Download Organ Donation Trends at Enloe Objectives Organ Donation History

4/25/2017
Organ Donation Trends at Enloe
Trauma and DCD
Jason Hower
Clinical Procurement Coordinator
Heal a life through organ and tissue donation
Objectives
• Explain Donation after Circulatory Death (DCD)
• Review Enloe’s recent organ donation history
– Trauma impact
• Discuss current donation trends
• Case review
Organ Donation History
• Transplants began prior to Brain Death criteria
– 1954– 1st successful human kidney transplant
– 1963– 1st successful lung transplant
– 1967– 1st successful heart transplant
• 1968 – Harvard committee defines brain death
– 1983 Uniform Determination of Death Act
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Organ Donation History
• Brain Death and Transplant evolved separately
• Prior to Brain Death Law:
– donation occurs after “traditional” determination of
death
• After Brain Death laws, practice differs:
– Eastern states vs. Western states
Hospital Refers
Patient
Donor Network
Evaluation
Brain Death
Declaration
Family Decides to
Withdraw
Donation
Discussion
Donation
Discussion
Donation occurs AFTER death
Brain Death vs. DCD
Brain Death
• Patient is declared dead as a result of
an absence of brain function.
•
•
•
Cardiorespiratory function
maintained by vent
Perfusion, organ function continue
Usually no warm ischemic time on
organs, but there will be cold
ischemic time
Circulatory Death
• Patient is declared dead as a result of
an absence of cardiac function.
•
All cardiorespiratory function ceases.
•
Warm ischemia
•
Warm ischemic time is more harmful
to the organs than cold ischemic
time.
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Brain Death vs. DCD
Brain Death
• Patient is declared dead as a result of
an absence of brain function
Cardiorespiratory function
maintained by vent
•
Perfusion, organ function continue
•
Usually no warm ischemic time on
organs, but there will be cold
ischemic time
•
Circulatory Death
• Patient is declared dead as a result of
an absence of cardiac function
•
All cardiorespiratory function ceases.
•
Warm ischemia
•
Warm ischemic time is more harmful
to the organs than cold ischemic
time.
The Process
•
Hospital refers potential donor
•
Potential for DCD determined by Donor Network
•
Family makes decision to withdraw
•
Donation offered to family
•
Timeframe for withdrawal set
•
Organs allocated, hospital maintains patient
•
Comfort measures, extubation
Evaluation - Predictability
•
Statistical model (reflexes, oxygenation index)
•
Age, history, admission course
•
Diagnostics, severity of injury
•
Lab values
•
Neurological status
•
Vent parameters, respiratory drive
•
Airway assessment
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Comfort Care during Withdrawal
of Life Support
•
As in the ICU, patients receive medication to alleviate any
discomfort that may be experienced during the
withdrawal of life support.
•
The doctor that declares the patient dead is responsible
for administering comfort care medications. Transplant
surgeons are not involved in prescribing comfort care
medication or determining when it should be given.
Family Presence
• The patient’s family may decide to be present during
their loved ones last moments.
• If the withdrawal of care occurs in the ICU, this is easily
accommodated
• If the withdrawal of care occurs in the OR, the hospital
must OK this practice.
• Sometimes the withdrawal can occur in an adjacent
procedure room or the PACU to allow the family to be
present
Timeline
• Surgical Team will arrive 1 hour prior to planned
OR time (time withdrawal of care will occur)
• Surgical Coordinator will assist hospital staff in
setting up OR
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Huddle
• Donation Staff:
– Administrator On Call
– Transplant & Surgical Coordinators
– Family Care & Program Consultant
• OR Staff:
– Circulator, Scrub
• Transplant Surgeons
• Declaring Doctor, nurse, clergy
***Make sure everyone is present
Huddle
• The plan for the DCD will be discussed:
• Description of events
• Description of roles and responsibilities
• Declaring Doctor will discuss plan of withdrawal
• The set up of instruments and the room
• Who will be in the room during the withdrawal
• Hospital has a bed ready for the patient back in the ICU should
the case not proceed in the OR
• If the patient does not die within ~1 hr, the recovery will not
occur and the patient will be brought back to the ICU or other
designated area
Withdrawal
• Limit the number of people in the room during
the withdrawal (Privacy for Family):
– Declaring physician
– ICU nurse (to give comfort care meds)
– Donor Network staff to record vitals
– Family support (Donor Network, clergy)
• The transplant surgeons are often scrubbed in
and waiting at this time in a separate room.
