Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: Organ transplantation has proven to be life-saving for thousands of patients and a growing number of disease processes.
Speaker: However, the gap between available organs for transplant and patients on organ transplant waiting lists continues to grow.
Speaker: In today's episode of the podcast, we will discuss the ICU management of the organ donor.
Speaker: Our guest is Dr. George Williams.
Speaker: He's a professor of anesthesiology, critical care, and pain, professor of surgery, and vice chair for critical care medicine at the McGovern Medical School of the University of Texas in Houston.
Speaker: Dr. Williams is also a medical co-director of the surgical intensive care unit at the Lyndon B. Johnson General Hospital and executive medical director for the donor specialty care unit Memorial Hermann Hospital at TMC.
Speaker: He is an immediate past president of the Texas Society of Anesthesiologists and currently serves as chair for the American Society of Anesthesiologists Committee on Critical Care Medicine.
Speaker: George, welcome to the podcast.
Speaker: Thank you so much for having me, Sergio.
Speaker: I'm very excited to be here.
Speaker: Excellent.
Speaker: And as we were discussing before we started recording, I believe this is a very critical topic for our clinicians in the ICU.
Speaker: But I want to hear from you, a transplant expert and ICU colleague.
Speaker: Why should critical care clinicians in the community care about this topic?
Speaker: Well, absolutely.
Speaker: Well, first of all, I mean, this is a topic in a patient population that affects everyone.
Speaker: I mean, we've all, regardless of our clinical focus, regardless of our specialty, have encountered patients that have end organ disease so severe that they end up looking at having to go to the intensive care unit, potentially having to have an organ transplant surgery.
Speaker: And when one of those people that we know goes and gets the transplant they need, we all celebrate because it's a life-saving, life-restoring experience for them.
Speaker: And what's special about this is that it's something that all of us have an opportunity to make a positive difference in.
Speaker: If we're a physician, there's clear ways we can do that.
Speaker: We'll be talking about that hopefully a lot today, but also even patients.
Speaker: and the community can make a difference in terms of volunteering to be donors and in educating other members of the community, making sure that hospitals are ready to actually support organ donation and have the knowledge and community support for that particular enterprise.
Speaker: So something that's not relegated only to the medical expertise of the physician community, but physicians, nurses, community leaders, politicians,
Speaker: It affects everyone.
Speaker: So this is one of those rare opportunities in my mind, Sergio, that allows us all to come together for a common cause to help people that, in essence, all of us have met at one point in our lives or another.
Speaker: This is a very important topic.
Speaker: Perfect.
Speaker: And I think maybe we could go with a little bit of historical perspective on the role of the intensivist in managing organ donors.
Speaker: And I would imagine that even your professional career from training to where you are today, things have evolved very rapidly.
Speaker: Organ transplantation is young compared to many other areas of medicine, but also something that is growing at a very rapid pace.
Speaker: Yes.
Speaker: I mean, wow.
Speaker: I think about, that's a great question, Sergio.
Speaker: I think about,
Speaker: the experience I had when I first was a resident in terms of our ability to manage organ donors.
Speaker: It was literally like, hey, there's an organ donor in bed number 10 and they need a central line.
Speaker: Will you come do it?
Speaker: And yes, and then I just leave.
Speaker: And then the wheels just keep turning.
Speaker: And then fortuitously, I was really blessed with the opportunity to start staffing a neuroscientist ICU immediately upon completing my fellowship.
Speaker: And, um, in that experience, we had a tremendous amount of organ donors because of the nature of the disease processes that come to a trauma center and vascular center of excellence like Herman, um, in the neurosciences intensive care unit.
Speaker: And I found that the role of the intensivist was still not defined, almost coming, like we need a procedure done.
Speaker: If we need a quick opinion on this, fine, come by.
Speaker: But otherwise, your role is PRN as needed and functionally very limited.
Speaker: We were all educated on, hey, if you have an organ donor,
Speaker: please be helpful.
Speaker: And we've always tried to do that.
