Organ Donation Past, Present and Future
Donation after Brain-Stem DeathDBD
Dr Peter HallDr Dale GardinerDr Gerlinde Mandersloot22nd May 2013
1
Organ Donation Past, Present and Future
Regional Data
Dr Peter Hall CLOD
Calderdale and Huddersfield NHS Trust
2
YORKSHIRE
Session Objectives
• Present regional data for DBD
• Understand that DBD gives better organs than DCD
• Increase rate of neurological confirmation of death by increasing confidence in the Diagnosis of Death
• Increase quality of DBD organs
– adoption of extended care bundle and compliance with the six early interventions in donor optimisation
– collaboration in Scout pilot
3Organ Donation Past, Present and Future
Organ Donation Past, Present and Future
Donation after Brain Death (DBD)Mechanically ventilated patient where death has been confirmed using neurological criteria.
KidneysLiver
Pancreas
LungsHeart
Small Intestine
52 donors
-1.9% (from 5 years ago)
YORKSHIRE
Organ Donation Past, Present and Future 5
YORKSHIRE
Donation in Yorkshire2003‐2013
137.5%
‐1.9%
30.4%
Organ Donation Past, Present and Future 6
YORKSHIRE
Donation in Yorkshire2003‐2013
Organ Donation Past, Present and Future
pancreasliver
lungs
kidneys
heart
DCD DBD
intestine
-------- National rate
8782
76 74
86
7873 76 76 74 76 74
ND
test
ed (%
)
0
20
40
60
80
100
Team
Easter
n
London
Midlands
North
West
Northern
Northern
Ire
land
Scotla
ndSouth
Centra
lSouth Eas
tSouth
Wales South
West
Yorkshire
DBD- Neurological death testing rate
1 April 2012 to 31 March 2013, data as at 4 April 2013
Organ Donation Past, Present and Future 8
Tied 9th with 3 others
YORKSHIRE
ND
test
ed (%
)
0
20
40
60
80
100
Number of neurological death suspected patients
0 5 10 15 20 25 30 35
1
10 11
12
13
14
15
16
2
3
4
5
6
7
8
9
Trust National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL
DBD- Yorkshire Neurological death testing rate
Organ Donation Past, Present and Future 9
1 April 2012 to 31 March 2013, data as at 4 April 2013
1 Bradford2 York3 Harrogate (with 6)4 Airedale5 Sheffield Children’s6 Barnsley (with 3)7 Rotherham8 Chesterfield9 Sheffield10 Nth Lincolnshire & Goole11 Doncaster and Bassetlaw12 Leeds13 Hull and East Yorkshire14 United Lincolnshire Hospitals15 Calderdale and Huddersfield16 Mid Yorkshire Hospitals
Mean no. of organs donated per donor
1 April 2012 to 31 March 2013, data as at 4 April 2013
Tied 6’thNorthern (1st) : Every 10 donors save 3 more lives than we do
10Organ Donation Past, Present and Future
YORKSHIRE
Organ Donation Past, Present and Future
Diagnosis of brain‐stem death
11
37 years on37 years on1976 2008
Dr Dale GardinerAdult Intensive Care Consultant, Nottingham Midlands, Clinical Lead for Organ Donation Member of the UK Donation Ethics Committee
Organ Donation Past, Present and Future
We are explorers
not inventors.
13Organ Donation Past, Present and Future
14Organ Donation Past, Present and Future
15Organ Donation Past, Present and Future
Brain death: Discovered not Invented (by intensive care)
16Organ Donation Past, Present and Future
1964, Keith Simpson “there is life so long as
circulation of oxygenated blood is maintained to live
brainstem centres”
17Organ Donation Past, Present and Future
1976 (clarified 1979)UK Criteria for
Diagnosing Death using Neurological Criteria Published.
18Organ Donation Past, Present and Future
2008UK Criteria for
Circulatory Criteria published for the 1st
time. 5 minutes.
