Management Flashcards
OPTN Policy 2
What donor documentation is submitted to UNOS to enable complete and accurate evaluation of donor suitability by transplant programs?
((What (9) items must be uploaded to Donornet?))
a. ABO
b. ABO subtype
c. IDT
d. Death pronouncement
e. Authorization for donation
f. HLA
g. Donor evaluation and management
h. Donor medical and behavioral history (UDRAI)
i. Organ intraoperative findings
OPTN Contractor
UNOS
OPO must perform these 4 things & report the resulting information to all receiving OPOs or transplant hospitals:
- Attempt to obtain the deceased donor’s medical and behavioral history from one or more individuals familiar with the donor ( UDRAI )
- Review the deceased donor’s medical record.
- Complete a physical examination of the deceased donor, including the donor’s vital signs.
- Document in the deceased donor medical record if any of this information is not available and the reason it is not available.
UDRAI for each potential deceased donor must include all of the following 3 things
- Any testing used to identify the presence of transmissible diseases or malignancies or any other known condition that may be transmitted by the deceased donor organ and may reasonably impact the recipient.
- Whether the potential deceased donor has factors associated with an increased risk for disease transmission, including blood-borne pathogens.
- Whether the potential deceased donor has a history of prior exposure or treatment with nonrecombinant Human Pituitary Derived Growth Hormone (HPDGH). If so, the potential deceased donor has an increased risk of prion disease and the host OPO must communicate this information to all transplant programs receiving organs from the donor.
PHS Increased Risk
If the deceased donor meets the criteria for increased risk for HIV, Hepatitis B, and Hepatitis C transmission set forth in the current U.S. Public Health Services (PHS) Guideline or the host OPO cannot obtain the information necessary to make this determination, the host OPO must identify the donor as having increased risk for transmission of HIV, Hepatitis B, and Hepatitis C and communicate this information to all transplant programs receiving organs from the deceased donor.
What blood samples for deceased donor serological screening should be used?
OPOs must use qualified (non-hemodiluted) blood samples. If a qualified sample is not available for testing, a hemodiluted sample may be used for deceased donor screening tests.
What must you do if you use hemodiluted/ non qualified blood samples for serological screening?
PHS Increased Risk
OPO must treat the deceased donor as presenting an increased risk for disease transmission
Hemodilution proof:
OPO must document in the deceased donor medical record a complete history of-
All blood products and intravenous fluid transfusions the deceased donor received since admission to the donor hospital.
OPO must assess all potential deceased donor blood samples obtained for serological screening tests using what method?
Hemodilution using a U.S. Food and Drug Administration (FDA) approved hemodilution calculation.
Deceased Donor Blood Type Determination Requirements(4)
- Be drawn on two separate occasions (minimum 5min apart)
- Have different collection times
- Be submitted as separate samples
- Have results indicating the same blood type
What ABO requires subtyping?
A
host OPO must document either that subtyping was completed or the reason it could not be completed.
What ABO is subtyping optional?
AB
Requirements for subtyping (4)
-
1. Be tested on PRE PRBC transfusion samples*
2. Be drawn on two separate occasions
3. Have different collection times
4. Be submitted as separate samples
What must you do if you receive conflicting subtype results?
Subtype results must NOT BE REPORTED to UNOS
Allocate based off primary blood type.
The deceased donor is not eligible for a match run until the host OPO completes ABO verification and reporting as follows:
-Two different qualified health care professionals, must each make an independent report of the donor’s blood type as well as subtype (if applicable) to UNOS.
- Both qualified health care professionals must use all blood type and subtype determination source documents to verify they:
a. Contain blood type and subtype results for the donor
b. Indicate the SAME blood type and subtype on the two test results
c. Match the result reported to UNOS
Required Deceased Donor General Risk Assessment
7
- Arterial blood gas results
- Blood type
- Chest x-ray
- CBC
- Electrolytes
- Serum glucose
- Urinalysis, within 24 hours before cross clamp
- Blood and urine cultures
Required Deceased Donor Infectious Disease Testing (7)
1- HIV 2- Hepatitis B 3- Hepatitis C 4- Cytomegalovirus (CMV) 5- Epstein-Barr Virus (EBV) 6- Syphilis (RPR) 7- Toxoplasma
All tests results must be reported to all recipient transplant hospitals
ASAP but no later than 24 hours after receiving the test result.
