Management of the Cardiac Donor

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Management of the Cardiac Donor

• Monica Colvin-Adams, MD
• University of Minnesota
• Heart Failure/Cardiac Transplant

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What are the goals?

• Successful organ recovery
• Timeliness in order to save patient and minimize
  ischemic time
• Respectful organ recovery
• Optimize the function of each organ
• Place as many organs as possible
• Keep the doctors happy?

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Aim of Organ Transplant Breakthrough
Collaborative (OTBC)

• Save or enhance thousands of lives a year by
  maximizing the number of organs transplanted from
  each and every donorachieve an average of 3.75
  organs transplanted per donor.
• ---- Launched October 2005

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.7
Collaborative starts here
.65
.6
.55
Conversion rate
.5
.45
.4
Jun-03
Jun-04
Jun-05
Mar-02
Jun-02
Mar-03
Mar-04
Mar-05
Mar-06
Jun-06
Mar-07
Sep-02
Dec-02
Sep-03
Dec-03
Sep-04
Dec-04
Sep-05
Dec-05
Sep-06
Dec-06
Month/Year
Data source OPTN database as of 8/2007
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Organ Donation / Organ Transplantation
Breakthrough Collaboratives in Synergy
Organs Transplanted Per Month With 12 Month
Moving Average
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Close the Gap Reach Capacity, Achieve 35,000

• Capacity is reached when a DSA produces 75
  conversion rates
• 3.75 organs transplanted per donor and 10 DCD
  (with 2.75 OTPD)
• generates sufficient resources to transplant the
  resulting organ supply.

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Goal of the Transplant Growth and Management
Collaborative (TGMC)

• Save or enhance thousands of lives a year by
  maximizing the number of organs transplanted from
  each and every donor and building the necessary
  capacity within the Nations transplant programs
  to transplant 35,000 organs annually.
• Launched in October 2007

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Learning Objectives

• Define hemodynamics and the meaning of the
  various measurements
• Describe the hemodynamic concerns that arise with
  managing patients experiencing brain death
• Discuss the tensions between organ procurement
  groups related to varying hemodynamic targets
• Identify strategies to support the donor while
  yielding the greatest number of viable organs for
  transplant

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Donor Assessment and Evaluation
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Donor Assessment and Evaluation
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And then there are the issues surrounding the
patients death. . .

• Cause of death potential for organ trauma
• Potential aspiration risk of lung injury
• Brain injury associated with myocardial
  suppression
• Diabetes insipidus fluid losses build quickly
• Intubated, ventilated patient - risk for pneumonia

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Assessment and Evaluation

• Demographics
• ABO
• Cause of brain death
• Time of declaration
• Viral serologies
• Substance use

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Donor History

• Thoracic trauma
• Hemostability
• Pressors/inotropes
• Down time (duration of cardiac arrest)
• CPR
• Hypotension

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Donor Issues that may affect the outcome of the
recipient

• Ischemia Time
• Age
• Size
• Cause of Death
• Substance Abuse

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Ischemic Time

• Four hours is acceptable
• Prolonged ischemic time associated with mortality
  and possibly graft vasculopathy after heart
  transplant, especially when complicated by older
  donor, increased resource utilization-conflicting
  data
• Longer ischemic times may be acceptable in
  pediatric patients
• Ischemic injury and contraction band necrosis
• Preventive measures post-conditioning, warm
  blood cardioplegia
• Increased ischemic time allows for prospective
  CM, LVAD patients

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Age

• Patient specific approach
• Up to age 50-55
• ISHLT registry increased mortality with older
  donors
• Relationship between donor age and CAV (?) age
  related endothelial dysfunction
• RV failure due to stiffer hearts
• Donor age gt 50 is a predictor of perioperative
  and long-term mortality

Del Rizzo et al. JHLT 1999
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Analysis of Ischemic Time and Age UNOS analysis
Russo et al. Cardiothoracic Transplantation 2007
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Analysis of Ischemic Time and Age UNOS analysis
Russo et al. Cardiothoracic Transplantation 2007
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Size Matters

• Donor mismatch greater than 30 is a
  contraindication
• Undersizing
• Pulmonary Hypertension
• Oversizing
• Acute MI and urgent LVAD implantation
• Multiple cardiac surgeries with adhesions
• Cachexia

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Case Donor Management Goals

• SBP gt90
• CVP 4-8
• Final PO2 gt350
• PH 7.35-7.45
• Glucose lt200
• Temp 96.8-99.6
• UO 1-2cc kg/hr
• NA lt160
• Total Fluid Balance _at_ DM and OR