Eugene Bouchut1846
Rene´ Laennec 1819
UK Definition of Death
19Organ Donation Past, Present and Future
“… irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe…
therefore irreversible cessation of the integrative function of the brain‐stem equates with the death of the individual.”
2008
UK Definition of Death
20Organ Donation Past, Present and Future
All human death is anatomically located
to the brain.
“… irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe…
therefore irreversible cessation of the integrative function of the brain‐stem equates with the death of the individual.”
2008
Organ Donation Past, Present and Future
1 death : 3 sets of criteria
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Neurological Criteria
Circulatory Criteria Somatic Criteria
Dx Death using Neurological Criteria
Organ Donation Past, Present and Future 22
1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
• Cause tells you irreversibility, based on the natural history of the disease
• Cause tells you how long you should observe before testing:
• ‘Typical’ > 6 hours
• Hypoxia 24 hours
• Atypical ? longer
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Organ Donation Past, Present and Future
Organ Donation Past, Present and Future
> 10000 patients 10 years
…37 years
Organ Donation Past, Present and Future
D. Alan Shewmon, MD
Organ Donation Past, Present and Future
‘Although we were unable to restore his consciousness or spontaneous breathing, the boy lived several more years.’(page 195)
Organ Donation Past, Present and Future
Organ Donation Past, Present and Future 28
1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
2. An exclusion of reversible conditions capable of mimickingor confounding the diagnosis of death using neurological criteria.
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Dx Death using Neurological Criteria
Organ Donation Past, Present and Future 29
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
• Clinical judgement essential
• Impossible to create rules covering
every situation
• Difficulties mainly with
thiopentone and midazolam
• Plasma concentrations not good
predictors of effect
• Use of antagonists
Dx Death using Neurological Criteria 2. An exclusion of
reversible conditions capable of mimickingor confounding the diagnosis of death using neurological criteria.
Organ Donation Past, Present and Future 30
1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes.
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Dx Death using Neurological Criteria 2. An exclusion of
reversible conditions capable of mimickingor confounding the diagnosis of death using neurological criteria.
Brain‐stem reflexes
Organ Donation Past, Present and Future 31
Pupils (II, III)
Corneals (V, VII)
Pain (V, VII)
Gag (IX, X)
Cough (IX, X)
Oculovestibular (III, VI, VIII)
Oculocephalic
Suck Paediatric
Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001;344:1215-1221 + AoMRC (2008)
ConsciousnessAscending reticular activity systemBreatheMedulla Oblongata
Apnoea Test
Organ Donation Past, Present and Future 32
Recommended method: After pre‐oxygenation, disconnect the patient from the ventilator and administer oxygen via a suction catheter in the endotracheal tube at a rate of >6 L/minute. If oxygenation is a problem, consider the use of a CPAP circuit (eg Mapleson B). The apnoea test is performed only twice in total.
Stopping: 5 minutes observation paCO2 rise > 0.5 KPa
Starting: paCO2 > 6.0 KpapH <7.4
1. An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes.
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Dx Death using Neurological Criteria 2. An exclusion of
reversible conditions capable of mimickingor confounding the diagnosis of death using neurological criteria.
In 2012,1238 tests performed, death confirmed in 1220 = 98.5%
Testing for Brain‐stem Death
Organ Donation Past, Present and Future 34
“This form is consistent with and should be used in conjunction with, the AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of Deathand has been endorsed for use by the following institutions: Faculty of Intensive Care Medicine, Intensive Care Society and the National Organ Donation Committee.”
Full
Abbreviated
Organ Donation Past, Present and Future 35
Organ Donation Past, Present and Future
WHY TEST?
Organ Donation Past, Present and Future
WHY TEST?
1. To eliminate all possible doubt regarding survivability
2. To confirm diagnosis for families
3. To protect doctors in cases subject to medico‐legal scrutiny
4. To provide choice regarding organ donation
Organ Donation Past, Present and Future
diagnosis decision
Organ Donation Past, Present and Future
Brainstem death in the
Organ Donation Past, Present and Future
TWO TESTS or ONE?
