Sunday, March 19, 2006

Donor Management

Lest you think my job is all Kleenex and hugs, it does have a clinical side. When we start to take over donor management varies with hospital, circumstance and personel involved. Tonight, for instance, I'm in an ICU that we work with pretty frequently. The doctor has already done the first clinical exam for brain death and the family understands that she is not going to survive. The intensivist told me to do whatever I want to manage the patient and she will sign the orders.

This is very nice for me. The earlier we manage the patient clinically, the more likely we'll have healthy organs to recover. For instance, this patient had been given Mannitol to keep the ICP down and was going into DI, so she was peeing like crazy and her BUN and creatinine were going up. The hospital had already discontinued the Mannitol, but her urine output was over 300cc/hour. Also her blood pressure was low(80-90/50), she was tachycardic and she was on 15mcg/kg/min of Dopamine. So, I did a few things: first, a liter bolus of normal saline followed by a rate of 125cc/hr. Then I gave a bolus of T4(synthroid) followed by a continuous drip. After brain death, hormone production is impaired including TSH and a rapid decline in free triiodothyronine occurs. Replacing with T4 helps maintain cardiac stability. I also had them start a pitressin drip at 0.5 units/hour, figuring that it will stem the DI and raise the BP.

She still was hypotensive for a while, so we gave more fluid boluses and increased the T4. After about 2 hours, her heart rate started to come down and her BP was up to 100/60. Her urine output was now about 75cc/hour. We were starting to come down on the dopamine ever so slowly. Also, her BUN and creatinine were trending down to normal.

If the hospital didn't let us manage her this way, she could easily have gone into kidney failure. The low BP would have caused decreased perfusion of the organs. High doses of pressors will do that also. Managing the brain dead patient is like standing in the middle of a see saw and trying to find the right balance. It's a challenge to the staff as well. They have been caring for the brain injured patient-keeping fluid input low, not turning the patient. Then I come along and want to pour fluids into the patient and do frequent turning and suctioning. It's a 180 degree turn around. A lot of staff challenge our right to be on the unit. ICU nurses are especially protective of their patients-I should know, I used to be one. Some hospitals won't let us do anything. The patient could be declared brain dead and consented for donation and they still don't want to let us do anything.

Once a patient is brain dead and consented, we pick up the all the costs (except for funeral arrangements). We'll order echocardiograms, cardiac cath's, bronchoscopies, CXR's, EKG's and labs, labs, labs. It's nice to have a triple lumen for CVP and A-line in too. We pay for the consults and the anesthesiologist when we get to the OR(but that's for another day). We'll start hormone replacement therapy: T4(if not already up), pitressin, insulin. We send blood for serologies and typing. We'll start giving Solumedrol, 15mg/kg every 8 hours to try and stem the catecholamine cascade. We'll work with respiratory therapy to maintain maximum oxygenation-vent changes, chest PT, suctioning. And correct anything else that comes up, electrolyte imbalances, infection, etc. And try to support the family and share the organs and arrange for the teams to come in and fight the OR for a time keeps me busy.


Kim said...

Whoa - I had no idea all this was required! Many years ago we had a donor that needed fluids, but I wasn't involved in the care (this was when I was in ICU) and so had no idea of what was involved! Thanks for the "inservice"! : )

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Margaret Agard said...

Donor management,

In response to your article.It was very well done.I am a ICU RN, brain patients have a history of being unpredictible. I have had first hand experience with those who seemed like there was no hope, and they defied the odds.Bear in mind,it is very distressing for some family members parting with their love ones.