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The Deceased Organ Donor
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Transplant SurgeonsNot All On the Same Page
CVP 6-10
The more the merrier
CVP 2-5
CVP 10-12
Keep it perfused
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What do they really mean?
Fluid excess can stress the heart
Fluid excess can cause alveolar infiltration and
render lungs untransplantable
Hypoperfusion can stimulate ATN, injuring the
kidney and complicating recovery
The liver is less volume sensitive except in
severe volume depletion or shock
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Whats a Donor Coordinator to Do?
Cardiac Surgeon
Liver Surgeon
Donor Coordinators
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Yellow Port PAP/PCWP
Distal opening Pulm. Art.
Blue port CVP/RAP
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Brain Death
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Physiologic Effects of Brain Death
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Effects of Brain Death
Martin Smith JHLT 2004
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Aggressive management

• Early ID of donors
• Admit to ICU
• PA catheter
• IVF resuscitation
• VP to maintain MAP gt70 if IVF fail
• Hormonal treatment when dopamine or DBE gt 10
  mcg/kg/mn
• Management of complications of brain death

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Thyroid Hormone

• Decreased T3 (triiodothyronine) and conversion of
  T4 (thyroxine) to T3 after brain death
• Results in lactic acidosis, hypotension
• Thyroid hormone is a positive inotrope
• Shown to reverse lactic acidosis in experimental
  model

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Hormone Replacement Therapy

• Increases Organ Salvage

• Improves Outcomes

• N 123
• Aggressive management T4
• Organ recovery 3.9 /- 1.7 vs. 3.2 /- 1.7,
  P0.048
• Retrospective study

• UNOS analysis
• Addition of T4
• 46 decrease in risk of death at 30 days
• 48 decrease in risk of graft dysfunction

Salim et al. Clinical Trans 2007
Rosedale et al. Transplantation 2003
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Interventions
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Importance of Serial Echos

• 16 patients with WMA
• 13 with EF lt 50
• 12 patients improved EF between echos 1 and 2
• Responsiveness to dobutamine is acceptable

Zaroff et al. JHLT 2003
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Hemodynamics
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Hemodynamics of Forward Flow
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Hemodynamics of Forward Flow
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Hemodynamic Monitoring
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Hemodynamic Measured Values
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Hemodynamic Goals

• SBP gt100 lt150, DBP gt50, lt90
• HRlt100 gt50
• CVP 4-6
• UO 1-2cc/kg/hr
• Sustained hypotension increases inflammatory
  response from previous pro-inflammatory
  activation by sympathetic discharge associated
  with brain stem herniation (Arbor, 2005)

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Volume Resuscitation

• Resuscitation

• Maintenance

• NaCl
• CVP lt4, Na lt150, UO lt1-2cc/kg/hr
• D5W-Na gt150
• Colloids-avoid 5 albumin

• IVF
• Na lt150-D51/2 NS
• Na gt150-D5W
• Addition of K per serum K levels and frequency
  of K replacement
• Rate-adjust to maintain CVP 4-6, UO 1-2cc/kg/hr

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Hypotension Hypertension

• SBP lt100, HR lt100
• Dopamine-max 20 mcg/kg/min
• SBP lt100, HR gt100
• Neosynephrine-max 200mcg/min
• Fluid Resuscitation
• NaCl- bolus if CVP lt4, Na lt150
• D5W-Na gt150
• SBP lt100, EF lt40, CVP gt6
• Dobutamine

• BP 150/90, HR gt100
• Labetalol 10-20mg IVP Q10min, max 300mg
• Esmolol gtt 50mcg/kg/min-titrate max
  200mcg/kg/min
• BP 150/90, HR lt100
• Nipride gtt
• 0.1mcg/kg/min-titrate max 8mcg/kg/min

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Arrhythmias

• Tachycardia in absence of hypotension
• Diltiazem
• Esmolol
• Labetalol
• Arrythymia-atrial/ventricular
• Diltiazem
• Esmolol
• Amiodarone

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Hemodynamic Impact of Commonly Used Meds in Donor
Management
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Pulmonary

• GOALS

• Interventions

• SaO2 96, PaO2 100 on 40 FiO2, PCO2 35, CVP 4-6
• PaO2 gt350 on 100 FiO2
• CXR clear
• UO 1-2cc/kg/hr

• Lasix, Torsemide, Bumex
• Aggressive pulmonary toilet (Link vest/CPT vest
  Q2hrs)
• Early bronchoscopy
• Aggressive Ventilator management

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Ventilatory Management

• TV 10cc/kg
• PEEP 5cm H2O
• FiO2-adjust keeping SaO2 gt96, PaO2 gt100. Keep
  FiO2 at lowest setting
• I/E Ratio 12
• Rate-PCO2 x rate/40
• End expiratory pause 0.5 sec
• Sigh 1.5xTV Q2hrs (if able)
• PIP lt30

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Pulmonary Recruitment Maneuvers

• Anesthesia bag w/manometer
• Inflate and deliver breath to 40cm pressure hold
  x45 secs as tolerated-may repeat hourly PRN
• PEEP 10 x2hrs

