ICM - Care of the beating Donor

Question 1

Pathophysiological changes in BSD

Answer 1

CVS Increased BP to maintain perfusion whilst ICP rises Cerebral herniation —> pontine ischaemia —> CATECHOLAMINE STORM Intense vasoconstriction, SVR and tachy Risk of myocardial ischaemia Cushings (hypertension plus brady) —> baroreceptor reflexes Foreamen magnum herniation —> loss of sympathetic tone, vasodilation, hypotension Need for vasopressorsResp Hydrostatic pressures - pulmonary oedema Apneoa and cardiac arrestEndocroine Cranial DI — fluid and electrlyte losses Hypothalamus - hypothermia and hypothyroidCoag - catecholamines affect platelet function

Question 2

Cardiovascular goals in BSD

Answer 2

HR 60-120.minSBP > 100mmHgMAP 60-80PCWP 10-15mmHgCI>2.1 min/m2SvO2 > 60%CVP 6-10SVRI 1800-2400 dynes.sec/cm5/m2

Question 3

CVS management goals

Answer 3

Restore an effective circulating volumeAvoid overloadVasopressin is first choice.If no change in CI, inotropes (NHS BT say DOPAMINE)

Question 4

Ventilatory goals

Answer 4

Recruitment manoeuvresLPV —> 4-8ml/kg of IBWPEEP 5-10Limit peak pressure to <30Chest physioHead upABG targets

Question 5

ABG targets in BSD

Answer 5

PH 7.35 - 7.45PaO2 > 10kpaCO 4.5-6SpO2 > 94 for the lower fio2

Question 6

Metabolic principles in BSD

Answer 6

Give 15mg/kg methylpred — stops increase in extra vascular lung water Associated with increased organ retrieval —> use ASAPActive warmgin to 36-37.5C

Question 7

Endocrine principples in BSD

Answer 7

Insulin to BM 4-10Early vasopressin MAY prevent DIPituitary hormones (esp thyroid descrease) but T3 replacement no longer routineIf Na>155 give NG water or dextrose

Question 8

Haem principles of BSD

Answer 8

Blood/blood products if indictated Local transfusion triggers BUT evidence transfusion affect organ function post transplant Fix coag only if significant ongoing bleeding

Question 9

What is cranial DI

Answer 9

Primary loss of ADH due to ischaemiaUrine output > 4ml/kg/hourSerum Na > 145Serum osmol > 300 mosmol/kgUrine osmol < 200If UO sudden rises, do not wait from plasma/urine testsReplace fluid with minimal sodium Desmopressin 0.5-4mcg ivIF vasopressin not managing