Mod13: Anesthesia for Organ Procurement Flashcards
Anesthesia for Organ Procurement
When a hospital identify a potential donor, which organization is notified?
The local organ procurement organization (OPO)
Organ Procurement
Once notified, which next steps are undertaken by the OPO?
Donor evaluation
Brain Death diagnosis confirmed or testing in progress
Consent once Brain Death diagnosis confirmed
Testing and Allocation of organs
Organ Procurement
The local agency that coordinate activities with the recovery of organs is known as:
OPO
Organ Procurement Organization
Organ Procurement - OPO
Why do OPO works within Federally designed service area?
To ensure no competition for organs
Organ Procurement - OPO
Which agency certifies OPOs?
CMS
Organ Procurement - OPO
Which agency/legislation regulates OPOs?
Medicare/Medicaid Act
Organ Procurement - OPO
True or False: Working Relationships exist betwen hospitals and the OPO in the OPO service area
True
Organ Procurement - OPO
Approximately how many OPO’s in the U.S.?
62
Organ Procurement - CMS Regulations
Based on on CMS Regulations, which other entities must Hospitals sign an agreement with regarding organ procurement?
Organ Procurement Organization (OPO’s)
Tissue Bank
Eye Bank
Organ Procurement - CMS Regulations
Hospitals must notify the OPO about what?
Every death and every imminent death (brain death) that occurs in the hospital
Organ Procurement - CMS Regulations
Hospital must work in conjunction with the OPO to assure that the family of every potential donor is offered what?
The option of donation, if they are good candidate
Organ Procurement - CMS Regulations
Any individual who initiates discussion or provides information about donation or requests donation must be:
an OPO Representative or have been
Trained by the OPO
Organ Procurement - CMS Regulations
Any individual who initiates discussion or provides information about donation or requests donation must be an OPO representative or have been trained by the OPO
Penalties for failure to comply include:
Lose JCAHO accreditation
Lose Medicare/Medicaid Funding
Organ Donation - Background Information
True or False: Organ Transplantation may be the only treatment for some chronic diseases & disorders
True
Organ Donation - Background Information
Number of Americans awaiting transplantation (Waiting Lists):
Currently over 115,000
Someone added every 10 minutes
Organ Donation - Background Information
Of those currently awaiting transplants, how many are Georgians*?
10,500
Organ Donation - Background Information
How many people die each day awaiting transplants?
20
Source: United Network for Organ Sharing Data
Organs and Tissues that Can be Donated
ORGANS that Can be Donated include:
Heart - Lung - Liver - Kidney - Pancreas
Organs and Tissues that Can be Donated
TISSUE that Can be Donated include:
Heart Valve - Bone - Skin - Cornea - Intestine
Definition of Brain Death
What’s the Anatomical Definition of Brain Death?
Destruction of all neural tissue above the 1st vertebrae

Understanding Brain Death
In essence, what is Brain Death?
Loss of brain stem function
Understanding Brain Death
Absence of which brain stem reflexes constitute clinical diagnosis of Brain Death?
Pupillary light reflex
Corneal reflexes
Oculocephalic reflex
Oculovestibular reflex
Apnea test
Understanding Brain Death
How can the Oculocephalic reflex be tested?
Doll’s head maneuver

