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Optimization of the Potential Organ Donor Ali Salim, MD Professor of Surgery Chief, Division of Trauma, Burns, Surgical Critical Care, and Emergency General Surgery
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Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

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Page 1: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Optimization of the

Potential Organ Donor

Ali Salim, MD

Professor of Surgery

Chief, Division of Trauma, Burns, Surgical Critical Care, and Emergency General Surgery

Page 2: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Disclosures

I have nothing to disclose

Page 3: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Disclosures

I have nothing to disclose

Except…..

Page 4: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 5: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Why should we know about

donation??

Page 6: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

33,611 Transplants performed in 2016

15,946 Donors

Page 7: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

The Organ Shortage Problem

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

1992

1996

2000

2004

2007

2009

2012

2014

2016

19

deaths/day

7000/year

Waiting list

Transplants

Page 8: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Did you know??

Centers for Medicare/Medicaid Services

& ACS

Notification process

Declaration of brain death

Organ procurement organization (OPO)

relationship

Performance Improvement (PI) program

Patient/family opportunity to donate

Page 9: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 10: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 11: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Level I, II, III Trauma Centers

Must have an established relationship with a

recognized OPO

Must have a written policy for triggering

notification of the regional OPO

Must review its solid organ donation rate

annually

Must have written protocols defining clinical

criteria and confirmatory tests for the

diagnosis of brain death

Page 12: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Cause of Death of Donors

40%

4%

35%

21%

Page 13: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Outline

Types of Donors

Declaration of Brain Death

Critical Care Management

Page 14: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Types of Donors

Living Donors

Deceased Donors

Donors after Neurologic Determination of Death

Donors after Circulatory Determination of Death

Page 15: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 16: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Cadaveric “Brain Dead” Donors

Cadaveric donors 82%

Living donors 18%

Page 17: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Types of Donors

Living Donors

Deceased Donors

Donors after Neurologic Determination of Death

Donors after Circulatory Determination of Death

Page 18: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Types of Donors

Deceased Donors

Donors after Neurologic Determination of Death

Donors after Circulatory Determination of Death

Page 19: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Two Ways to Declare Death:

Cardiac Death Death declared on basis

of cardiopulmonary

criteria

Irreversible cessation of

circulatory and

respiratory function

DCD

8% deceased donors

Brain Death Irreversible loss of all

functions of the brain,

including brain stem

Non-DCD or DBD

92% deceased donors

Two Ways to Declare Death

Page 20: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Types of Donors

Deceased Donors

Donors after Neurologic Determination of Death

Donors after Circulatory Determination of Death

Page 21: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Declaring Brain Death

1. Pre-requisites

2. Clinical Examination

3. Ancillary Testing

4. Documentation & Organ Donation

Page 22: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Declaring Brain Death

1. Pre-requisites

2. Clinical Examination

3. Ancillary Testing

4. Documentation & Organ Donation

Page 23: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 24: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Pre-requisites

Known proximal cause & irreversibility

Absence of confounders

Electrolyte, metabolic, endocrine, acid-

base disturbances

Intoxication/drug effects

Page 25: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Pre-requisites

Known proximal cause & irreversibility

Absence of confounders

Electrolyte, metabolic, endocrine, acid-

base disturbances

Intoxication/drug effects

Hypothermia

> 36 C (from 32)

Systolic Blood Pressure

> 100 mm Hg (from 90)

Page 26: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Declaring Brain Death

1. Pre-requisites

2. Clinical Examination

3. Ancillary Testing

4. Documentation & Organ Donation

Page 27: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Clinical Exam: COMA

Motor response to painful stimuli

•Sternum

•Supraorbital nerve

•Nail bed

Adapted from: Wijdicks. NEJM. 2001

Page 28: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Clinical Exam: BRAINSTEM

REFLEXES

Adapted from: Wijdicks. NEJM. 2001

Page 29: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Clinical Exam: BRAINSTEM

REFLEXES

Pupillary Light Reflex

Corneal Reflex

Gag Reflex

Oculocephalic Reflex (Dolls Eyes)

Oculovestibular Reflex (Cold Calorics)

Page 30: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Clinical Exam: APNEA

Absence of a breathing drive

Tested by CO2 challenge

Prerequisites

Normotension

Normothermia

Euvolemia

Eucapnia (35-45)

Absence of hypoxia

Page 31: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Clinical Exam: APNEA

