Donation after Brain-Stem Death DBDodt.nhs.uk › pdf › yorkshire_dbd_presentation.pdf · optimisation – collaboration in Scout pilot Organ Donation Past, Present and Future 3

Organ Donation Past, Present and Future

Donation after Brain-Stem DeathDBD

Dr Peter HallDr Dale GardinerDr Gerlinde Mandersloot22nd May 2013

1


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


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%


YORKSHIRE

Donation in Yorkshire2003‐2013


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


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



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


Tied 6’thNorthern (1st) : Every 10 donors save 3 more lives than we do


YORKSHIRE


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


We are explorers

not inventors.




Brain death: Discovered not Invented (by intensive care)


1964, Keith Simpson “there is life so long as

circulation of oxygenated blood is maintained to live

brainstem centres”


1976 (clarified 1979)UK Criteria for

Diagnosing Death using Neurological Criteria Published.


2008UK Criteria for

Circulatory Criteria published for the 1st

time. 5 minutes.

Eugene Bouchut1846

Rene´ Laennec 1819

UK Definition of Death


“… 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


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


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


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





> 10000 patients 10 years

…37 years


D. Alan Shewmon, MD


‘Although we were unable to restore his consciousness or spontaneous breathing, the boy lived several more years.’(page 195)




2. An exclusion of reversible conditions capable of mimickingor confounding the diagnosis of death using neurological criteria.

DEATH



Dx Death using Neurological Criteria


DEATH



• 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.



3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes.

DEATH





Brain‐stem reflexes


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


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


3. A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes.

DEATH





In 2012,1238 tests performed, death confirmed in 1220 = 98.5%

Testing for Brain‐stem Death


“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



WHY TEST?


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


diagnosis decision


Brainstem death in the


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


TWO TESTS or ONE?

2008 Dr A performs Dr B observes

SWAP




TWO TESTS or ONE?

ALIVE

Test 1

ALIVE

Test 2

DECEASED

2008 Dr A performs Dr B observes

SWAP



Time of

Death


20081976

Lesson 1


Lesson 2


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


Lesson 4

Induced hypothermia has unpredictable consequences

See Lesson 3

Advice: warm to normothermia and then wait 24 hours


Lesson 5

NO EEG


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?’


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


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


‘Collateral damage’

• Hormonal • Diabetes insipidus

• Hypovolaemia• Hypernatraemia

• T3 / T4 reduces• ACTH• Blood glucose

• Hypothermia


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)



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


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


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


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


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


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


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)


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


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


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


Documents

Donation after Brain-Stem Death DBDodt.nhs.uk › pdf › yorkshire_dbd_presentation.pdf · optimisation – collaboration in Scout pilot Organ Donation Past, Present and Future 3