Title: Barb NelsonAgnew, Hospital Liaison
1Donation After Cardiac Death
- Barb Nelson-Agnew, Hospital Liaison
- Andrea Tighe, RN, CPTC
- LifeSource
2We 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.
3LifeSource
Federally designated organ procurement
organization for MN, ND, SD, and portions of WI.
Provides the link between donor hospitals and
transplant centers.
42007 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
5Transplantation WorksPre-liver transplant, 6
months post-liver transplant. 88 success rate.
6The Growing NeedFor Transplantable
OrgansOrgan Donors vs. Wait Listed Patients
Based on OPTN data through May 31, 2007
www.OPTN.org
7HHS - 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
8Collaboratives
- ODBC
- 75 donation/conversion rate
- Achieved by adopting/adapting best practices
- Monitored by CMS and JCAHO
- OTBC
- 3.75 organs transplanted per donor
9Initiatives 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)
10HRSA 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
12LifeSource 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
13Donation 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
14DCD 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
15Potential 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
16Patient 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
17Operating 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
18Operating 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
19When?
20Organ Recovery
- Recovery Team
- Operating Room Staff
- Donation Coordinators
21Case 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.
22Case 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
23Case 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
24Outcome
- Right and left kidneys transplanted locally
- Heart valves, tissue and eyes recovered for
transplant - Pancreas, liver and R. lung placed for research
25Case 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.
26Case 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
27Case 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
28Outcome
- Liver transplanted within region
- Both kidneys recovered for transplant-poor
anatomy therefore discarded - Heart valves transplanted
29Case 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
30Case 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
31Case 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
32Outcome
- Liver, pancreas and kidneys recovered and
transplanted - Tissue and eyes recovered for transplant
33Your close collaboration and cooperation is
integral for effective family care, saving lives
and a successful donation program.
Thank You!