Speaker: But I think that the role has evolved tremendously over time and to where we are right now, where we actually have intensivists being expected to play a formal role in the management of organ donors to actually make decisions about the type of fluid and the content they're in, the decision of what type of vasopressor to use, what sorts of interventions, positioning, ventilator settings,
Speaker: Right now, we're evolving the field of critical care medicine to not be a cork that goes into the hole or a Band-Aid that fixes something while we're waiting for the donor to go to the operating room, but actually with the opportunity to potentially, by management of the donor, to actually make a difference in terms of how much of an impact, how much of a gift that that donor can have.
Speaker: And I should say that once we started managing organ donors specifically in my unit, in my practice, in my group, we started calling our organ donors heroes.
Speaker: And we felt that that was a...
Speaker: a very telling and good term because we say patient is not accurate because they've already passed away because they're a brain dead organ donor.
Speaker: And we don't want to, you know, we, if we say organ donor, that's, it's almost like a, it's a slightly depersonalizing sort of thing, but hero really encompasses the entire nature of what this person before they passed away intended to do to make a positive difference in their community and to help save the lives of other people.
Speaker: off dialysis and get people out of, you know, when they're in liver failure, for example, to give them a second chance at life.
Speaker: So that, that term hero, I think is important because it personalizes and really engages us as intense, basically like, Hey, this is not my patient, but this is a hero.
Speaker: This is someone who is rushing in to help save someone else.
Speaker: And I have a role to play in that.
Speaker: And so it's evolved tremendously in my mind over the past 13 years of my practice.
Speaker: And I love that perspective.
Speaker: I've never thought about it like that, but I do agree with you in the term of calling them heroes.
Speaker: And also when you think about it, George, good critical care saves lives.
Speaker: Once a patient is declared dead by neurologic criteria, good critical care still saves lives by preserving those organs, right?
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: I am...
Speaker: I think as an intensivist, it's important to keep that in mind because we're human beings too.
Speaker: And sometimes once someone has passed away and they're now declared brain dead, it can be like, well, my part is over.
Speaker: I did everything I could.
Speaker: There's nothing left for me to contribute here.
Speaker: And our role as evolving to help with management of organ donors really is a 180-degree turn from that perspective.
Speaker: It's more like I did everything I can for this patient.
Speaker: They've already passed away.
Speaker: Now let me do everything I can for several other people that may benefit from this patient's gift.
Speaker: It's a big paradigm shift.
Speaker: Perfect.
Speaker: And I want to jump right into the clinical management of the organ donor.
Speaker: But before we do that, if you could just give us a very short definition and difference between DBD and DCD.
Speaker: Oh, yes.
Speaker: Well, that's a very important distinction.
Speaker: DBD, a donation at the brain death, is someone who's brain dead.
Speaker: They're officially dead.
Speaker: They actually have a time of death recorded in a chart.
Speaker: That's a really straightforward concept for most people.
Speaker: However, DCD donation at the cardiac death is really interesting.
Speaker: It's someone who's at the end of life where the family is planning to withdraw care.
Speaker: and the decision is made that they still want to be an organ donor, we actually time the withdrawal of life support measures and the conversion of comfort care to a time that the operating room is ready, that our transplant procurement surgical team is ready.
Speaker: And if the patient expires with, or if the hero expires within a set timeframe, it's usually within 60 to 90 minutes, then we, um,
Speaker: We are able to still take certain organs, and there's a lot of discussion behind that.
Speaker: I hope we get to it, Sergio.
Speaker: We can take certain organs and actually facilitate donation, even in the event that the heart's already stopped after five minutes.
Speaker: So it's a fascinating opportunity because...
Speaker: Right now, we're getting to almost 25% of organs are donated via DCD, and we have opportunities to make that even happen more.
Speaker: So it's a very exciting opportunity coming up in that respect.
Speaker: Perfect.
Speaker: So let's start with management of the brain-dead organ donor, which, like you stated, is the majority of organ donations as of now still.
Speaker: And before we get into the topic, just for our listeners, the whole...
Speaker: concept and the whole procedure to declare a patient brain dead obviously is a podcast on itself and we have done that podcast before and I will reference those in the show notes.
Speaker: But once we're assuming that we already have made that process and that we all agree that the patient is brain dead or has been declared dead by neurologic criteria, it
Speaker: Let's talk about the care of those donor patients or those heroes, George, and maybe start with a little bit of a general overview of the pathophysiology of brain death.
