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Preserving the Donation Opportunity

Preserving the Donation Opportunity. Shared Goals. Maintain urine output Maintain oxygenation Maintain normothermia Maintain normoglycemia Prevent/treat infection. Optimize organ perfusion and medical suitability. What are the most common Challenges.

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Preserving the Donation Opportunity

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  1. Preserving the Donation Opportunity

  2. Shared Goals • Maintain urine output • Maintain oxygenation • Maintain normothermia • Maintain normoglycemia • Prevent/treat infection Optimize organ perfusion and medical suitability

  3. What are the most common Challenges • Hypotension (hypovolemia, vasodilatory shock) • Diabetes Insipidus / Hypernatremia • Oliguria • Metabolic (acid/base, electrolytes, glucose) • Hypoxemia, Ventilator settings • Hypothermia

  4. Hemodynamics • Goal: Maintain Systolic BP>90; CVP of 6-8 mmHg • Hypotension /hypertension • Heart rate fluctuations-dysrhythmias • Coagulopathy • Interventions • -CVP < 6 and (H &H) normal • Lactated Ringers or Normal Saline fluid bolus of 500 cc over 30 minutes for SBP < 90 mmHg. • -CVP < 6 and (H&H) < 8, then administer 1-2 units of PRBC’s

  5. Vasoactive IV fluids/drips • Vasopressors commonly used are: • Dopamine • Epinephrine • Neosynephrine • Levophed/Norepinephrine • Vasopressin (AVP) low dose

  6. Oxygenation • Goal: Maintain PO2>100mm Hg and pH7.35-7.45 • Potential Problems: • Hypoxemia • Acid Balance Disturbances • Neurogenic pulmonary edema • Interventions: • Tidal volume of 7-10cc’s/kg • Steriods • Suctioning; in-line treatments • Therapeutic bronchoscopy • PEEP (5)

  7. Acid- Base and Electrolytes Goals • pH -7.35-7.45 • Electrolytes- Na, K, Ca, Mg, P - WNL • Glucose- < 150 • U/O 1-3 ml/kg/min Interventions • Adjustments of Vent and/or Na Bicarbonate IV • Appropriate IVF – LR, NS, .5 NS (Depending on Na, K, Gluc) • Appropriate supplementation FOR K+ ,Ca++, Mg++,P+++ • Insulin –bolus and/or continuous drip • DDAVP or Fluids, Diuretics, Mannitol

  8. Urine Output • Goal: Maintain Urine Output 1ml/kg/hr in the Adult or 2ml/kg/hr in the Child • Potential Problems: • Diabetes insipidus • Hyperglycemia • Interventions: • Volume replacement • DDAVP / vasopressin • K+ replacement

  9. Temperature • Goal: Maintain Core Temperature Between 97-100 F • Hypothermia • Hyperthermia • Interventions • Heating/cooling blankets

  10. Other IV fluids (drips) • Dobutamine--used to treat heart failure, may be combined with dopamine. May be used as a pressor in pediatric patients • Vasopressin--used to treat shock, diabetes insipidus; enhances the effectiveness of other vasoactive medications. May be used as a pressor in pediatric patients • Nipride--used to treat hypertension • Esmolol, Verapamil, Adenosine---used to correct irregular heartbeats

  11. InfectionGoal: Ensure Absence of Infection Use of Broad Spectrum Antibiotics Obtaining cultures as needed Blood Sputum Urine Monitor WBC’s

  12. TemperatureGoal: Maintain Core Temperature Between 97-100 F Hypothermia Hyperthermia

  13. Family Preparation

  14. What can You Do • Check yourself • Offer open honest communication • Have them tell you what they understand the situation to be • Offer them support by involving pastoral Care

  15. Allowing families time to process the death and brain death explanation is IMPORTANT • “Decoupling” - separating the brain death explanation from the request for organ donation • Decoupling may be a valuable tool in obtaining consent for donation • Siminoff, et al concluded that the most important factor in obtaining consent was time spent with the OPO

  16. Creating the Bridge Hospital is an advocate of organ donation Patient Care Conferences Timely notification Appropriate requester Families satisfaction with quality of care Frequent communication Time with loved one Understanding of brain death *Source: JAMA July 4, 2001 and Collaborative High Leverages Changes

  17. Pre-request Conference • A sensitive, timely and informed consent • How to accomplish…. “huddle” with hospital staff to determine: • The key decision maker • Family’s understanding of the grave prognosis • Review communication plan • Determine who, when, where and how the communication will occur • Revise the plan as needed

  18. Guiding principles • For the family, their grief and loss are primary, not the donation— and all of our actions are guided by this awareness. • We are not taking something from families. We are giving information to families about an important opportunity: • To consider the opportunity of donation

  19. Wouldn’t it be Nice?

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