Organ DonationOrgan DonationEnd of Life care in the Operating RoomEnd of Life care in the Operating Room
Matthew BockMatthew BockSurgical recovery coordinatorSurgical recovery coordinator
University of Wisconsin University of Wisconsin
Organ Procurement OrganizationOrgan Procurement Organization
1-866-UWHC OPO1-866-UWHC OPO
(1-866-894-2676)(1-866-894-2676)
PerspectivePerspective
Remembering why we’re hereRemembering why we’re here
Save lives through transplantationSave lives through transplantation
Supporting the family’s choiceSupporting the family’s choice
Honoring the patient’s wishesHonoring the patient’s wishes
Donation after Cardiac Death Donation after Cardiac Death (DCD)(DCD)
Uniform Determination of Death Uniform Determination of Death ActAct, 1980, 1980
Irreversible cessation of circulatory and Irreversible cessation of circulatory and respiratory function respiratory function - OR-- OR-
Irreversible cessation of all functions of Irreversible cessation of all functions of the entire brain, including the brain stemthe entire brain, including the brain stem
Two ways to donateTwo ways to donateDeceased Organ DonationDeceased Organ Donation
Donation After Donation After
Brain DeathBrain Death
Donation After Donation After
Cardiac Death Cardiac Death (DCD)(DCD)
Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:
-Clinical exam-Clinical exam-Apnea test-Apnea test
DCDDCD
Severe neurological Severe neurological injuryinjury
Does not meet criteria Does not meet criteria for brain deathfor brain death
Family has elected to Family has elected to withdraw supportwithdraw support
Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:
-Clinical exam-Clinical exam-Apnea test-Apnea test
DCDDCD
Severe neurological Severe neurological injuryinjury
Does not meet criteria Does not meet criteria for brain deathfor brain death
Family has elected to Family has elected to withdraw supportwithdraw support
Clinical Diagnosis of Clinical Diagnosis of Brain DeathBrain Death
Unresponsive to all stimuli Unresponsive to all stimuli No spontaneous respiratory activity No spontaneous respiratory activity All brain stem reflexes are absent:All brain stem reflexes are absent:– Pupillary response to lightPupillary response to light– Corneal reflexesCorneal reflexes– Oculo-vestibular reflex (caloric response)Oculo-vestibular reflex (caloric response)– Oculocephalic reflex (doll’s eye Oculocephalic reflex (doll’s eye
phenomenon)phenomenon)– Gag reflex Gag reflex
Apnea TestApnea Test
Make sure patient has normal body temp, blood pressure, Make sure patient has normal body temp, blood pressure, volume status, ABG’svolume status, ABG’sDisconnect from ventilatorDisconnect from ventilatorMonitor continuous pulse oximetryMonitor continuous pulse oximetryAdminister 100% O2 at 6 L/min into the tracheaAdminister 100% O2 at 6 L/min into the tracheaMonitor closely for respiratory movementsMonitor closely for respiratory movementsCheck serial ABG’s, or at approx. 8 minutesCheck serial ABG’s, or at approx. 8 minutesIf no respiratory movement and arterial PCO2 is > 60 mm Hg, If no respiratory movement and arterial PCO2 is > 60 mm Hg, the apnea test supports the clinical diagnosis of brain deaththe apnea test supports the clinical diagnosis of brain death
Apnea TestApnea Test
Make sure patient has normal body temp, blood pressure, Make sure patient has normal body temp, blood pressure, volume status, ABG’svolume status, ABG’sDisconnect from ventilatorDisconnect from ventilatorMonitor continuous pulse oximetryMonitor continuous pulse oximetryAdminister 100% O2 at 6 L/min into the tracheaAdminister 100% O2 at 6 L/min into the tracheaMonitor closely for respiratory movementsMonitor closely for respiratory movementsCheck serial ABG’s, or at approx. 8 minutesCheck serial ABG’s, or at approx. 8 minutesIf no respiratory movement and arterial PCO2 is > 60 mm Hg, If no respiratory movement and arterial PCO2 is > 60 mm Hg, the apnea test supports the clinical diagnosis of brain deaththe apnea test supports the clinical diagnosis of brain death
Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:
-Clinical exam-Clinical exam-Apnea test-Apnea test
DCDDCD
Severe neurological Severe neurological injuryinjury
Does not meet criteria Does not meet criteria for brain deathfor brain death
Family has elected to Family has elected to withdraw supportwithdraw support
Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:
-Clinical exam-Clinical exam-Apnea test-Apnea test
DCDDCD
Severe neurological Severe neurological injuryinjury
Does not meet criteria Does not meet criteria for brain deathfor brain death
Family has elected to Family has elected to withdraw supportwithdraw support
Severe Neurologic InjurySevere Neurologic Injury
TraumaTrauma– MVA, FallMVA, Fall
SDHSDH
AnoxiaAnoxia– Cardiac Arrest, Cardiac Arrest,
near drowningnear drowning
Brain DeathBrain DeathSevere neurological Severe neurological injuryinjuryMeets Brain death Meets Brain death criteria: criteria:
-Clinical exam-Clinical exam-Apnea test-Apnea test
DCDDCD
Severe neurological Severe neurological injuryinjury
Does not meet criteria Does not meet criteria for brain deathfor brain death
Family has elected to Family has elected to withdraw supportwithdraw support
Two ways to donateTwo ways to donate
Donation After Brain DeathDonation After Brain Death
Patient is maintained on Patient is maintained on ventilator for organ ventilator for organ recoveryrecovery
Organs dissected insituOrgans dissected insitu
3-4 hour surgery3-4 hour surgery
Donation After Cardiac DeathDonation After Cardiac Death
(DCD)(DCD)
Patient is extubated in the Patient is extubated in the Operating Room or ICUOperating Room or ICU
Surgery begins 5 minutes Surgery begins 5 minutes after cessation of cardiac after cessation of cardiac function and declaration by function and declaration by patient’s physicianpatient’s physician
Rapid recovery with organs Rapid recovery with organs procured en bloc. procured en bloc.
Two ways to donateTwo ways to donate
Donation After Brain DeathDonation After Brain Death
Patient is maintained on Patient is maintained on ventilator for organ ventilator for organ recoveryrecovery
Organs dissected insituOrgans dissected insitu
3-4 hour surgery3-4 hour surgery
Donation After Cardiac DeathDonation After Cardiac Death
(DCD)(DCD)
Patient is extubated in the Patient is extubated in the Operating Room or ICUOperating Room or ICU
Surgery begins 5 minutes Surgery begins 5 minutes after cessation of cardiac after cessation of cardiac function and declaration by function and declaration by patient’s physicianpatient’s physician
Rapid recovery with organs Rapid recovery with organs procured en bloc.procured en bloc.
Two ways to donateTwo ways to donate
Donation After Brain DeathDonation After Brain Death
Patient is maintained on Patient is maintained on ventilator for organ ventilator for organ recoveryrecovery
Organs dissected insituOrgans dissected insitu
3-4 hour surgery3-4 hour surgery
Donation After Cardiac DeathDonation After Cardiac Death
(DCD)(DCD)
Patient is extubated in the Patient is extubated in the Operating Room or ICUOperating Room or ICU
Surgery begins 5 minutes Surgery begins 5 minutes after cessation of cardiac after cessation of cardiac function and declaration by function and declaration by patient’s physicianpatient’s physician
Rapid recovery with Rapid recovery with organs procured en bloc. organs procured en bloc.
““We don’t do that here”We don’t do that here”
ICU nurseICU nurseRTRT
OPO staffOPO staffNo family yetNo family yet
Who is involved?Hospital-Anesthesia Anesthesia -Surgical Technician/Scrub NurseSurgical Technician/Scrub Nurse-Circulating NurseCirculating Nurse
Abdominal Transplant Team- Surgeon- Surgeon- Physician Assistant- Physician Assistant- Surgical Recovery Coordinator- Surgical Recovery Coordinator
Cardiothoracic Team- Surgeon- Surgeon- Surgical Fellow- Surgical Fellow- Surgical Recovery Coordinator- Surgical Recovery Coordinator
PaperworkPaperwork
Consent x2Consent x2Time outTime outPost Op Post Op dispositiondispositionDeath packetDeath packet
Prep & drapePrep & drape
Femoral cutdownFemoral cutdown
Cover patient and Cover patient and back tableback table
Unnecessary staff Unnecessary staff exits the roomexits the room
DCD Withdrawal in the ORDCD Withdrawal in the OR
Accommodating the FamilyAccommodating the Family
Meds, Withdrawal & DeclarationMeds, Withdrawal & Declaration
How long can we wait?How long can we wait?
Rapid En-bloc recoveryRapid En-bloc recovery
Organ Preservation TimeOrgan Preservation Time
Heart: 4-6 hrsHeart: 4-6 hrs
Lungs: 4-6 hrsLungs: 4-6 hrs
Liver: 12 hrsLiver: 12 hrs
Pancreas: 18 hrsPancreas: 18 hrs
Kidneys: 24 hrsKidneys: 24 hrs
A wedding storyA wedding story