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Why you do what you do? Nikki Dotson-Lorello RN, BSN, CCRN, CPTC Organ Recovery Coordinator LifeShare Of The Carolinas Why is my dead patient so busy??? Demanding Organ Recovery Coordinator • We expect a lot in the first few hours so optimal staffing is one on one! • Keep your daggers in your pocket please!! • Usually after the first few hours things will slow down. How many lines do you really need? • You will be grateful for the central line when you see the amount of labs tubes we need. And no they will not need a blood transfusion • Ton of medications, most likely blood pressure support in the early stages, so that central line is again very handy! • Respiratory Therapy will love me for the arterial line I will have to have! If we pursue lungs, TONS of ABG’s! LifeShare Orders • Admit and readmit • Labs for baseline references • Chest Xrays, possible implementation of lung protocol, possibly CT scan • EKG, possibly ECHO and Cath Lab • Tons of medications and fluid changes They were stable before death, what happened? Physiologically speaking! • No Hypothalamus, therefore no thyroid hormones • No ADH • No temperature control • No blood sugar control • No parasympathetic response systems, causing cardiovascular dilation • Little to no BP and HR control No Hypothalamus, NEED Thyroid Fix • Levothyroxine=T4; Bolus then start a drip • D50 amp • 20 units Regular Insulin • 2 Grams Solumedrol ALL MUST BE GIVEN CLOSE TOGETHER!!!! DIABETES INSIPIDUS No Hypothalamus + No ADH = Loss of free water and sodium increase Diabetes Insipidus Fix • Hourly I&O • If UOP exceeds 800ml/hr, need ADH-Vasopressin, Goal UOP 150300 ml/hr • Urine Replacement ml:ml hourly • Low Sodium fluids • Replace electrolytes • Monitor CVP, BP and HR No more sugar for me please! • Blood sugar check q2hr • Bolus insulin or even start a drip • Look out for increased UOP, may indicate an elevated blood sugar!! It’s getting hot in here! Goal temp 96.8-99.5 Cold = warm blankets to body and head, warm circuit to ventilator, warm fluids and/or bair hugger, turn up the thermostat! Hot = remove blankets, cooling blanket, ice packs and turn down thermostat! Just gets you ready for menopause Who turned the lytes out? • • • • Prior to brain death medical management can lead to challenges Mannitol/diuretics to reduce swelling IVF fluid restriction to avoid pulmonary edema or CHF DI Excessive blood due to trauma or coagulopathy Please fix the Lytes! • • • • • Replace K+ Replace Phos if <2.5 Reduce Na, monitor IVF for Na If NA <130, consider 3% CaCl or Ca Gluconate for cardiac function • Monitor q4hr and check q1hr after any replacements Complication: DIC • Common with head trauma-GSW, Open head injuries, closed head trauma’s • Concern with organ donor-clotting of vascular system causes necrosis or organs PTT< 38 PT< 15 Platelets >65,000 Fibrinogen >100,000 How do you fix it? • Observe for any bleeding • Monitor coags • Use PRBC’s, FFP, cryoprecipitate • Treatment will not cure but will slow process BP, it’s up, it’s down! No parasympathetic or sympathetic responses It’s UP • Treat with Labetalol or Nipride It’s Down • Treat with Dopamine, Levothyroxine, Neosynephrine, Levophed, Albumin 5%, IVF boluses dependent on lytes and CVP Now for the CVP of SVV!! • Monitor Hydration • Consider albumin of Na up • Tricky if placing lungs, need hydration for kidneys, dry for lungs! If that was not enough, what about the pH? • No respiratory drive, need to know if metabolic acidosis or alkalosis • Keep pH and pCO2 normal • Acidosis most common, collaborate with RT, may need NaHCO3 • Monitor TV and FiO2 • ABG’s q2-4, hours • HOB up • Rotate and percuss • Suction Two Sides to the Story • Primary goal is to return the organ function back to baseline to optimize for placement • Ideally this will make the transplant as easy as possible for the recipient Mathematically Speaking….. Collaboration Nurse + MD + LifeShare ORC = Organ Recovery Organ Recovery + Transplant = Recipient GO TEAM! Questions??