Adapted from: Wijdicks. NEJM. 2001

Repeat ABG: 8 min

Arterial PCO2

• > 60 mm Hg OR • 20 mm Hg increase over baseline

Apneic oxygenation-

diffusion technique

Page 32: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Declaring Brain Death

1. Pre-requisites

2. Clinical Examination

3. Ancillary Testing

4. Documentation & Organ Donation

Page 33: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Ancillary Tests

Only if clinical exam incomplete, unreliable

or unsafe

1. Brain perfusion scan

2. EEG

3. Transcranial doppler

4. Conventional angiography

Page 34: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Declaring Brain Death

1. Pre-requisites

2. Clinical Examination

3. Ancillary Testing

4. Documentation & Organ Donation

Page 35: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Documentation & Donation

Time of death:

pCO2 reached target value

Ancillary test interpretation

Page 36: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Documentation & Donation

Organ donation:

Federal & State law requires contact with organ

procurement association

OPO to approach family

Page 37: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Organ Donor Timeline

Injury

1st Brain death

2nd Brain Death

Family consent

Organ Retrieval

OPO Management

Page 38: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Types of Donors

Deceased Donors

Donors after Neurologic Determination of Death

Donors after Circulatory Determination of Death

Page 39: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Types of Donors

Deceased Donors

Donors after Neurologic Determination of Death

Donors after Circulatory Determination of Death

Page 40: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Timeline of DCDD

Page 41: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 42: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 43: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Outline

Types of Donors

Declaration of Brain Death

Critical Care Management

Page 44: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Outline

Types of Donors

Declaration of Brain Death

Critical Care Management

Page 45: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 46: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

23 yo male

Transcranial GSW to head

Visible brain matter

GCS 3

Pupils fixed – 4 mm

Intubated, hypertonic saline, Head CT

Page 47: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 48: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

Cardiac Arrest in CT

Resuscitated

Coagulopathic

Second cardiac arrest on arrival to

SICU

pH – 6.8, base deficit 25

Page 49: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

Mulitiorgan system failure

Declared brain death

Family/patient strong desire for organ

donation

Page 50: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

Organ donation offered

Page 51: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

Organ donation offered

Liver

Heart

Both kidneys

Page 52: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

Why was he so sick??

Page 53: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Catecholamine surge

↑HR, ↑ BP, ↑ CO, ↑ SVR

Page 54: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

DI DIC

arrhythmias

pulmonary edema acidosis hypothermia

hypotension

Page 55: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Complications of Brain

Death

0%

10%

20%

30%

40%

50%

60%

70%

80%

PLTs DIC pressor DI card

isch

acid renal

failure

NPE

Salim et al. Am Surg 2006;72:377-381.

Page 56: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

DI DIC

arrhythmias

pulmonary edema acidosis hypothermia

hypotension

Organ Loss up to 25%

Page 57: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 58: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Case review

Cardiac Arrest in CT

Resuscitated

Coagulopathic

Second cardiac arrest on arrival to

SICU

pH – 6.8, base deficit 25

Page 59: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Why?

Hemodynamic instability

Autonomic dysfunction

Aerobic to anaerobic metabolism

Release of vasoactive inflammatory

mediators

Page 60: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Elevation of pro-inflammatory cytokines

IL-1 – 16%

IL-6 – 100%

TNF- - 28%

CRP – 98%

PCT – 87%

2009;88:582-588

http://journals.lww.com/transplantjournal/pages/currenttoc.aspx
Page 61: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Why?

Hemodynamic instability

Autonomic dysfunction

Aerobic to anaerobic metabolism

Release of vasoactive inflammatory

mediators

Low levels of T3, T4, cortisol, insulin

Reversal with replacement of T3

Page 62: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

The Role of thyroid hormone Salim et al Arch Surg 2001;136:1377-1380

T4 administration

Total Vasopressor

Dose

(mcg/kg/min)

Time interval in hours

Time 0 is start of T4

Page 63: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Cardiovascular Collapse??

A fluid problem…….

A hormonal problem……

An attention problem……

Page 64: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Wood et al NEJM 2004;351:2730-2739

Page 65: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Cardiovascular Collapse??

A fluid problem…….

A hormonal problem……

An attention problem……

Donor management is key to

preventing collapse

Page 66: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Organ Donor Timeline

Injury

1st Brain death

2nd Brain Death

Family consent

Organ Retrieval

OPO Management

CVC

ADM

Page 67: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

What is Aggressive Donor

Management?