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Withdrawal
• If the family wishes to be present, they will
enter the room at this time.
• When the patient is determined to have
reached cardiac death, the doctor will declare
• The 5 minute waiting period begins, the family
is escorted out
• At the end of the 5 minute period, the
transplant surgeons may enter and begin the
recovery surgery.
Withdrawal
• If the patient does not reach asystole within the
pre-determined time frame of 60 minutes or
less, they will not become an organ donor but
may still become a tissue donor after asystole.
• The patient is taken back to the ICU or other
room in the hospital where they will continue to
receive comfort care medications until they
reach asystole.
• They are not reintubated.
Important Points
1) Withdrawal and comfort care are directed by the declaring
doctor from the hospital.
– Donor Network and transplant centers DO NOT have any
input as to what comfort care medications are given.
2) Limit the number of people in the room during the withdrawal.
– Only 1 person from DNW should be present in the room
during withdrawal in order to record vitals and provide
updates to the transplant surgeons
– If the family is present, having an FRC in the room is also
appropriate
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Withdrawal
Patient
Reaches
Cardiac Death
Patient Does
Not Reach
Cardiac Death
Organ
Recovery
Commences
Patient
brought back
to ICU
Ethics of DCD
• Surgical recovery of organs occurs only after declaration of
death and with explicit authorization of the donor and/or
donor's family.
• Death is declared by doctors not affiliated with organ recovery
or transplantation.
• The transplant surgeons are not present during the time of
withdrawal of life support.
• After cardiac death is declared, a 5 minute
observational/waiting period begins
Ethics of DCD continued
• Patients and their families, in collaboration with their
health care providers, decide if and when to withdraw
artificial support.
• Decisions to withdraw artificial support are made
independent of whether or not the person becomes a
donor.
• Donor Network West is never involved in decisions to
withdraw treatment.
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Ethics of DCD continued
• Practice differs between facilities
• DCD donation is family driven
• All families informed of potential to donate
DCD at Enloe
• 2012 – 2 donors, 0 DCD (0 trauma)
• 2013 – 8 donors, 0 DCD (7 trauma)
• 2014 – 4 donors, 0 DCD (2 trauma)
• 2014 – Revised DCD procedure, checklist
• 2015 – 9 donors, 2 DCD (1 trauma)
• 2016 – 11 donors, 2 DCD (4 trauma, 1 DCD*)
Case #1
• 39yo male s/p drowning
• 4 days in NTICU, donation brought up by family
• Initial BD exams not consistent w/BD, DCD authorized
• BD exams repeated on day 5
• Heart, liver, kidneys transplanted, lungs r/o in OR
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Case #2
• 35yo male s/p fall from horse
• Bilateral craniectomy on day 2
• PM shift, day 2:
– CT shows complete infarct rt. Hemisphere
– Family brings up donation, wants to wait for BD
– DCD authorized as plan B
• DCD donation on day 5
• Lungs (!!), liver, kidneys transplanted, heart for
research
Challenges?
Intermountain Donor
Services
Nevada Donor Services
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Challenges?
• WARM ISCHEMIA/COLD ISCHEMIA
• Predictability
• Instability
DCD potential from trauma
• Severity of injury, not quite BD
• Instability
• Family fatigue, timing for comfort care
• Interventions prevent herniation
Donation from trauma
• % Donors/trauma pt.s = declining*
– Increasing age/comorbidity
• Lower trauma mortality
• Organs per donor 1.6x higher (BD vs. DCD)
– 2x higher for hearts
DONATION OPPORTUNITIES ARE PRECIOUS
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Preserve donation opportunities
• Early identification
– Clinical Cues
• Early notification
• Aggressive intervention (avoid deceleration of care)
• PLAN AHEAD FOR DONATION DISCUSSIONS!
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