Required OR info for Deceased Kidney Donors (6)
- Intra op Kidney anatomy - including number of blood vessels, ureters, and approximate length of each
- Injuries to or abnormalities
- Anesthesia Record (Recovery blood pressure and urine output information; 17. Recovery medications)
- Type of recovery procedure,
flush solution and method, and flush storage solution - Warm ischemia time and organ flush characteristics
Required LABS for Deceased Kidney Donors (4)
- HLA information
- Assurance that final blood and urine cultures are pending
- Final urinalysis
- Final blood urea nitrogen (BUN) and creatinine
Required INFO for Deceased Kidney Donors (9)
- Donor name
- Donor ID
- Date of admission for the current hospitalization
- Ethnicity
- Relevant past medical or social history
- Current history of abdominal injuries and operations
- Current history of average blood pressure, hypotensive episodes, average urine output, and oliguria
- Current medication and transfusion history
- Indications of sepsis
Required INFO for Deceased Liver Donors
- Donor name & 2. UNOS ID
- Ethnicity
- Height & 5. Weight
- Vital signs
- Social history, including drug use
- HPI in hospital including current medications, vasopressors, and hydration
- Current history of hypotensive episodes, urine output, and oliguria
- Indications of sepsis
Required LABS for Deceased Liver Donors
- Aspartate aminotransferase (AST)
- Bilirubin (direct)
- Other laboratory tests within the past 12 hours including:
- Human leukocyte antigen (HLA) typing
Required INFO for Deceased Heart Donors
- Height & 2. Weight
- Vital signs
- HPI w/ treatment in hospital including vasopressors and hydration
- Cardiopulmonary, social, and drug activity histories
- Details of any documented cardiac arrest or hypotensive episodes
Required Labs/Work up for Deceased Heart Donors (5)
- 12-lead EKG
- ABG and ventilator settings
- Cardiology consult if performed
- Echo
- Human leukocyte antigen (HLA) typing
Required Information for Deceased Lung Donors
- Height & 2. Weight
- Vital signs
- HPI & treatments including vasopressors and hydration
- Smoking history
- Cardiopulmonary, social, and drug activity histories
- Details of any documented cardiac arrest or hypotensive episodes
Required Labs/Work up for Deceased Lung Donors (5)
- ABG Challenge (on 5 PEEP/ 100% FiO2) within 2 hours prior to the offer
- Bronch results
- CXR (interpreted by a radiologist) within 3 hours prior to the offer
- Sputum gram stain, with description of sputum
- Lung Laterality
- HLA typing
Required Information for Deceased Pancreas Donors
Donor Demographics (1. Donor name; 2. Donor ID; 3. Ethnicity; 4. Weight)
- Date of admission for the current hospitalization
- Alcohol use (if known)
- Current hx of abdominal injuries and operations including pancreatic trauma
- Current hx of average blood pressure, hypotensive episodes, cardiac arrest, average urine output, and oliguria
- Current medication and transfusion history
- Pertinent PMH or social history including pancreatitis
- Familial history of diabetes
- Insulin protocol
- Indications of sepsis
Required Labs/Work up for Deceased Pancreas Donors (6)
- Fam hx of DM
- Serum amylase
- Serum lipase
- HLA
- Insulin Protocol
- HbA1c (if Performed)
When should a Kidney Biopsy be done?
- Should be done for kidneys with a Kidney Donor Profile Index (KDPI) score greater than 85%
- And at the request of the accepting surgeon for all other kidneys
How many glomeruli are minimally acceptable on Kidney Biopsy?
25 glomeruli
When should Coronary angiography be done?
