The Role of the Respiratory Therapist in Organ Donation The ...

The Role of the Respiratory
Therapist in Organ Donation
Presented by
Oscar Colon, RN CPTC
In-house Clinical Donation Specialist III
The Sharing Network
• Private non-profit service organization
• Federal designation to provide recovery
services
• State licensed
• Available 24 hours/7 days a week
• Arrange for the recovery of all organs and
tissues
Organ Transplant
Waiting Lists
January 2010
105,000Total Waiting in U.S.
3,100 Total Waiting In NJ
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Hospitals
Conditions of Participation
1. Refer all deaths to the
OPO. Referral must be
“timely” and
“imminent.”
2. Hospitals must
participate with their
approved OPO in
Medical Reviews.
3. Only staff trained or
employed by an OPO
may offer families the
options of donation
4. All request for donation
must be a collaborative
effort between OPO and
hospital.
5. Develop cooperative
relationships with eye
and tissue banks.
6. The OPO must
determine donor
suitability.
Current Clinical Triggers:
When to Refer
Imminent Death Referrals
Regardless of age, diagnosis, cause of death, sedation or religious beliefs
call on all vented patients
within 1 hour of meeting any of the following clinical triggers:
• Glasgow coma scale (GCS) 5 or less
• Absence of 2 or more of the following reflexes:
Cough Reflex
Gag Reflex
Pupillary response to light Corneal Reflex
Response to Pain
Loss of Respirations
• Call when contemplating discussions of the following:
Before withdrawal of life support, making End of Life Decisions -
while organs for transplant are still viable
How the staff sees us:
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Incidence of Brain Death
• About 75,000 deaths per year in N.J.
• 32,000 – 34,000 of those deaths in hospitals
• Only 275-325 are brain dead and medically
suitable
• That is less than .01% of all deaths
Organ Donation
One organ donor can save up to 8 lives
• Heart
• Lungs
• Liver
• Kidneys
• Pancreas
• Small Intestine
Tissue Donation
(50 or more potential recipients)
• Bone - orthopedic surgeries such as spinal, knee
replacements, hip revisions and dental procedures.
• Soft tissue – for sport injuries such as Achilles tendon
replacement
• Corneas – restores sight
• Heart valves – used for heart valve replacement
surgery
• Blood vessels – for bypass surgery
• Skin – used for wound and burn grafting
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Steps in the Donation Process
• 1. Referral
• 2. Evaluation
• 3. Consent
• 4. Maintenance
• 5. Recovery
• 6. Follow-up
The Referral
• Report all deaths –mandated by COP
• Cardiac deaths – Call within 1 hour after the
patient expires
• Potential organ donor – Call within 1 hour
when the patient meets clinical triggers at or
initiation of brain death protocol, Glasgow
Coma Scale of 5 or less
The Evaluation
• Response –on sight transplant
coordinator
• Donor suitability-lab data, current
status
• Requirements for declaration of death
• Medical and social history thru chart
review
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The Consent
• Family assessment-legal NOK and decision
makers
• Decoupling information
• Presentation of donation options by
“Effective Requestor”
• Legal consent
• Testing -infectious disease screening
• Medical examiner
Maintenance
• Maintain optimal organ function
• Maximize on number of recipients
• Maintain hemodynamic stability
• Adequate oxygenation
Organ Sharing
• All recipients listed with UNOS (United
Network for Organ Sharing)
• Match run lists from donor information
• Each organ has separate list
• OPO mandated to share organs by list
• Local centers get greatest priority
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The Recovery
• Use of operating room at donor hospital
• Surgical recovery and preservation of
organs
• Tissue recovery after organs recovered
• Reconstruction of body
• Body released – to medical examiner or
funeral home
Follow up
• Family - provide follow up letter
• Hospital staff - outcomes and appreciation
• Family aftercare support
• Communication - donor family and
recipient(s)
When are you dead
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New Jersey Legal Definition
• “An individual who has sustained either (1)
IRREVERSIBLE cessation of circulatory and
respiratory functions, or (2) IRREVERSIBLE
cessation of ALL functions of the brain including
the brain stem, is dead.
A determination of death must be made in
accordance with accepted medical standards.”
State Regulations for Brain Death
• Board of Medical Examiners took law and
passed regulations
• Assure consistent practice
• Create standard of care
• Provided level of authority to develop new
standards as time progressed
Brain Death: Board Of ME
Appropriate Observation Period
Age
Cause of Injury
Clinical Exams:
Minimum
Period of
Observation
Confirmatory
Test
Any age Any cause One exam only Yes
< 2 months Any cause 48 hours No
2 to 12
months
Any cause 24 hrs No
> 12 months Any cause 6 hrs No
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Ascertain Irreversibility
• Known etiology
• Rule out intoxication
• Rule out abnormal metabolic states
• Rule out profound hypothermia
• Temporal space between exams
Ascertain Totality
• Unresponsiveness GCS of 3
• Absence of brain stem reflexes
• Apnea
• Acceptance of spinal reflexes
• Cerebral Doppler
Confirmatory Tests
• Nuclear Cerebral Blood Flow Study
• Cerebral Vessel Angiography / MRI
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The Apnea Test
• A method to determine absolute apnea
• Based on a finding that apnea cannot be
reliably diagnosed unless it occurs in a
setting of adequate hypercarbic stimulation
of the brainstem.