Page 68: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

What is Aggressive Donor

Management?

Hemodynamic Management Invasive monitoring with endpoints

Page 69: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Hemodynamic Management

Target criteria

MAP > 60

PCWP 8-12

CVP 4-12

CI > 2.4

SVR 800-1200

Dopamine < 10

Page 70: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

What is Aggressive Donor

Management?

Hemodynamic Management Invasive monitoring with endpoints

Hormonal therapy

T3 or T4

Methylprednisolone

Vasopressin

Page 71: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Hormone Therapy

Rapid IV bolus of: 1 amp 50% dextrose

20 units insulin

2 g Solumedrol

20 mcg T4

Continuous T4 infusion at 10 mcg/h

T4 only used in hemodynamically unstable donors

(combined vasopresssor dose > 10mcg/kg/min)

Page 72: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

The Role of thyroid hormone Salim et al Arch Surg 2001;136:1377-1380

T4 administration

Total Vasopressor

Dose

(mcg/kg/min)

Time interval in hours

Time 0 is start of T4

Page 73: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Wheeldon et al 1995;14:734-742

Aggressive Donor Management

PAC

HRT (MP, T3, Insulin, Vasopressin)

52 “unacceptable” donors

44 transplanted Donor MGT

Page 74: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

What is Aggressive Donor

Management?

Ventilator Management

Page 75: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

What is Aggressive Donor

Management?

Ventilator Management

Appropriate tidal volumes (10 cc/kg)

Prevent atelectasis

Recruitment maneuvers

Fluid restriction (diuretics)

Bronchoscopy (frequent suctioning)

Prevent aspiration (elevate HOB)

Page 76: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

2002;124:250-258

http://jtcs.ctsnetjournals.org/current.shtml
Page 77: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Aggressive management

CVP monitoring

Methylprednisolone 15 µg/kg

Fluid restriction

Diuresis

Inotropes titrated for stability

bronchoscopy

2002;124:250-258

http://jtcs.ctsnetjournals.org/current.shtml
Page 78: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

2002;124:250-258

Successful lung procurement can

be optimized with aggressive

donor management

http://jtcs.ctsnetjournals.org/current.shtml
Page 79: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 80: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

ICU admission

Dedicated team fluids, pressors, T4

Early identification

(ADM)

Instituting a User-Friendly Protocol

Page 81: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Salim A. J Int Care Med. 2008

Page 82: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 83: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Aggressive Donor Management

Salim et al. J Trauma, 2005;58:991-994

Aggressive Donor Management

↑153 organs over 3 years

Page 84: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

New Terminology

Catastrophic Brain Injury Guidelines

Goal – to maintain hemodynamic stability

in patients with devastating brain injury

Page 85: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Organ Donor Timeline

Injury

1st Brain death

2nd Brain Death

Family consent

Organ Retrieval

OPO Management

CVC

ADM

Page 86: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Organ Donor Timeline

Injury

1st Brain death

2nd Brain Death

Family consent

Organ Retrieval

OPO Management

CVC

CBIG

Page 87: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Salim A. J Int Care Med. 2008

Page 88: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 89: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Donor Management Goals

Creating a checklist that anyone can follow……

Page 90: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Critical Care Endpoint DMG

1. Mean Arterial Pressure (MAP) 60 – 100 mmHg

2. Central Venous Pressure (CVP) 4 – 10 mmHg

3. Ejection Fraction (EF) > 50%

4. Vasopressor use 1 and low dose

5. Arterial Blood Gas pH 7.3 – 7.45

6. PaO2:FiO2 (P:F) > 300 on PEEP = 5

7. Serum Na 135 – 160 mEq/L

8. Blood Glucose < 150 mg/dL

9. Hemoglobin (Hb) > 10 mg/dL

10. Urine Output (averaged over 4 hours) 1-3 cc/kg/hr

Page 91: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 92: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014
Page 93: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Outline

Types of Donors

Declaration of Brain Death

Critical Care Management

Page 94: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

Outline

Types of Donors

Living, Deceased (DCD, DBD)

Declaration of Brain Death

Protocols need to be in place

Critical Care Management

Management of catastrophic brain injuries

Page 95: Optimization of the Potential Organ Donor · The Organ Shortage Problem 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 19 deaths/day 1992 1996 2000 2004 2007 2009 2012 2014

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