Speaker: Yes, absolutely.
Speaker: Well, first of all, my compliments to you, Sergio, and your team for having already covered brain death.
Speaker: Like you said, it's a big topic.
Speaker: And the pathophysiology is very interesting because you no longer have participation of the central nervous system in maintaining vascular tone and maintaining the actual circulatory needs of the end organs.
Speaker: So
Speaker: Functionally, a brain-dead patient is a lot like a septic patient.
Speaker: They're vasodilated.
Speaker: From a hemodynamic standpoint, they're functionally hypovolemic because of that vasodilatation, and that vasodilatation is not due to fenestration of the capillary.
Speaker: but just due to loss of sympathetic outflow.
Speaker: So these patients tend to be very, very hypotensive, requiring significant amounts of vasopressors, which is very, very unique in and of itself.
Speaker: So when I say it's unique, it can feel a lot like sepsis, but once you get volume resuscitation started,
Speaker: Without antibiotics or any of the other sort of complexities that we tend to see in critical care, we can actually get patients to where they're on minimal or no vasopressors.
Speaker: And so that cardiovascular component of the physiology of brain death is very, very important.
Speaker: And that's really the central aspect of what we do when we take care of our brain dead heroes is to focus on resuscitation.
Speaker: And it can feel concerning towards making sure that we preserve the lungs and making sure that we're not volume overloaded in the hero at that point.
Speaker: But we actually are very systematic in making sure that we are attended to those respiratory effects later and using ultrasound and all the tools that we have as intensivists to make sure we're not overshooting.
Speaker: So we take heroes and basically make them very, very stable, use
Speaker: within about 18 hours you can see a tremendous difference so that cardiovascular physiology is the biggest single impact that we see from that we see from the physiology of brain death perfect now and before we dive into some of the specific organ effects and support any general principles of management that you want to share with our audience George
Speaker: Well, you know what?
Speaker: I would say it's almost like what you said a few minutes ago, Sergio.
Speaker: When you're taking care of a brain-dead donor, good critical care is good donor care.
Speaker: we should be attentive to the same things that we were before the hero was alive.
Speaker: I think that that was, while the hero was alive, I'm sorry.
Speaker: I think that that's really the general crux that I found.
Speaker: If I could just comment briefly, Sergio, when I first started getting involved in this, oftentimes my organ procurement organization would call me while I was driving home or leaving the operating room or leaving another ICU,
Speaker: asking for help.
Speaker: in terms of how to fix some of the physiologic arrangements.
Speaker: This was long before we actually created a donor specialty care unit.
Speaker: And by doing that consistently, I started to see that, well, you know, if we hadn't have taken away all the good critical care practices that we had before the, that we had before the patient actually expired, then I wouldn't have to come and rescue all that.
Speaker: So functionally, if you have a hero in front of you, turn off the part of your clinical brain that says they've already died.
Speaker: There's nothing
Speaker: can do and actually think of them like a patient that could recover, resuscitate them in the same way, pay attention to their exam findings the same way, and treat the anomalies the same way.
Speaker: That's a very, I would say that's the 98% of what we do is just being a good critical care doctor and being attentive to those details.
Speaker: And like you said, George, I think a lot of it is just changing our mindset, right?
Speaker: And understanding that when the patient was not, before they were declared brain dead, critical care is aimed at preserving organ function in order to allow the patient to live.
Speaker: Once the patient is declared dead by neurologic criteria, becomes a hero, the goal is still the same, to preserve organ function, but now it's for other patients to live thanks to that hero.
Speaker: Exactly.
Speaker: Serge, you said it so great, you should have your own podcast.
Speaker: Ha ha!
Speaker: So let's dive into the specific organ failures or organ effects and the support required.
Speaker: And you mentioned when you talked about pathophysiology, the cardiovascular impact.
Speaker: So obviously, this is, like you said, one of the most important ones.
Speaker: So why don't we just talk about what we see and what are the things that we should be aiming for as goals and paying attention to?
Speaker: Absolutely.
