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Brain-dead patient awaiting organ tx (Management of patient before…
Brain-dead patient awaiting organ tx
Pathophysiology of brain death
Raised ICP - brain herniation with pontine ishaemia
Hyper adrenergic - pulmonary and systemic HTN - increased biventricular afterload - myocardial ischaemia
May have cushing's reflex from baroreceptors
After herniation, loss of spinal cord sympathetic activity - reduced vasomotor tone - vasodialtion and impaired cardiac output
diabetes insipidus - further fluid and electrolyte loss
RESULT - most patients need ICU intervention to remain haemodynamically stable
Duty of care
Patient is certified as dead from the time of the second exam which confirms brain death.
Duty of care is now as a donor and management is guided by 'best interest' - new invasive monitoring / drugs may need to be started for donation purposes
Management of patient before retrieval
Support of donor family
Info and sensitive support about process
Grief and bereavment, adequate time for discussion
Respectful treatment of the deceased
Usual nursing care - washes, turns etc.
Donor coordinator
Staff and family support
Obtain details about medical and social history
Liaise with all involved teams
Usually develop haemodynamic instability
Adrenergic driven increase in afterload
Loss of spinal activity - vasodilation
Diabetes insipidus, dehydration, electrolyte disturbance
Hypothalamic dysregulation and hyper/hypo thermia
Catecholamine effects on Plt function and activation of Plasminogen activator
Critical care setting
Aim to maintain normal physiology
Autonomic storm of brain stem compression - short acting antihypertensives to decrease myocardial stress, standard arrhythmia management
Then... loss of SNS output - vasopressors/inotropes
DI mx: fluids, electrolyte replacement, DDAVP
Invasive monitoring
Target haemodynamic parameters
Hormonal resus - use if persistent haemodynamic instability (Vasopressin, T3, Methylpred)
General measures
Stop unnecessary meds
Continue Abx and enteral feeds
30 deg head up, routine suctioning, PEEP
Sugar, electrolyte and fluid mx
Active warming
Stop nephrotoxins
Protocol use
Helps with organisational, ethical and clinical challenges
Increases the number of organs recovered
Helps medical/social management
Intra op
Adequate monitoring and IV access
Laparotomy extended by median sternotomy
Ongoing organ function support - aim normal vent and hamodyn targets, blood products if required
Anaesthesia and analgesia not required
May need volatile and paralysis to overcome spinal reflexes and SNS response (not for anaesthesia)
Good comms btw team members
Post op
Return of organs not completely transplanted (e.g. heart after valves removed)
May have autopsy
Offer family opportunity to see donor after completion of organ procurement