2008
= 2 TESTS (regardless of organ donation) Legal support from case law& Bolam & Bolithio tests
Dr A performs Dr B observes
SWAP
Dr B performsDr A observes
Organ Donation Past, Present and Future
TWO TESTS or ONE?
2008 Dr A performs Dr B observes
SWAP
Dr B performsDr A observes
= 2 TESTS (regardless of organ donation) Legal support from case law& Bolam & Bolithio tests
Organ Donation Past, Present and Future
TWO TESTS or ONE?
ALIVE
Test 1
ALIVE
Test 2
DECEASED
2008 Dr A performs Dr B observes
SWAP
Dr B performsDr A observes
= 2 TESTS (regardless of organ donation) Legal support from case law& Bolam & Bolithio tests
Time of
Death
Organ Donation Past, Present and Future
20081976
Lesson 1
Organ Donation Past, Present and Future
Lesson 2
Organ Donation Past, Present and Future
Lesson 3
Take your time
•Slow down (minimum 6 hours)•Don’t over-read coning on CT•Atypical presentation = wait •Hypoxic brain injury
>24 hours
Organ Donation Past, Present and Future
Lesson 4
Induced hypothermia has unpredictable consequences
See Lesson 3
Advice: warm to normothermia and then wait 24 hours
Organ Donation Past, Present and Future
Lesson 5
NO EEG
Organ Donation Past, Present and Future
Lesson 6
Start with Lesson 2 = use your brain and examine your patient
1. Clinical brain death + NO flow = Death
2. Clinical brain death + flow = Wait See Lesson 3 = take your time and ask‘Is reversibility possible?’
Organ Donation Past, Present and Future
www.clodlog.comUsername: DalePassword: Gardiner
Gardiner, Shemie, Manara & OpdamInternational Perspective on the Diagnosis of DeathBr J Anaesthesia Supplement January 2012
www.odt.nhs.uk
Dr Gerlinde Mandersloot20th April 2012
Optimising the brainstem dead
donor
Dr Gerlinde ManderslootNational Clinical Lead - Donor Optimisation
Organ Donation Past, Present and Future 50
Donor optimisation
• Ameliorate ‘systemic’ effects of brain stem death
• Why?• Increase number of donors• Increase number of organs per donor• Increase quality of organs
• Who takes responsibility?• ICU staff: medical and nursing• SN-ODs• Retrieval teams
• ‘Scout’• Cardio-thoracic teams
Organ Donation Past, Present and Future 53
‘Collateral damage’
• Hormonal • Diabetes insipidus
• Hypovolaemia• Hypernatraemia
• T3 / T4 reduces• ACTH• Blood glucose
• Hypothermia
Organ Donation Past, Present and Future 54
Incidence of organ involvement
• Hypotension 81%
• Diabetes insipidus 65%
• DIC 28%
• Cardiac dysrrhythmias 25%
• Pulmonary oedema 18%
• Metabolic acidosis 11%
J Heart Lung Transplantation 2004 (suppl)
Organ Donation Past, Present and Future 55
Organ Donation Past, Present and Future 56
Evidence
• Totsuka Transplant Proc. 2000; 32;322-326
• High sodium in liver donor doubles graft loss
• Rosendale Transplantation 2003. 75 (4): 482-487
• Protocol increased organs per donor 3.1 to 3.8. Increased probability of
transplant.
• Snell J Heart Lung Transplant 2008;27:662-7
• 54% of Australian lung donations used for transplant vs. 13% in UK
Organ Donation Past, Present and Future 57
Principles
• Ameliorate ‘systemic’ effects of brain stem death• Why?