Speaker: So from a cardiovascular standpoint, when I was speaking about volume resuscitation, it really comes down to that.
Speaker: It's the goal of just to get the vasculature opened up again.
Speaker: When we have norepinephrine up above 0.1 mcg per minute,
Speaker: Plus vasopressin in many instances, which has a different role, really primarily endocrinologic.
Speaker: But if we're trying to use those two drugs for the end of improving SVR, it's really not, it's really particularly injurious to the organs.
Speaker: And, you know, interestingly enough,
Speaker: We found that in our practice that using a colloidal-based strategy is very effective.
Speaker: When I say colloidal-based, I'm specifically talking about albumin.
Speaker: We haven't really attempted to use any of the starches for black box reasons that are well-known generally to most of the listeners that you have.
Speaker: So really, we try to use albumin for cardiovascular resuscitation because it actually gives us
Speaker: a relatively consistent result for at least the 24 to 48 hours that we would expect it to.
Speaker: And that can get us very close to getting to the operating room.
Speaker: We look at factors from our monitoring perspective.
Speaker: Of course, we can use CVP, but we find that even keeping in mind the stroke volume variability with whatever tool you're using, whatever manufacturer you're using, the stroke volume variability is also a very good indicator to make sure that we're correcting volume anomalies as they occur.
Speaker: And we really do normally see a weaning of vasopressors within hours.
Speaker: I mean, if we, if when I round on a hero on day one, by day two, they're either off vasopressors or they're down to 0.03 to 0.05 mics per kg per minute norepinephrine.
Speaker: And that's usually where we end up landing.
Speaker: But I would say 80 to 90% of the time, they're actually off vasopressors.
Speaker: And that's a very, very important issue.
Speaker: that's a very, very important tool in terms of from the cardiovascular physiology standpoint.
Speaker: 100% of these patients should have arterial access because you're constantly going to be looking for your indications of indoor organ perfusion and all the monitoring that we just talked about in a moment ago.
Speaker: And we are universally make sure that they have central access in place so that all these things are very easy.
Speaker: We
Speaker: The worst thing we can end up doing is having delays and choosing what drug to give because of peripheral vasopressor administration policies or things like that.
Speaker: The patient's already technically expired and having all the access possible both for you and
Speaker: and the anesthesiology team when they go for the actual surgical part of the donation process is very important.
Speaker: So being pretty aggressive, a liter, liter and a half of albumin, not unusual for that reason.
Speaker: And that helps make the rest of the assessment process a lot more straightforward.
Speaker: And you usually don't have to keep doing it.
Speaker: Once you catch up with where their vasculature is,
Speaker: their neurot their sympathetics are totally gone so they're not going to reconstrict down we have to worry about them becoming hypertensive or mobilization issues you're just re-establishing a new baseline for their circulating blood volume instead of seven percent of body weight maybe it's more like eight or nine percent now because of the reduction in svr that we see in cardiovascular physiology for these patients for these heroes
Speaker: You mentioned vasopressors.
Speaker: Historically, or based on available evidence, obviously, in the ICU in general, with our sepsis patients and other patients, norepi usually first line, vasopressin second line, and others as needed in third line.
Speaker: Is there any value in going to vasopressin first?
Speaker: A great question.
Speaker: There generally is not value in going to vasopressin first.
Speaker: I would suggest thinking of vasopressin as a second rail or an independent railroad track.
Speaker: Using vasopressin specifically if we're trying to treat diabetes insipidus and we're thinking we'll see the effects of that.
Speaker: Norepinephrine is a fantastic first line, primarily because of that vascular tone, but also make sure that until you
Speaker: get the cardiac assessment completed that you actually have some support to increase cardiac output and thereby oxygen delivery where vasopressin will just get your afterload.
Speaker: So really norepinephrine is still a first line just like sepsis just like we talked about a few minutes ago and so it works very very well.
Speaker: And I should comment also on the role of dopamine or dobutamine or other inotropes if they're specific in the
Speaker: then we tend to potentially include those drugs.
Speaker: But usually our number one go-to is going to be norepinephrine, vasopressin,
Speaker: either second line or most usually I say greater than 75% of the time vasopressin is going to be specifically used to treat diabetes insipidus.
