transplant.bc.ca

DCD

PANBCOctober 29, 2011

Greg Grant

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DisclosuresDisclosures

BC TransplantBC Transplant

St Paul’s HospitalSt Paul’s Hospital

Mt. St. Jospeh’s HospitalMt. St. Jospeh’s Hospital

Vancouver General HospitalVancouver General Hospital

BC Women’s HospitalBC Women’s Hospital

BC AmbulanceBC Ambulance

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OBJECTIVESOBJECTIVES

-Understand the Types of -Understand the Types of Organ DonationOrgan Donation

-Understand the Differences -Understand the Differences between Brain Death and between Brain Death and

DCDDCD

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Types of DonationTypes of Donation

LivingLivingKidneyKidney

LiverLiver

Brain DeathBrain DeathLung, Heart, Liver, Pancreas, Lung, Heart, Liver, Pancreas, KidneyKidney

Deceased DonationDeceased DonationCornea, Skin, BoneCornea, Skin, Bone

Kidney, Liver, Pancreas Islet CellsKidney, Liver, Pancreas Islet Cells

Case HistoryCase History

• 49 year old man49 year old man

• Witnessed collapse at 10:25Witnessed collapse at 10:25

• Struck Head and small abrasionStruck Head and small abrasion

• ALS arrived 1034 – PEAALS arrived 1034 – PEA

• ROSC 10:55 - Down time 30 minutesROSC 10:55 - Down time 30 minutes

• SPH – No criteria for angio – SPH – No criteria for angio – Inf/Lat ST DepInf/Lat ST Dep

• CT no acute bleedCT no acute bleed

• GCS 3 – Cooling ProtocolGCS 3 – Cooling Protocol

HistoryHistory

• Exertional chest pain x 6 monthsExertional chest pain x 6 months

• Increasing pain over last weekIncreasing pain over last week

• Elevated LDL, Hypertension, Mild Elevated LDL, Hypertension, Mild Asthma, Asthma,

• Fluticasone, Fluticasone,

• Alcohol 12 drinks per weekAlcohol 12 drinks per week

Initial LabsInitial Labs

• Initial BloodsInitial Bloods– Troponin 0.09Troponin 0.09– Lactate 5.9Lactate 5.9

• 12 hours later12 hours later– Troponin 22.5Troponin 22.5– Lactate 1.4Lactate 1.4– CK 1091CK 1091

Course in ICU – Day 2Course in ICU – Day 2

• Cooling protocol stopped after 24 Cooling protocol stopped after 24 hours:hours:

• CT Head and Spinal protocolCT Head and Spinal protocol• 24 hours : Very abnormal c/w diffuse 24 hours : Very abnormal c/w diffuse

ischemic injuryischemic injury

• Neurology ConsultNeurology Consult– Intact brain stem reflexes, no response Intact brain stem reflexes, no response

to painful stimulation, arm movements to painful stimulation, arm movements with cough, - just coming off coolingwith cough, - just coming off cooling

Course in ICU – Day 3Course in ICU – Day 3

• Diffuse myoclonus, needed Diffuse myoclonus, needed suppression for ventilationsuppression for ventilation

• Treated with Midazolam and then Treated with Midazolam and then transitioned to Propofoltransitioned to Propofol

Course in ICU – Day 4Course in ICU – Day 4

• Continued myoclonusContinued myoclonus

• EEGEEG– Off sedation for 8 hoursOff sedation for 8 hours– Burst suppression pattern noted without Burst suppression pattern noted without

seizure activityseizure activity

• CT Scan CT Scan – Progression with loss of grey-white Progression with loss of grey-white

differentiation, particularly in basal ganglia, differentiation, particularly in basal ganglia, – Further effacement of SulciFurther effacement of Sulci

Course in ICU – Day 5Course in ICU – Day 5

• Neurology ConsultNeurology Consult– Myoclonus still present on face with occasional Myoclonus still present on face with occasional

whole body movements.whole body movements.– Pupils brisk, dolls eyes intact, corneal intact, Pupils brisk, dolls eyes intact, corneal intact,

gag present.gag present.– Diffuse spasticity of arms and legs with Diffuse spasticity of arms and legs with

sustained clonus in ankles and down going sustained clonus in ankles and down going toes.toes.

– No withdrawl to painful stimulus.No withdrawl to painful stimulus.– Breathing on PS 5 peep 5, normothermicBreathing on PS 5 peep 5, normothermic

Direction of CareDirection of Care

• Family meeting with Wife and supportFamily meeting with Wife and support

• Attending Intensivist discussed prognosisAttending Intensivist discussed prognosis

• Decision made to change to comfort careDecision made to change to comfort care

• Donation team met with familyDonation team met with family

• Consent obtained for donationConsent obtained for donation

• Second Physician opinion re Comfort CareSecond Physician opinion re Comfort Care

ConsentConsent

• Explanation of the procedureExplanation of the procedure– 24 hours delay to obtain tests for donation24 hours delay to obtain tests for donation– ExtubationExtubation– Regular comfort careRegular comfort care– When becoming unstable HeparinWhen becoming unstable Heparin– If died in 90 minutes 2 physicians examine and If died in 90 minutes 2 physicians examine and

declaredeclare– 2 minutes in the ICU room2 minutes in the ICU room– Travel to OR anti-roomTravel to OR anti-room– Reconfirmation death – 2 physicians – Reconfirmation death – 2 physicians – – To ORTo OR

Comfort CareComfort Care

• Family and friends present in the Family and friends present in the room during extubationroom during extubation

• Patient died 23 minutes after Patient died 23 minutes after extubationextubation

• Family left shortly after declarationFamily left shortly after declaration

• To OR for donationTo OR for donation