Understanding Brain Death
How can the Apnea test be performed?
Normothermic patient failling to initiate a breath when arterial CO2 is > 60
Potential Donors
Potential donors are patients who have sustained head injury and/or brain insult from which causes?
ICH 2° HTN, Aneurysm
GSW to head
Blunt trauma to head
Brain tumor
Extensive chart review follows to make sure a potential donor is indeed a good candidate
Donor Management
What is responsible for hemodynamic instability that usually follows Brain death?
Wide swings in hormone levels
Systemic inflammation
Oxidant stress
All negatively impact organ function
Donor Management
What cause the systemic vasoconstriction (especially in the coronary circulation) usually seen after Breath Death? How can this be managed?
Increased levels of Epinephrine and Norepinephrine in the body
Can be managed with Verapamil to prevent ischemic changes in the heart
Donor Management-Hemodynamics
What’s the fluid management goal in a transplant donor?
Keep pt euvolemic (critically important)
CVP between 6-12 mm Hg
Donor Management-Hemodynamics
Why should you keep Na <155 mmol/L and prevent hypernatremia?
Hypernatremia is associated with many systemic issues
Organ Procurement - Donor Surgery
These are busy cases for anesthesia. What would you being doing and what are your overall goals?
Drawing and treating labs
Ensuring donor stays stable while organs are being harvested
Organ Procurement - Donor Surgery
What will you eed for Surgery?
Drugs - Electrocardiograph
Arterial pressure catheter (for lab draws)
CVP catheter - Urinary catheter
Ventilator - Fluid warmers - HME - NGT
Tracheal suction catheters - Infusion Pumps
Heparinized blood sampling syringes (ABG draws)
Organ Procurement - Donor Surgery
Which drugs will you need for Surgery?
NMBs - Mannitol - Lasix - Dopamine - Heparin
Epinephrine - Bicarb - Lidocaine - Verapamil
Operative Management
Prior to surgery, where is donor assessment performed?
in the ICU, just as with any other case
Operative Management
What should you check in the donor’s chart?
Brain Death pronouncement
Noting date and time of death
Look for signature of physician
Consent for donation
Should be signed by donor’s next of kin
Operative Management
What should you carefully assess in the donor’s clinical presentation?
What support they are already on
How stable they are
Because of all the changes to happen intraop, preparation must be based on based on current/recent presentation
Operative Management
True or False: Donor’s operative management will continue as it has been preoperatively, making necessary adjustments in treatment to maintain BP.
True
Operative Management
Vent settings should be set to match ICU settings. When will you Not keep them at 100% FiO2?
If you are having the lungs transplanted
Keep < 60% in this case
If you are Not having the lungs transplanted
Keep at 100%
Operative Management
What could happen if FiO2 is > 60% and you are having the lungs transplanted?
Pulmonary Oxygen toxicity
Operative Management
Why should you keep PEEP as low as possible, preferrably not more than 5 cmH2O?
Any PEEP > 5 cmH2O will increase Right atrial pressure
which will further increase Hepatic congestion
which could make the liver unsuitable for transplant
Operative Management
Why must Mannitol, Lasix and Heparin be ready to administer
Administration of these is extremely time sensitive
Operative Management
True or False: Organ donors require anesthesia for hypnosis
False
Organ donors do not require anesthetics for hypnosis
But active reflexes often necessitate neuromuscular blocking agents
Operative Management
What are the benfits of volatile agents in donor’s surgery?
Ischemic preconditioning
Will reduce the risk of ischemic reperfusion injury that can occur when that organ is transplanted onto the recipient
Operative Management - Spinal Movements
In what proportion of donors are spontaneous spinal movements or spinal reflexes seen?
1/3
Operative Management - Spinal Movements
How do Spinal Movements manifest?
Spontaneous “spinal” movements of limbs
Arching of the back
Operative Management - Spinal Movements
What are negative consequences of spinal or spontaneous movements
May interfere with surgery
Can cause catecholamine release and HTN
Operative Management - Spinal Movements
How can spinal or spontaneous movements be prevented?
Long acting NMBAs
Operative Management
What’s the typical incision in donor’s surgery?
Midline incision

Operative Management
How does donor’s surgey typically last?
2-4 hours
Depends on which and how many organ(s) are recovered
Operative Management
Why is the potential for confusion greater in donor’s surgery?
Lots of people in the room
Roles sometimes unknown
Operative Management
If the heart is being recovered and a central line is in place, what will you be asked to do?
To withdraw the line prior to cross-clamping
Prevents central line from being trapped in that cross clamp area and potentially cause a shunt later when they excise the area, they could cut through the catheter and potentially loose blood out of that opening
Operative Management
If the lungs are being recovered, what will you be asked to do after cross-clamping? Why?
To manually inflate and deflate the lungs a couple of times
This will prevent small airway closure before the lung is transported
Operative Management
Why are bradyarrhythmias in pts with brain death unresponsive to atropine?
Because the brain stem is non functioning
Operative Management
How should you treat bradyarrhythmias in brain death patients?
With direct-acting, beta-sympathomimetic agents
such as Isoproterenol
Operative Management
How can you treat ventricular arrhythmias in brain death patients?
Lidocaine
Operative Management
During organ procurement, how do you know which physiologic parameters to keep the donor’s in?
They will be very specific in what parameters they want you to keep the patient in
They will let you know what’s going on while it’s going on
They will let you know what to expect because they know No anesthesia provider is wholly comfortable with organ procurement, since we don’t do them enough
Operative Management
What happens once the organs are taken out?
They will ask you to shut off your ventilator, thank you, you can shut off your monitors, and you can leave the room
And it will be weird feeling because you are used to never leaving a pt on the table.
But at this point they have taken all the organs necessary, and what’s left will start to shut down on its own, and they no longer need you in there assisting with anything else
Facts About Transplantation
From recovery to transplantation, how long are kidneys viable?
24 to 36 hours
Facts About Transplantation
From recovery to transplantation, how long is a Liver viable for?
6 to 8 hours
Facts About Transplantation
From recovery to transplantation, how long is a Heart viable for?
4 to 5 hours
Facts About Transplantation
From recovery to transplantation, how long is are Lungs viable for?
4 to 6 hours
Facts About Transplantation
From recovery to transplantation, how long is the Pancreas viable for?
8 to 12 hours
Benefits of Donation
From the donor’s family perspective, what are the benefits of donation?
Helps with the grieving process
Makes something positive out of a tragic situation
Benefits of Donation
From the Recipient’s perspective, what are the benefits of donation?
Gift of Life
Benefits of Donation
From the Health Care Professional’s perspective, what are the benefits of donation?
Makes something positive out of a tragic situation
Be it on the procurement end or the transplantation end