Speaker: Okay, before we move on to the next topic, you did mention that obviously the use of inotropes would be no different and similar targets.
Speaker: Now, can you tell us a little bit about how to manage bradycardia pharmacologically?
Speaker: Oh, wow.
Speaker: That's a that's actually a great point.
Speaker: There's if we're talking about bradycardia from assuming there's not an oxygenation problem or there's not a conduction defect that you're aware of.
Speaker: we actually, once you get past norepinephrine, it's actually very reasonable to actually treat, quote unquote, symptomatic.
Speaker: And I'm saying, I'm quoting the symptomatic because the hero's already expired, but symptomatic bradycardia that's actually causing hemodynamic consequences with some of the simpler agents, like scheduled glycopyrolate, literally just getting your chronotropy up withoutness, as long as your contractility is good.
Speaker: If the hero's
Speaker: that's when we really had to start talking about dobutamine, for example, to specifically get contractility better.
Speaker: But most of the vast majority of the time is really just trying to get that chronotropy up as a result of the fact that we no longer have the cardiac stimulation that we would expect from the central nervous system.
Speaker: So the cheap and simple things.
Speaker: So glycoparlate, atropine is a first line if it becomes really an emergency, but scheduled glycoparlate, Q6 hours is a fantastic first line when you actually have bradycardia in the hero.
Speaker: Excellent.
Speaker: Now you did mention diabetes insipidus.
Speaker: So I guess the next topic would be diabetes insipidus fluid and electrolyte therapy.
Speaker: Can you tell us a little bit more about that?
Speaker: Yes, boy, diabetes insipidus, we end up seeing a lot of this, as we can imagine, because so many of our patients are going to have substantial neurological injuries prior to the declaration of brain death.
Speaker: And diabetes insipidus being treated with a vasopressin infusion
Speaker: is really the first line for most of our organ procurement organizations.
Speaker: And since even as an intensivist, when we're managing these heroes, we do have the OPO, the organ procurement organization, following with us, vasopressin is simple, is unique.
Speaker: universally understood, it tends to get you a possible side effect of having some benefit for the blood pressure as well.
Speaker: So it's a fantastic first line.
Speaker: We really don't normally use DDAVP for the purposes of treating diabetes insipidus in that case.
Speaker: Furthermore, it's important to keep in mind that
Speaker: For our heroes, we do have something called DMGs, or donor management goals.
Speaker: This is particularly important in the United States.
Speaker: And I recognize, Sergio, that you have listeners worldwide.
Speaker: So speaking specifically for the United States, it's
Speaker: a sodium goal that is relatively normal.
Speaker: We want our sodium to be less than 150 here in the United States because there's part of the several factors that many organ procurement organizations are looking for.
Speaker: I did neglect to mention donor management goals for the cardiac component because those are very intuitive, making sure that you have a good blood pressure, mean arterial pressure, reasonable saturation.
Speaker: Those things are pretty intuitive, but sodium may not seem so intuitive because we're talking about patients, heroes that are brain dead, that have gone through the process in many instances of not only having a new diagnosis of diabetes insipidus,
Speaker: But also, many times they've come from the place of having a severe neurological injury where they're getting hypertonic saline to actually treat cerebral swelling.
Speaker: And so you can have the combination of
Speaker: diabetes insipidus and iatrogenic hypernatremia, which would see under these circumstances.
Speaker: And suddenly you have to really walk that back.
Speaker: So really getting an arrest, if you will, of the polyuria associated with diabetes insipidus is clearly the first line to make sure that we're treating that.
Speaker: But keeping that donor management goal of having a sodium that's not 180 or 170 and
Speaker: In different countries, in different OPOs, they have different thresholds, but literally working to get this sodium down to something relatively physiologic is considered ideal for a couple of reasons.
Speaker: The first thing is that while the brain no longer needs a sodium that's normal, and we don't have to concern ourselves with seizures taking place, there is concern that being severely hypernatremic alters the physiology of all the rest of the organs.
Speaker: These organs are not, they don't exist in a vacuum, so we want to make sure that we're attending to all the physiologic and metabolic needs there.
