Preserving the Donation Opportunity

Shared Goals

• Maintain urine output• Maintain oxygenation• Maintain normothermia• Maintain normoglycemia• Prevent/treat infection

Optimize organ perfusion and medical suitability

What are the most common Challenges

1. Hypotension (hypovolemia, vasodilatory shock)

2. Diabetes Insipidus / Hypernatremia

3. Oliguria

4. Metabolic (acid/base, electrolytes, glucose)

5. Hypoxemia, Ventilator settings

6. Hypothermia

Hemodynamics

•Goal: Maintain Systolic BP>90; CVP of 6-8 mmHg

•Hypotension /hypertension•Heart rate fluctuations-dysrhythmias•Coagulopathy

•Interventions-CVP < 6 and (H &H) normal Lactated Ringers or Normal Saline fluid bolus of 500 cc over 30 minutes for SBP < 90 mmHg.-CVP < 6 and (H&H) < 8, then administer 1-2 units of PRBC’s

Vasoactive IV fluids/drips

• Vasopressors commonly used are: – Dopamine

– Epinephrine

– Neosynephrine

– Levophed/Norepinephrine

– Vasopressin (AVP) low dose

• Goal: Maintain PO2>100mm Hg and pH7.35-7.45

• Potential Problems:

– Hypoxemia – Acid Balance Disturbances– Neurogenic pulmonary edema

• Interventions:

– Tidal volume of 7-10cc’s/kg – Steriods – Suctioning; in-line treatments – Therapeutic bronchoscopy– PEEP (5)

Oxygenation

Acid- Base and Electrolytes

Goals• pH -7.35-7.45• Electrolytes- Na, K, Ca, Mg, P - WNL• Glucose- < 150• U/O 1-3 ml/kg/min

Interventions• Adjustments of Vent and/or Na Bicarbonate IV • Appropriate IVF – LR, NS, .5 NS (Depending on Na, K, Gluc)• Appropriate supplementation FOR K+ ,Ca++, Mg++,P+++

• Insulin –bolus and/or continuous drip• DDAVP or Fluids, Diuretics, Mannitol

• Goal: Maintain Urine Output 1ml/kg/hr in the Adult or 2ml/kg/hr in the Child

• Potential Problems: – Diabetes insipidus

– Hyperglycemia

• Interventions:– Volume replacement

– DDAVP / vasopressin

– K+ replacement

Urine Output

Goal: Maintain Core Temperature Between 97-100 F

• Hypothermia

• Hyperthermia

• Interventions

• Heating/cooling blankets

Temperature

Other IV fluids (drips)

• Dobutamine--used to treat heart failure, may be combined with dopamine. May be used as a pressor in pediatric patients

• Vasopressin--used to treat shock, diabetes insipidus; enhances the effectiveness of other vasoactive medications. May be used as a pressor in pediatric patients

• Nipride--used to treat hypertension • Esmolol, Verapamil, Adenosine---used to correct

irregular heartbeats

InfectionGoal: Ensure Absence of Infection

Use of Broad Spectrum Antibiotics

Obtaining cultures as needed

Blood

Sputum

Urine

Monitor WBC’s

TemperatureGoal: Maintain Core Temperature Between 97-100 F

Hypothermia

Hyperthermia

Family Preparation

What can You Do

• Check yourself

• Offer open honest communication

• Have them tell you what they understand the situation to be

• Offer them support by involving pastoral Care

Allowing families time to process the death and brain death explanation is IMPORTANT

“Decoupling” - separating the brain death explanation from the request for organ donation

Decoupling may be a valuable tool in obtaining consent for donation

Siminoff, et al concluded that the most important factor in obtaining consent was time spent with the OPO

Creating the Bridge

Hospital is an advocate of organ donation Patient Care Conferences Timely notification Appropriate requester Families satisfaction with quality of care Frequent communication Time with loved one Understanding of brain death

*Source: JAMA July 4, 2001 and Collaborative High Leverages Changes

Pre-request Conference

• A sensitive, timely and informed consent

• How to accomplish…. “huddle” with hospital staff to determine: The key decision maker Family’s understanding of the grave prognosis Review communication plan Determine who, when, where and how the communication will

occur Revise the plan as needed

Guiding principles

•For the family, their grief and loss are primary, not the donation— and all of our actions are guided by this awareness.

•We are not taking something from families. We are giving information to families about an important opportunity:

To consider the opportunity of donation

Wouldn’t it be Nice?