-For male donors over 40 years old or female donors over 45 years old
-History of two or more of the following:
o Cocaine or amphetamine use
o Diabetes
o Hyperlipidemia
o Hypertension
o Intra-cerebral bleeding
o Significant smoking
o Strong family history of coronary artery disease
-at request of transplant surgeon
Lung Donor work up
Not required
- Measurement of chest circumference at the level of nipples
- Measurement by chest x-ray vertically from the apex of the chest to the apex of the diaphragm and transverse at the level of the diaphragm
- Mycology sputum smear
- Non-contrast CT of the chest, if requested by the transplant hospital
Goals for Deceased Donor Management
- Maintaining blood pressure for perfusion of vital organs
- Monitoring vital signs
- Administering IV therapy or drugs, as required
- Administering antibiotic therapy, as required
- Administering and monitoring fluid intake and output
Organ recovery procedure and the transplantation must not be performed by these 2 individuals
- The donor’s attending physician at the time of death
2. The physician who declares the time of death
On-site recovering surgeon must verify what 3 items Pre-Recovery with OPO staff?
Donor ID
Organ (and laterality, if applicable)
Donor blood type and subtype (if used for allocation)
When the intended recipient is known prior to organ recovery, the OPO must verify (with Two qualified health care professionals) what 3 additional pieces of information?
Intended recipient unique identifier
Intended recipient blood type
Donor and intended recipient are blood type compatible (or intended incompatible)
Organ Procurement Required documentation
- any medications administered
- flush solutions and additives with lot numbers
- organ anatomy, organ flush characteristics, flush solution amount, flush solution type
- organ abnormalities, and surgical damage, if any
Tissue Typing and Blood Type Verification Materials
OPO must provide
- One 7 to 10 mL clot red top tube (all organs)
- Two (ACD) yellow top tubes (KD & Panc)
- If available, one 2 by 4 cm wedge of spleen in culture medium (KD & Panc)
- Three to five lymph node samples
What must happen if DCD donor converts to brain death
Must re-execute the match system and allocate the organs according to the organ allocation policies.
OPO may choose not to reallocate organs
1. Donor instability
2. Lack of donor family approval and authorization
3. Other extraordinary circumstances
The host OPO must document the reason for not reallocating organs when a DCD donor converts to brain death
Who must NOT be present during Withdrawal of Life Sustaining Medical Treatment on a DCD donor?
No recovery personnel (surgeons and other recovery practitioners) may be present for the withdrawal of life-sustaining medical treatment or ventilated support.
Prior to the donor hospital withdrawing life-sustaining medical treatment or ventilated support, the OPO is required to conduct a timeout to confirm:
- The patient’s identification.
- The process for withdrawing life-sustaining treatment or ventilated support.
- Roles and responsibilities of the primary patient care team, the OPO team, and the organ recovery team.
- The hospital’s plan for continued patient care if the patient does not become a donor, and appropriate communication with the next of kin.
Who cannot declare death in a DCD donor?
a member of the OPO or the organ recovery team.
Define Circulatory death
Circulatory death is death defined as the irreversible cessation of circulatory and respiratory functions.
Declaration of death in DCD
Death is declared in accordance with hospital policy and applicable state and local statutes or regulation.
What must happen before Organ Recovery can proceed in a DCD donor?
Organ recovery will only proceed after circulatory death is determined,
inclusive of a predetermined waiting period of circulatory cessation to ensure no auto-resuscitation occurs.
How long after transfusion of RBC do you have to wait before mandatory subtyping of A Blood groups
120 days
Free Water Deficit
Free Water Deficit :
0.6 x weight (kg) x ( (Current Na/140) -1 )
Circulating Blood volume of toddler
75ml/kg
1 Unit PRBC should increase H & H about how much
Hgb- 3g/dl
Hct- 2.5%
For how long must OPO maintain complete deceased donor information/chart
7 years for all organs procured
For how long must OPO maintain blood specimens appropriate for serologic and nucleic acid testing (NAT)?
10 years after the date of organ transplant,
and ensuring these samples are available for retrospective testing
If donor has been exposed to non recombinant Human Pituitary Derived Growth Hormone (HPDGH), what is the Donor at risk for?
increased risk of prion disease
DDAVP
If urine output > 250cc above IV intake for the last 2 hours and serum Na > 145 mEq/L
Give DDAVP 1 mcg IV
Repeat in 1 hr If urine output has not declined below 200 mls above intake
Dopamine
vasopressor
- alpha agonist
- Primarily Alpha 1 effects
- increase vasocontriction.