• A PaCO2 of 60 mmHG or more is generally
considered adequate hypercarbic
stimulation of the respiratory centers.
Performing the Apnea Test
• Obtain a baseline ABG
• Make necessary ventilator changes to achieve a
PaCO2 of 40 mmHG and a pH

Performing the Apnea Test
• If spontaneous breathing does not occur and
patient is hemodynamically stable; after 10
minutes draw an ABG
• If PaCO2 is greater than 60 mmHG or 20
points above baseline PaCO2 and there
have been no spontaneous respirations; the
test is positive and the patient is considered
to be apneic
How can you help
• Notify MD/RN of changes in patients
ventilatory status
• Inquire if the referral has been made to
NJSN – If not call us 1800-541-0075
• Please do not mention Donation!!!!
• Be an active part of the healthcare team;
join in our huddles
• Provide aggressive pulmonary support
Something to think about..
• “What’s good for the Lungs is
good for the Body”
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How can you help
• Help overcome atelectasis
• Maintain HOB at 30 degrees
• Turn patient every 2 hours
• Frequent suctioning and good mouth care
• Chest PT every 4 hours
• Hyper inflate ETT cuff; which reduces aspiration
and protects the lungs
• Bronchodilators every 4 hours
• Pulmonary toilet
• Lung Recruitment
Pulmonary Management Goal
is to
Ensure adequate ventilation
• Pressure - Control Ventilation
• TV 10-15ml/kg
• Peep 5-10cm
• ABG’s every 2-3 hours adjust settings accordingly to
maintain optimal parameters
– pH 7.35 -7.45
– PaCO2 35-45
– PaO2 >100
– HCO3 22-26
– O2 Sat 95-100%
• PIP < 30 cm H2O
Requirements for Lung offers
• O 2 Challenge (pO2 > 300mmHg)
• Arterial Blood Gases
• Sputum Culture
• Chest X-rays
• Bronchoscopy
• Lung measurements
• Pulmonary Consult
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O2 Challenge
• Place patient on 100% FIO2 with 5cm
PEEP for 30 minutes
• After 30 minutes draw an ABG & switch
FIO2 back to original setting
• Lung Transplant Surgeons are looking for
PaO2 >300
What is DCD
• Formerly called Non-Heart-Beating-Donation, Donation After
Cardiac Death has been an end-of-life option for patients and
families for than 30 years.
• After the decision has been made that the patient has no chance of
survival and the family has decided to withdraw life support, the
Sharing Network is contacted and evaluates the patient for
medical suitability. If patient is suitable, the family is offered the
option of DCD.
• It is the recovery of organs from those patients who do not meet
the criteria of brain death. Usually, these patients have suffered a
severe, irreversible brain injury, but retain some brain stem
activity
DCD is Not a New Process……
• Kidney transplants began in the 1950s
• Early recoveries were from DCD donors
• Brain death criteria established in 1960s
• Recent renewed interest in DCD-the waiting
list is ever growing!
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SCORE:
8-12 High Risk for continuing to breathe after extubation
13-18 Moderate Risk for continuing to breathe after extubation
19-24 Low Risk for continuing to breathe after extubation
DCD TOOL
• Prior to the test record the BP, Pulse, O2 sat
• Disconnect the patient from the ventilator
• After 5 minutes and 10 minutes record the
following:
– BP, Pulse, O2 sat, respiratory effort (yes or no),
respiratory rate, Tidal volume, NIF
• If patient becomes unstable (O2 sat 40 3
2 – Tidal Volume
Tidal Volume > 200ml 1
Tidal Volume < 200ml 3
3 – Negative Inspiratory Force (NIF)
NIF > -20cmH2O 1
NIF -1 to -20cmH2O 3
****No Spontaneous Respirations automatic 9
5 - BMI
30 3
6 - Vasopressors
No Vasopressors 1
Single Vasopressor 2
Multiple Vasopressors 3
7 - Patient Age
0-30 1
31-50 2
51 + 3
8 - Intubation
Endotracheal Tube 3
Tracheostomy 1
9 - Oxygenation After 10 Minutes
O2 Sat. > 90% 1
O2 Sat. 80-89% 2
O2 Sat. < 79% 3
10- Leak Test: Present Absent Total Score →
Date of Extubation:
Date of Expiration:
Time of Extubation:
Time of Expiration:
Total Time:
Formula for Calculating BMI
BMI = (_________weight in pounds__________) X 703
(Height in inches) X (Height in inches)
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Respiratory Therapist’s Role in
the OR
Brain Dead – pulmonary management, help transport the
patient, preferably on a portable vent
- hand off to anesthesia
DCD - help transport the patient, preferably on a portable
vent
- assist the attending physician and the
ICU nurse with extubation in the O.R. as
per standard ICU procedure (suction,
extubate etc.)
Families
give the gift
of life...
if only we give
them the
opportunity.
Thank You !!!
Disclaimer
All lecture materials will be posted for 30 days after the date of
the conference. The material is intended for educational
purposes only, public distribution or use of this material is not
allowed without the speaker's permission. For more
information please contact:
http://shrp.umdnj.edu/programs/rspth/UH_conference.htm
Terrence Shenfield
Program Coordinator
shenfite@umdnj.edu
(973) 972-8825
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