Lung Donor Management Strategy
1.
KODA intensivist or clinician should call Dr.
Baz (cell phone 352-672-4381) as soon as possible to discuss management of any
potential lung donor. If he is not available call Dr. Shafii (cell phone
859-227-3575)
2.
They will want to know status of CXR (text image if possible), ventilator settings
and airway pressures (text image of
ventilator screen), and results of the oxygen challenge test when available.
3.
3 possible scenarios and our objectives:
a.
Good lung at beginning (clear CXR, PaO2 > 300
on 100% FiO2, normal compliance)
i. Objective-
Keep it good
b.
Bad lung at beginning
i. Objective:
1.
Identify cause
2.
Attempt to correct
c.
Good lung at beginning which deteriorates
i. Objective:
1.
Shouldn’t happen
2.
How to prevent
3.
How to reverse.
4.
Drs. Baz and Shafii identified key components to
donor management for optimal lung donation:
a.
Avoid excess fluids and use of vasoconstrictors
b.
Hormonal therapy: steroids, thyroid, vasopressin
c. Antibiotics—broad spectrum (iv cefepime or zosyn or
meropenem with IV zyvox)
d.
Lung protective ventilation
5.
Baz/Shafii believe early management prior to
declaration of brain death and in first 12 hours after brain death are critical
a.
Preventing fluid overload
b.
Preventing excess use of vasoconstrictors
6.
KODA intensivists should be involved in
management of all patients with catastrophic brain injury which is not thought
to be survivable and will likely progress to brain death or withdrawal of care.
This should be pursued aggressively.
7.
Strongly consider early placement of PAC in all
patients who are potential thoracic organ donors as well as FloTrac and early
cardiac ECHO to help provide evidence based, rational and optimal hemodynamic
and fluid management.
8.
The following include the recommendations of Drs.
Baz and Shafii
a.
Ventilator management
i. Tidal
volume 6-8 ml/kg IBW/PBW
ii. PEEP
5-10 cm H2O
iii. FiO2
40-50 %
iv. Recruitment
maneuver limited to 5 minutes maximum,
v. Keep
on at least 5 cm PEEP during apnea test, and during any transportation (Use
transport ventilator with PEEP on transports.)
b.
Bronchoscopy information desired:
i. Anatomy
ii. Is
there evidence of infection, i.e., presence of purulence
iii. Do not lavage unless absolutely
necessary to clear secretions. This may
worsen chest x-ray and blood gas exchange.
iv. Simply
aspirate any purulence to send for smear and culture
c.
Oxygen Challenge test
i. Prefer
on 5 cm PEEP, but OK up to 8 cm
ii. Initially
and q 12 hours and just before going to harvest.
d.
Antibiotics:
i. cefepime
(2 gm IV Q 8 hrs) and zyvox (linezolid) (600 mg IV Q 12 hrs)
ii. if penicillin allergy---may substitute
meropenem for cefepime.
e.
Hormonal therapy (corticosteroids, thyroid,
vasopressin
f.
Preferred vasopressor/inotrope is Dopamine 4
mcg/kg/min; No higher than 10
g.
CT scans
i. Individualized
indications---history of smoking in
donors (more than 20 pack-years, extent of pneumonia)
9.
It would be very beneficial to assess this
protocol and identify any problems to review every case in detail after the case is done.
a.
With CXR and clinical record including details
of fluid, vasoactive drugs, ventilator settings etc.
b.
Include KODA intensivist and KODA clinician,
Drs. Baz and Shafii
c.
Consider getting pathologic study of any rejected
lungs.
d.
Forward any concerns to Dr. Bernard, Chair of
the Organ Donation and Transplantation Action Council.
Meeting of E Hessel
with Maher Baz and Alexis Shafii to Discuss management of potential lung donors
Friday, Feb 5, 2016, 1100-1200; EAH Feb 6, 2016; 1430 EST; Revised Feb 12, 2016