- increase SVR
- In low doses some beta 1 effects
Dobutamine
+ Inotrope
- beta 1 agonist
- primarily beta 1 effects
- generally given to increase cardiac output
Where are Alpha 1 ; Beta 1 receptors found?
heart
Where are Alpha 2 & Beta 2 receptors found?
lungs
Levophed
Stimulates Alpha 1 & Alpha 2
and to a lower extent Beta 1 & Beta 2
Neosynephrine
selective ALPHA 1 -receptor agonist
mainly constricting larger arterioles and having virtually no effects on terminal arterioles
Isoproterenol
- Stimulates primarily β1 (high), β2 (low)
- increases heart rate
Hetastarch
- colloid
- Do not use for DI, coagulopathy, hypokalemia, hypovolemia
- Not to exceed 1500 mL/day
- may cause excess bleeding
- contains potassium & sodium
Low fibrinogen
if <100 give cryo 6 units
CPTC Prefers colloids in what scenario
ARDS/ hypoxia/ maximal vent support
CPTC prefers Crystalloids
for hypotension 1st line treatment
CVP
Right Atrial Pressure
Preload
Preload
Volume
Afterload
Resistance
1st line hypernatremia crystalloid
D5 0.2% NS
Good indications of hydration
CVP 10
Na <150
Beta 1
Heart
Dilates
-increase inotropic effect
- increased squeeze of the heart
Beta 2
Lungs
Dilates
ex albuterol
Alpha 1
Heart Constrict ex: Levo, Neo - Increase the squeeze of vessels, lead to vasoconstriction - Increase in SVR - Increase BP
Alpha 2
Lungs
Constrict
What puts a donor at increased risk for prion disease?
HUMAN derived growth hormone
What BETA AGONIST should be used in BD donors with Bradycardia
Isuprel
ABO universal DONOR
O
ABO universal RECIPIENT
AB
Goal of donor management
- optimize organ function
- postpone inevitable cardiopulmonary collapse of donor
- Transplant most organs per donor
Where do you produce Adrenocorticotropic hormone (ACTH)?
produced by the pituitary gland.
What is the function of ACTH? How does that present in a BD Donor?
- ACTH stimulate the production and release of cortisol from the cortex of the adrenal gland
- Hypotension is seen due to death of the hypothalmic- pituitary- adrenal axis
Massive chatecholamine storm and loss of ADH & ACTH which occurs after brain death may cause (4)
- vasodilation and systemic inflammation
- neurogenic pulmonary Edema
- anerobic metabolism
- acute LV failure
T4
Levothyroxine onset
3-4 hrs
DI clinical manifestations
- copious amounts colorless urine
- specific gravity of 1.005 or less
How do you measure RIGHT sided preload
CVP
How do you measure LEFT sided preload
PCWP
Dopamine @ 2-10 mcg/ kg/min is a ______
Beta 1 Agonist
Dopamine @ 10-20 mcg/ kg/min is a ______
Alpha 1 Agonist
Drugs effecting Beta 1 work on the
Heart
Drugs effecting Beta 2 work on the
Lungs
Coagulopathies after brain death may occur due to
Thromboplastin Release
Facial trauma may cause an increase in ______
Amylase
ORC should pay attention to echo results for (3)
- Left Ventricle and septal wall measurements
- segmental or global akinesis
- valvular dysfunction
Normal septal wall an Left ventricle thickness measurements
1.2cm
Wall motion abnormality usually related to BD
global akinesis
What is required just before making a lung offer
CXR within 3 hrs
Challenge ABG within 2 hrs
Consolidation on CXR is indicative of
Severe PNA
ECD Criteria
-age 60 and older
- age 50-59 with
HTN + Creat>1.5 + CVA
HTN + Creat>1.5
HTN + CVA
Creat>1.5 + CVA
When should you consider Cryoprecipitate?
Fibrinogen less than 100
