something to Shout About
4.01
3.58
3.53
3.18
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Something to Shout About
WOW look at this!
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Conclusions

• Overall OTPD higher with intensivist involvement
• gt250 increase in lung transplant rate
• 80 increase in of time donor management goals
  were met
• 100 decrease in ATN rates in donors managed by
  intensivists

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Key Components to Effective Donor Management

• EARLY Intervention (CBIG utilization)
• Hemodynamic monitoring is a must!
• Swan, SVO2, PiCCO Catheter w/ appropriate
  interventions
• Adequate assessment of pulmonary status
• Bronchoscopy
• Aggressive ventilator management
• Recruitment strategies
• Intricate fluid and electrolyte management
• Intense FOCUS on above areas IMMEDIATELY!

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Where we are today

• 24/7 on call intensivist for all donors in MTN
  DSA
• Participate in monthly case review at MTN
• Monthly continuing education of Organ Procurement
  Coordinators
• Increased coordinator competencenot so likely to
  rush to OR
• Collaboration on current studies
• Narcan, SVO2, Lactate, CBIG
• Our data has been presented at SCCM and World
  Transplant Congress
• Set the precedent for intensivist model across
  the country
• Participation in several national Intensivist
  workshops to increase need for involvement in
  donor management

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Donor Management Goals

• MAP gt 60 (or age appropriate if pediatric donor)
• C.I. gt 2.5
• Urine Output 0.5-3cc/kg/hr
• pH 7.30 7.45
• PF Ratio gt 300, if lt 60 PFR should be gt 350
• Pressor dose within specified range
• These goals should be met within 12 hours of
  consent/pronouncement (whichever comes last)

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The POWER of Donor Management Goals

• We meet our goals 30 of the time
• When goals are met (within 12 hrs)
• 3.98 OTPD
• 40 heart transplantation rate
• 43 lung transplantation rate
• When goals are NOT met (within 12 hrs)
• 3.08 OTPD
• 31 heart transplantation rate
• 19 lung transplantation rate
• When goals are NEVER met
• 2.63 OTPD
• 35 heart transplantation rate
• 2 lung transplantation rate

January 1 December 31, 2007 169 cases (DCD
excluded)
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Utilization of Recruitment(High PEEP, Open Lung)

• 89 cases (2005-2007)
• Initial mean PFR 270
• Final mean PFR 336
• Mean increase 66
• OTPD 3.96
• 29 lung donors
• 60 heart donors

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Utilization of APRV

• 45 cases (2005-2007)
• Initial PFR 213
• Final PFR 321
• Mean increase 108
• 3.51 OTPD
• 23 lung utilization

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Holding the Gains..But More Improvement is
Needed
Collaborative Starts Here
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Collaborative starts here
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Family Support Communication

• On-site early
• Huddle with team

• Communication tool
• Scripting
• Team approaches

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Phase I Anticipatory Guidance ______ has
suffered severe damage to his brain. Things look
very bad at this time. We are doing everything we
can to help him recover.   NOTE When the
family asks, what are our options or what is
going to happen next, remember, they may not be
asking a leading question about organ donation.
The family may be asking you to save their loved
one.   Phase II Patient condition
worsens Despite our best efforts there has been
no improvement. In fact, his condition is
worse.   Phase III Brain death testing
planned There appears to be no brain function
left. We need to confirm this with a series of
tests   Phase IV Brain death testing
completed We have finished the testing and
found that ______________ has permanently lost
all brain function. This means that he has died.
(MD, RN and MTN coordinator present).   Phase V
Initial donation discussion MTN coordinator
(MD and RN present) initiates discussion of organ
donation when timing is appropriate. What if the
family brings up donation? Tell them My
commitment is to care for your loved one. I will
call someone who is an expert in that field and
ask them to speak with you.
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Donation Requesting Best Practices

• Familys who first have been communicated with
  effectively throughout the admission are five
  times more likely to donate
• Donation is not mentioned to the family until the
  family understands the grave prognosis or brain
  death has actually occurred

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Making Effective Requests

• Elements of effective requests
• Timely consult to MTN
• Team huddle to discuss family POC
• Utilizing an effective requestor
• Following the family POC
• Reassessment, if required
• Why is effective requesting so important????

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Effective Requesting Saves Lives

• Brain dead donors
• Effective requests 78 consent rate
• Ineffective requests 55 consent rate
• DCD donors
• Effective requests 75 consent rate
• Ineffective requests 10 consent rate

Midwest Transplant Network 2007
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Initial Response/Final Response
Initial response 67 consents 21 declines
Final response 77 consents 11 declines
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Lives Saved by Reapproaching Declines

• Declines decreased 21 to 11
• 10 additional donors
• 48 conversion rate on reapproaches

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Duties of a Physician Champion

• Resource
• Advocate
• Promote collaboration
• OPO advisor
• Support team approaches, reapproaches
• Support familys goals for complete donation
• Give the family time give the OPO time

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Donors Dont Always Look Like Donors

• 54 y/o woman
• OLT for autoimmune hepatitis
• ICH post OLT
• R/O for liver and kidney donation

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Actual Donors
United Network of Organ Sharing reporting data,
2008
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Unfortunate Case14 year old Male
accidental GSW wound to head , coding on
presentation to first facility. Resuscitated and
transferred to our Center. Family was entrenched
on notion that he was not brain dead. Lots of
News coverage. Required lots of resources and
support to get through including OPO.
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Conclusion

• Trauma deaths are different from medical deaths
• All personnel need to know issues involved with
  successful procurement
• Family requires a lot of attention and resources
  prior to pronouncement of death
• If you ask them, donor families will tell you
  they received something positive from the
  experience
• Keep in touch with literature
• Modernize practice to fit what is successful in
  other venues
• PDSAs
• Collaborative approach is fun, rewarding and
  optimal for all the players involved