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Breathe Easy:Making Lung Offers That Can Be Accepted
Adam Bell, BS, CCEMT-P, CPTC
Donor Network of Arizona
NATCO Annual Meeting Aug 11, 2014
Disclosures
There are no financial conflicts of interest from the presenters for this approved course.
All individuals in positions to control content of the educational activity have disclosed all financial relationships and there are no conflicts of interest.
There is no commercial support of this educational activity.
There is no off-label usage/no product related to this activity.
Objectives
Identify 3 reasons transplant center physicians may not be familiar with offers when they become primary
List 5 things an OPO can do to speed allocation and acceptance of lungs
List 8 elements of a “complete” lung offer
Describe 3 factors transplant centers can consider to help identify which recipients might be appropriate for a given set of lungs
Indications for Lung Transplant
Congenital
Idiopathic Pulmonary
Fibrosis
Cystic Fibrosis
Pulmonary HTN
A1AT , COPD
CLAD
…and recipients have myriad comorbidities
Ethical Concepts in Organ Allocation
Beneficence
Non-Malfeasance
Justice (equitable distribution)
We don’t work in sales. Our goal must be to help recipients rather than to place organs.
If it’s bad: write it in neon!
Why isn’t the Transplant Center familiar with my offer?They gave a “Prov Yes.”
Incomplete offers
Call centers and non-physician staff taking offers
Decision makers are busy
Offer may change before becoming “primary”
What do Transplant Centers want?
To transplant organs with good long-term outcomes
That’s really it, but, they have to protect recipients from bad offers, and that’s our fault.
Using Donor Highlights
FBO and ground time info
Allocation plan and laterality issues
DCD tool
Direct Centers to what their organ needs (LU team see Echo, and CT-chest)
If “backing up” Who will be recovering what and when, Will you delay XC?
Attachments in UNET
Are NOT available in mobile view
Searchable documents are best
Legibility is an issue
Small, discrete, well labeled attachments are better
If it matters: Type it into UNET!
Med-Soc Follow up
Old Op-notes re chest surgeries
High Risk
H&P vs. Med-Soc
Travel
Place of birth? (Immunization Hx)
TB 2
Never tested +, but…
Ever tested at all?
Hx and follow up
Latent TB QuantiFeron test (24 hrs)
CDC QuantiFeron info
CT is more sensitive than CXR
Bronchoscopy findings
Did secretions clear easily?
Did they re-accumulate?
Aspiration? (Of What? Where?)
Legibility of report
Clarify findings before Dr. leaves
Pulmonary Contusions
Hard to eval pre-OR
(progressive process)
CT
Fx sternum or scapula? (Force)
Have a plan for R and L separately PRN
Pulm venous gas in OR?
Ex-Vivo perfusion may provide eval tool in non-inflammatory setting
When to CT
30+ pack years (maybe 20)
Suspicion for TB or consolidated pneumonia
Significant chest trauma
Most donors over 60
Pulm Embolism
Need to R/O malignancy
Quiz Show
Vent: PIP, rate, mode, PEEP, Tidal Vol, FiO2, I:E ratio (in APRV high and low times and P high and low also)
Recruitment: When relative to ABGs? How? Ongoing (how & when?)
Why is your PcO2 high or low?
Fluid management plan?
Why is your PA pressure high?
Why are other centers saying “No?”
If you’re going to cath anyway
Get R side pressures
Leave a SWAN in
Combine this with the CT road trip
If not traveling on a vent, use a PEEP valve
Transplant Center Challenges
Front line staff may lack autonomy
Lack of R/O criteria
Listed pts who aren’t local
(recipient transport times)
Surgeon availability
Time to set up flights
Willingness to spend $$ on flights (DCD, others recovering far away?)
Transplant Center Responsibilities
Search for any global R/O
Decline based on antigens to avoid
Decline based on size
Decline based on available organs and laterality
Create a list of ??s that need to be answered by OPO and testing requests
Exhausting the list:Heroic or Wasteful?
830 isn’t a reason; it’s a vague code
STOP and ASK WHY !!
Innate vs. treatable issues
“Fix” your donor before making more offers
Consider stopping when efforts are clearly futile
Know when to fold ‘em
COPD
Pulm HTN refractory to diuresis
HCV
Aspiration of things you can’t remove
Severe aspiration of gastric contents, food, gravel, glass etc.
Bullets in LU parenchyma
Reaching Transplant Center Staff:Using the OPO Console
OPO staff contact info can be found in the Match Run
Setting OR times
Do not set OR times prior to placing all organs, period
If you’ve ignored the above, stop making offers when OR timing will R/O those offers
In Summary
Thorough donor testing is essential to recipient safety
Both OPO and Transplant Center staff need to seek clear and open communication at all times
Offers need to be complete, and Transplant Center responses timely
Special Thanks To:
Cleveland Clinic
Lung Transplant Program Staff
…and
Thank YOU, for your daily dedication!!