Speaker: But secondary,
Speaker: the sodium level, for example, as an indirect marker of intentiveness to care.
Speaker: If someone's getting fluid resuscitated, if they're in diabetes insipidus and they get enough volume to correct diabetes insipidus volume status, as well as their urine output, then you will see those individuals, those heroes having better sodium.
Speaker: So in a way, the sodium level has been used as a surrogate
Speaker: for the degree of critical care that we're seeing.
Speaker: So it's a very great question you ask there.
Speaker: Diabetes insipidus is the number one thing we actually see.
Speaker: Sometimes you'll see some, just want to mention it, sometimes you'll have certain circumstances where there's cerebral salt wasting or some residual cerebral salt wasting, particularly if the hero originally had an aneurysmal subaractoid hemorrhage presentation.
Speaker: But the vast majority of sodium perturbations that we're going to be addressing is with hypernatremia.
Speaker: Perfect.
Speaker: And I think it just speaks to like what you said before, of really staying on top of that as soon as we start seeing increasing urine output and changes in sodium, not waiting to get really out of line and be more aggressive in treating it early.
Speaker: Right.
Speaker: Exactly.
Speaker: Exactly.
Speaker: So very, I guess, in the same line, endocrine effects and hormonal supportive treatment has been something discussed in these patients.
Speaker: Can you tell us where we stand today?
Speaker: Oh, wow.
Speaker: I would say that this is a place where more data would be very helpful.
Speaker: Yeah.
Speaker: The T4 has actually been used as an infusion to help optimize cardiac function.
Speaker: And that supplementation, just because of the nature of what it is, falls under the endocrine canopy.
Speaker: But you may see OPO is looking at estrogen therapy administration because estrogen therapy as well has been associated anecdotally and with retrospective data to improve cardiac function.
Speaker: The more we look at it, the more we found that that is really not something that's actually useful.
Speaker: And so it literally was we were seeing it all the time.
Speaker: Our OPO felt very strongly that we should continue estrogen therapy.
Speaker: And then we were able to stop estrogen therapy after about a year of that because we we were concerned about the hypercoagulable effects from it.
Speaker: And there was just no good prospective data to actually support it.
Speaker: So from an endocrinologic standpoint and supplementation therein, the T4 is still accepted as a useful infusion to optimize cardiac function, even though it's not universally used.
Speaker: We have some reasonable data that
Speaker: supports that.
Speaker: And so it has remained stable.
Speaker: Estrogen has kind of come and gone.
Speaker: It's been very interesting in that respect.
Speaker: And I should mention while we're on endocrine, glucose as well, you know, being attentive and here comes a good critical care again, making sure that you have a glucose of less than 180 is a very reasonable thing for a living patient, let alone a hero.
Speaker: And so we actually have, you know, insulin infusions that we'll have to start from time to time in the donor
Speaker: of glucose is appropriate because that prevents osmotic diuresis.
Speaker: It prevents all the other issues associated with the hyperglycemia that we all know to be an issue in the living patient as compared to the hero that's going for donation.
Speaker: I've seen in some instances, George, that organ procurement organizations will ask for large doses of steroids.
Speaker: I understand that the idea is that you are treating cytokine storms or high cytokine levels that could occur after the initial brain death event.
Speaker: And especially in the lung, that might be important from what I understand.
Speaker: Where do we stand with that today?
Speaker: So that's still, this is really more local or regional practice instead of formalized accepted practices based off of prospective randomized controlled data.
Speaker: We actually have, even in our OPO scene, efforts to actually schedule steroids, we still do that very often.
Speaker: But it's really not clear if,
Speaker: if and how that's actually helpful.
Speaker: It is almost something that has to align with another clinical goal in order to really be justified.
Speaker: Let's say we know that the HERO's cortisol level is very low and they're still requiring vasopressures, we can use that intrinsic conversion of steroids to norepinephrine to facilitate more hemodynamic stability.
Speaker: but it's really not, there's not a good reason.
Speaker: Like for example, even if we look at lung injury, there's true lung inflammation as substantial.
Speaker: Yes, but we really have to really focus on really good toileting to make sure that we're treating that inflammation.