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Pulmonary medications

• Albuterol/Atrovent neb Q4HRS, Q2HRS PRN
• Solumedrol 2G IV (30mg/kg lt70kg) followed by 1 G
  (15mg/kg lt70kg) in 12 hrs
• Dopamine 3mcg/kg/min (if not infusing, absence of
  HTN)
• Zosyn 3.375G IV Q6HRS
• Narcan 8mg IVP-use with quick herniation
  syndromes, not effective in anoxic/occlusive CVA

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Neurogenic Pulmonary Edema

• Common occurrence with brain death
• Within minutes to hours of CNS insult
• Blast Theory
• Permeability Defect Theory

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Neurogenic Pulmonary Edema Blast Theory

• Massive sympathetic discharge
• Systemic arterial hypertension, peripheral
  vasoconstriction, increased pulmonary arterial
  pressure and pulmonary mircovascular
  vasoconstriction
• Pulmonary congestion with development of
  pulmonary edema
• Endothelial damage

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Permeability Defect Theory

• NPE caused by neurologic increase in capillary
  permeability
• Sympathetic stimulation affects vasculature
  permeability from altered endothelium allowing
  fluid to enter the interstitial space

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Management of NPE

• Narcan
• 8 mg IVP x1
• -Shown to prevent/reduced NPE in sheep (Peterson,
  et al. 1983)
• -Suggests role of endorphins in alteration of
  pulmonary capillary permeability
• -Controversial
• -May increase spinal reflexes

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Diabetes Insipidus

• Hypothalamic/hypophyseal loss of function
  limiting posterior pituitary ADH production
• UO gt 250cc/hr x2 hours
• Vasopressin gtt
• DDAVP IVP
• Crystalloid bolus

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Anaerobic Metabolism

• Levothyroxine (T4) gtt
• Any remaining hypothalamic/pituitary function too
  low to maintain adequate hormone levels causing
  anaerobic metabolism and mitochondrial
  dysfunction
• Increased lactate and pyruvate levels with
  decreased cortisol levels are associated
  w/increased vasopressor/inotropic requirements
  and decreased myocardial contractility

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Anaerobic metabolism cont.

• T4 (Levothryoxine)
• T4 400mcg/500cc D5W
• Pre-medicate in rapid succession in order as
  follows
• 1 amp D50 IVP x1
• 2 G Solumedrol IVP x1 (If 1 G already given as
  ordered above give an additional 1 G IVP)
• 20U regular insulin IVP X1
• 20 mcg T4 IVP x1
• Start T4 IV gtt at 10mcg/hr, max 50mcg/hr. Rate
  increases determined by Donation Coordinator.

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Coagulopathy

• Common occurrence with direct brain injury (GSW,
  penetrating/blunt injury)
• -rapid consumption of circulating clotting
  factors from release of thromboplastin,
  fibrinogen and tissue plasminogen (DIC)
• Dilution
• -large volume resuscitation with colloids and
  crystalloids
• -not as common

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Coagulopathy Management

• -FFP
• -platelets
• -cryoprecipitate
• -vitamin K IV

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Hemodynamic Strategy 1Optimize Fluid Status

• Volume resuscitation important before initiating
  pressors
• Target wedge pressure (5 - 10 mmHg)
• Target CVP (4 - 7 mmHg)
• Target SVR (800 - 1200 dynes/sec/cm-5)
• Consider replacing urine output ml/ml with D5W
  0.45NaCl 20 mEq KCl/liter

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Hemodynamic Strategy 2Optimize Cardiac Output

• Target cardiac index gt 2.5 L/min/m2
• Hormonal resuscitation
• Methylprednisolone (SoluMedrol)
• Vasopressin
• Triiodothyronine or thyroxine
• Vasoactive infusions
• Dopamine
• Dobutamine
• Levophed
• Neosynephrine

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Hemodynamic Strategy 3Optimize Blood Pressure

• Pressure Flow x Resistance
• Blood Pressure C.O. x SVR
• Vasoactive infusions effecting blood pressure
• Dopamine
• Dobutamine
• Levophed
• Neosynephrine

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Summary

• Aggressive management results in improved organ
  availability
• Aggressive management improves outcomes
• Reassess!
• Involve the transplant center

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Case

• 22 yo male potential donor
• Motorcycle accident
• OPO called prior to brain death
• History of occasional cocaine use, ETOH
• No medical history
• No significant family history

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Case Exam

• BP 87/60 HR 115 O2 sat 100
• No JVD, Lungs clear, trace edema
• What initial steps should you take?

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• Patient receives aggressive hydration while
  undergoing assessment
• 8 hours later, BP still 85/60 HR 118
• What next?

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Echo

• EF probably normal, but concern for basilar
  hypokinesis, mild RV dilatation pictures are
  limited
• RA 12 PA 34/15 PCWP 15 CI 4
• What are your options?
• Other potential issues patient is CMV ,
  potential recipient is CMV-
• What if patient were HCV

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The other side

• 55yo patient with ischemic cardiomyopathy
• History of MI
• PA 70/45 prior to VAD, now 45/22 with PCWP 17
• BMI 33 kg/m2
• What are the considerations for this patient?