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Barb NelsonAgnew, Hospital Liaison

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JCAHO and CMS recommend every hospital with a ventilator have a DCD policy in place. ... Your close collaboration and cooperation is integral for effective ... – PowerPoint PPT presentation

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Title: Barb NelsonAgnew, Hospital Liaison


1
Donation After Cardiac Death
  • Barb Nelson-Agnew, Hospital Liaison
  • Andrea Tighe, RN, CPTC
  • LifeSource

2
We believe that lifeis a gift to
shareLifeSource
We pledge to provide the bridge between the loss
of life and the gift of life Through organ
tissue donation transplantation.
3
LifeSource
Federally designated organ procurement
organization for MN, ND, SD, and portions of WI.
Provides the link between donor hospitals and
transplant centers.
4
2007 UNOS Waiting List
  • As of August, 2007 there were 96,697 people
    waiting to receive an organ transplant.
  • 2,616 reside in North Dakota, Minnesota, and
    South Dakota.
  • There were 28,931 organs transplanted in the US
    in 2006.
  • Patient Survival Rates One Year After Transplant
  • Kidney 96
  • Pancreas 94
  • Liver 88
  • Heart 88
  • Heart-Lung 67
  • Lung 84

5
Transplantation WorksPre-liver transplant, 6
months post-liver transplant. 88 success rate.
6
The Growing NeedFor Transplantable
OrgansOrgan Donors vs. Wait Listed Patients

Based on OPTN data through May 31, 2007
www.OPTN.org
7
HHS - Organ Donation Transplantation
Breakthrough Collaboratives
  • Organ Donation Breakthrough Collaborative (ODBC),
    2003
  • Based on best practices
  • Goal increase donation/conversion rates in US
  • Organ Transplantation Breakthrough Collaborative
    (OTBC), 2005
  • Built on success of ODBC
  • Goal save more lives through transplantation

8
Collaboratives
  • ODBC
  • 75 donation/conversion rate
  • Achieved by adopting/adapting best practices
  • Monitored by CMS and JCAHO
  • OTBC
  • 3.75 organs transplanted per donor

9
Initiatives are working!
  • Conversion/Donation Rates
  • 2004 2005 2006 2007
  • National 55 59 63 69
  • LifeSource 65 67 73 80 (thru
    July)
  • Lives saved through transplantation
  • 2004 2005 2006 2007
  • 20,044 21,211 22,201 9,222 (thru May)

10
HRSA Medal of Honor
  • In 2006 and 2007, 12 hospitals in the LifeSource
    DSA qualified to receive the HRSA Medal of Honor
    for maintaining a 75 conversion rate over a
    12-month period.

11
LifeSource Donation Activity

12
LifeSource Experience 2004-2007
  • 33 DCD Cases in the LifeSource region from 2004
    July, 2007
  • 70 Organs Transplanted
  • - 51 kidneys
  • - 17 livers
  • - 2 pancreas
  • Donor age range 13 years 59 years

13
Donation after Cardiac Death Donor Profile
  • Maintained on a ventilator
  • Devastating neurological injury
  • Head trauma
  • Anoxic injury
  • Cerebral vascular accident
  • Does not meet brain death criteria
  • Family desires withdrawal of support
  • Likely to die within 60-90 min. following the
    withdraw of support

14
DCD Activity Nationwide
  • JCAHO and CMS recommend every hospital with a
    ventilator have a DCD policy in place.
  • Yearly Number of DCD Donors in the United States
  • Source UNOS

15
Potential Organ Donor Devastating Brain Injury /
Ventilator Dependent
Donation after Cardiac Death
Donation after Brain Death
BRAIN DEATH EXAMINATION
Exam c/w brain death Death determined by neuro
criteria
Exam Not c/w brain death
Donation discussed with family (LifeSource)
  • Family/MD initiate topic W/D med treatment
  • LifeSource Coord discussion with family
  • Family supportive of donation

Patient supported during organ evaluation
allocation
Patient evaluated as potential DCD candidate
  • Withdrawal of medical treatment
  • Pronouncement of death
  • Surgical Recovery

Surgical recovery
16
Patient Evaluation for DCD Suitability
  • Age
  • Weight
  • ABO
  • Past Medical History
  • History of Present Illness
  • Current Clinical Condition
  • Organ Function
  • Respiratory Drive Assessment
  • Respiratory Rate
  • Tidal Volume
  • Minute Ventilation
  • Negative Inspiratory Force (NIF)
  • Changes in Hemodynamics Oxygen Saturation
  • Length of Time off Ventilator

17
Operating RoomSet-up and Instrumentation
If family chooses to be present All
instrumentation will be covered Room
warmed Windows draped Lights dimmed Soft
music turned on prior to family arrival
  • Major Abdominal
  • Thoracic
  • Vascular
  • Sternal saw