• Increase number of donors• Increase number of organs per donor• Increase quality of organs
• Who takes responsibility?• ICU staff: medical and nursing• SN-ODs• Retrieval teams
• ‘Scout’: who are they attached to?• Cardio-thoracic teams• Abdominal teams• Free standing
Organ Donation Past, Present and Future 58
What do we aim for ?
• General stability• Examples of target values
• MAP: 60 – 80 mm Hg• Heart rate: 60 – 100 / min SR• CI: > 2.1 l/min/m2
• Guidelines• Australian• Canadian• Map of Medicine• ICS• NHSBT
Organ Donation Past, Present and Future 59
Cardiovascular management
• Summary of cardio vascular target values• MAP: 60 – 80 mm Hg• CVP: 4 – 10 mm Hg• Heart rate: 60 – 100/min SR• CI: > 2.1 l/min/m2 (can be higher, be aware of myocardial stunning)• Filling targets: no good evidence for any specific targets, depends on
device• SvO2 > 60%• SVRI target
• Secondary target• Dehydration temptation to maintain MAP with vasopressors rather than filling
Organ Donation Past, Present and Future 60
Respiratory management
• Recruitment manoeuvre• Post BSD testing: apnoea test resulting in atelectasis• After suctioning / disconnection• When SpO2 drops / FiO2 increases
• Lung protective ventilation: 4 – 8 ml/kg ideal body weight• Permissive hypercapnia with pH > 7.25• Optimum PEEP (5 – 10 cm H2O) and FiO2 (aim for < 0.4 as able)• Head–up positioning (30 - 45°)• Suctioning, physiotherapy as required• Antibiotics for purulent secretions: local microbiology surveillance• Avoid over-hydration
Organ Donation Past, Present and Future 61
Managing Diabetes insipidus
• Very common occurrence• Pathophysiology
• Posterior pituitary failure• Polyuria: output > 4ml/kg/h• Dehydration with Na+
• Usually at least partially addressed with stabilisation for BSD testing• Treatment:
• Fluids• Vasopressin• DDAVP
• Aim for u-output 0.5 – 2.0 ml / kg / h
Organ Donation Past, Present and Future 62
Hormonal treatment
• Vasopressin• Reduction in other vaso-active drugs• Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time)
• Liothyronine (T3)• No clear evidence yet for either use or not• May add haemodynamic stability in very unstable donor• Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team
• Methylprednisolone in all cases• Dose: 15 mg/kg up to 1g
• Insulin• At least 1 unit/h (Occasionally may need to add glucose infusion)• ‘Tight’ glycaemic control (4 - 10 mmol/l)
Organ Donation Past, Present and Future 63
Haematological management
• DIC seen occasionally as direct consequence of BSD• May require correcting prior to BSD testing if bleeding
• Hb > 8 g/dl (~ 10 g/dl traditionally advocated) (even > 7g/dl ?)• No evidence on harm with lower Hb, but some evidence of harm with
blood transfusions and organ function post transplant• Where Hb borderline, ensure blood available for retrieval procedure: local
protocols and antibodies will determine whether G&S only, or units to be cross matched
• Use of clotting factors• Only where bleeding is an issue• Monitor clotting status• Use local hospital protocol• Retrieval procedure may require additional products
Organ Donation Past, Present and Future 64
General measures
• Maintain normothermia (active warming may be required)• Thrombo-embolism prophylaxis
• Stockings• Sequential compression devices• LMWH
• Positioning• Head-up• Side to side• Attention to cuff pressures and leaks to prevent aspiration
• Continue NG feeding (may be reduced/ stopped for bowel transplant)
• Antibiotics according to sensitivities or empirical according to Trust guidelines
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Monitoring optimisation
• Implementation: use of care bundle• Adherence easy to monitor• Audit first 5 priorities
• Results of optimisation evaluated• Number of organs retrieved• Increase in cardiothoracic organs retrieved
• Quality of organs: organ function in recipients• Delayed graft function• Quality: biomarkers• Duration of graft function: long term project
Organ Donation Past, Present and Future 66