Red Book - Care Of The Heart 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 vasopressors

Resp
Hydrostatic pressures - pulmonary oedema
Apneoa and cardiac arrest

Endocroine
Cranial DI — fluid and electrlyte losses
Hypothalamus - hypothermia and hypothyroid

Coag - catecholamines affect platelet function

Question 2

Cardiovascular goals in BSD

Answer 2

HR 60-120.min
SBP > 100mmHg
MAP 60-80

PCWP 10-15mmHg
CI>2.1 min/m2
SvO2 > 60%

CVP 6-10

SVRI 1800-2400 dynes.sec/cm5/m2

Question 3

CVS management goals

Answer 3

Restore an effective circulating volume

Avoid overload

Vasopressin is first choice.

If no change in CI, inotropes (NHS BT say DOPAMINE)

Question 4

Ventilatory goals

Answer 4

Recruitment manoeuvres

LPV —> 4-8ml/kg of IBW
PEEP 5-10
Limit peak pressure to <30

Chest physio
Head up

ABG targets

Question 5

ABG targets in BSD

Answer 5

PH 7.35 - 7.45

PaO2 > 10kpa

CO 4.5-6

SpO2 > 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 ASAP

Active warmgin to 36-37.5C

Question 7

Endocrine principples in BSD

Answer 7

Insulin to BM 4-10

Early vasopressin MAY prevent DI

Pituitary hormones (esp thyroid descrease) but T3 replacement no longer routine

If 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 ischaemia

Urine output > 4ml/kg/hour

Serum Na > 145

Serum osmol > 300 mosmol/kg

Urine osmol < 200

If UO sudden rises, do not wait from plasma/urine tests

Replace fluid with minimal sodium

Desmopressin 0.5-4mcg iv

IF vasopressin not managing