18
Operating RoomWithdrawal of Treatment / Roles
  • Donor
  • Critical Care RN (Surgery Scrubs) Administers
    Comfort Care measures and declares patient
  • Attending Physician Comfort Care orders and
    Declares patient
  • (Surgery Scrubs) (may or may not be present)
  • Family or Next-of Kin Family has option to be
    present with donor
  • (May or may not wear until cardiac death occurs
  • White Jump Suit and Head Cover)
  • Donation Coordinators Monitors VS q 1 minute
    family support
  • monitor
  • (Surgery Scrubs)
  • Pastoral Care (Surgery Scrubs) Family Support if
    famly present
  • Respiratory Care Assist with respiratory
    support during

19
When?
20
Organ Recovery
  • Recovery Team
  • Operating Room Staff
  • Donation Coordinators

21
Case Review 1
  • 26/M/C s/p trauma-ped vs. auto
  • Family chose to withdraw support, LifeSource
    introduced DCD 5 days after admission.
  • DCD Evaluation Score 14-15 (moderate risk for
    continuing to breathe after extubation). Rapidly
    de-saturated during DCD evaluation.

22
Case Review 1, cont.
  • Injuries included SAH, facial fx., Left
    pulmonary contusion, LLE fx.
  • Intubated orally, PO2 174 on FIO2 50
  • No vasopressor support
  • Labs upon admit Bun 10, Cr. 0.7
  • Labs prior OR Bun 14, Cr. 0.7, AST 81, ALT 52,
    Total Bilirubin 0.4

23
Case Review 1, cont.
  • OR Entrance time 0210
  • Extubation 0224
  • Declaration 0328
  • Incision 0330
  • Cross Clamp (CC) 0337
  • Average BP 140/70, O2 sat poor signal ???
  • Minute 50 BP ? 90/45
  • Asystole minute 57
  • Withdraw of support to Declaration 64 minutes
  • Declaration to Cross Clamp 9 minutes
  • Warm Ischemic Time (extubation to CC) 73
    minutes
  • Using BP lt 90/45 WIT 23 minutes

24
Outcome
  • Right and left kidneys transplanted locally
  • Heart valves, tissue and eyes recovered for
    transplant
  • Pancreas, liver and R. lung placed for research

25
Case Review 2
  • 47/F/C s/p MVA with an anoxic injury/Closed Head
    Injury unknown amount of down time and 18
    minutes of CPR.
  • Family chose to withdraw support, LifeSource
    introduced DCD 8 days after admission.
  • DCD Evaluation Score 17 (moderate risk for
    continuing to breathe after extubation). Rapidly
    de-saturated during DCD evaluation.

26
Case Review 2, cont.
  • Injuries included CHI, left pneumothorax with
    chest tube, flail chest, rib fxs., pulmonary
    contusions, splenic laceration.
  • Intubated orally, PO2 85 on an FIO2 of 40
  • No vasopressor support
  • Labs upon admit Bun 15, Cr. 0.8, AST 197, ALT
    79
  • High Bun 30, Cr. 1.2, High AST 332, ALT 160,
    Total Bilirubin 1.7
  • Labs prior to OR Bun 22, Cr. 0.7, AST 109, ALT
    121, Total Bilirubin 1.4

27
Case Review 2, cont.
  • OR Entrance time 0957
  • Extubation 1040
  • Declaration 1110
  • Incision 1115
  • Cross Clamp (CC) 1117
  • Average BP 125/50, O2 sat unable to detect
  • Minute 25 BP ? lt90/40
  • Asystole minute 30
  • Withdraw of support to Declaration 30 minutes
  • Declaration to Cross Clamp 7 minutes
  • Warm Ischemic Time (extubation to CC) 37
    minutes
  • Using BP lt90/40 WIT 13 minutes

28
Outcome
  • Liver transplanted within region
  • Both kidneys recovered for transplant-poor
    anatomy therefore discarded
  • Heart valves transplanted

29
Case Review 3
  • 13/M/C s/p anoxic injury with 20-30 minutes down
    time and CPR
  • Family interested in donation. LifeSource
    evaluated for DCD 5 days after admission.
  • DCD Evaluation Score 11-12

30
Case Review 3, cont.
  • Anoxic Brain Injury
  • Intubated orally, PO2 165 on FIO2 45
  • Dopamine _at_ 7.5 mcg/kg
  • Labs upon admit Bun 19, Cr. 0.8 (no liver labs
    drawn)
  • Labs prior to OR Bun 8, Cr. 0.4, AST 49, ALT
    19, Total Bilirubin 0.3

31
Case Review 3, cont.
  • OR Entrance time 0115
  • Extubation and vasopressor turned off 0129
  • Declaration 0141
  • Incision 0148
  • Cross Clamp (CC) 0158
  • Average BP 85/60, O2 sat ? rapidly
  • Asystole minute 12
  • Withdraw of support to Declaration 12 minutes
  • Declaration to Cross Clamp 17 minutes
  • Warm Ischemic Time (extubation to CC) 29
    minutes

32
Outcome
  • Liver, pancreas and kidneys recovered and
    transplanted
  • Tissue and eyes recovered for transplant

33
Your close collaboration and cooperation is
integral for effective family care, saving lives
and a successful donation program.
Thank You!
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