Speaker: And we only have one and a half days really to get that inflammation where it needs to be.
Speaker: So if you,
Speaker: If we're giving steroids, they would have to have a tremendous effect so fast because by then we're already starting to reach out to centers to see who.
Speaker: recipient would be ideal for the organs that we're talking about.
Speaker: And therefore, it's really a mixed bag.
Speaker: So you'll see steroids, but steroids are not indicated universally.
Speaker: And there is not, I do not believe there is a reasonable expert consensus to advocate for their consistent use in the hero population.
Speaker: Perfect.
Speaker: What about respiratory effects and respiratory support?
Speaker: And obviously, there's two aspects to this.
Speaker: On one hand, lungs are a very precious and needed organ for transplantation, but also without good oxygenation, all the organs will suffer.
Speaker: So any thoughts or any recommendations on respiratory effects and support?
Speaker: Yes, absolutely.
Speaker: You know what?
Speaker: Lung protective ventilation is the name of the strategy when it comes to respiratory support.
Speaker: From the moment they get under our care, the first thing that we do is to perform a bronchoscopy and to make sure that we're recruiting the lungs.
Speaker: It's just that simple.
Speaker: We keep our peak pressures low.
Speaker: We try to adjust our peak in order to achieve that.
Speaker: We frequently use recruitment modes such as, but not limited to, bi-level or APRV.
Speaker: I recognize that those are both proprietary terms, but really reverse ITE ventilation.
Speaker: is a strategy that works extremely well with heroes because like you said, they, they're brain dead.
Speaker: So we're not able to really effectively recruit, um, uh, those, those, the other regions of the lung that would have been captured by the things that are functioning brain does like side breathing and coughing.
Speaker: So because of that, um, being particularly aggressive on pulmonary toileting,
Speaker: Clearing out secretions proactively and starting off immediately with lung protective ventilation strategies and recruitment strategies is absolutely key to making sure that we give the lungs the best chance of getting matched to a recipient across the country.
Speaker: And you did mention bronchoscopy.
Speaker: That is usually just to get samples to rule out infection and do pulmonary toilette.
Speaker: Yes, we get samples from both sides immediately upon when we do a first bronchoscopy.
Speaker: But we'll actually, we will do bronchoscopy every 24 hours to make sure there's pulmonary toilet.
Speaker: And it doesn't mean that we, I should actually mention one thing also, Sergio, we really minimize our irrigation volumes as well.
Speaker: So this is not...
Speaker: a great patient to do 50 ml of saline in and out of the lung because it just makes your recipient transplant centers nervous.
Speaker: This is where we go with the bronchoscope.
Speaker: If there's no secretions, we're in and out, get out of dodge.
Speaker: That's great.
Speaker: We've documented that the lungs are healthy.
Speaker: If there are secretions, we are very attentive and trying to make sure that we clear the mucus that we see and report to each other very, very closely and the OPO.
Speaker: Everything that we found.
Speaker: So that toileting reporting part is very, very important.
Speaker: And if I could just also mention that we're still very aggressive.
Speaker: There is a very nice study that showed improved transplant success when patients are put in prone position as well.
Speaker: So if there's an oxygenation issue when the hero first gets under our care, we won't hesitate to prone position them in addition to the bile that we just talked about, APRV that we just talked about, so that we're recruiting the lungs as much as possible
Speaker: Thereby, by the first 24 hours when it's time to do our oxygen challenge test, we're in a good position.
Speaker: And then we can put them on a regular mode if the recipient center is concerned about oxygenation.
Speaker: We've already done our due diligence to provide great recruitment effort for that hero.
Speaker: And as you mentioned earlier, other organ systems, the DMGs would be the same we had before, protect the lung, targets for oxygenation and targets for CO2, correct?
Speaker: Correct.
Speaker: Absolutely, absolutely.
Speaker: So one of our DMGs, for example, is a P to F ratio greater than 300.
Speaker: That makes sense.
Speaker: You want to have lungs that don't require 90% oxygen to get good oxygen delivered to those organs because that's a problem in the hero who's donating to the recipient.
Speaker: It's going to be a problem in the recipient.
Speaker: So being very aggressive and not taking chances, not assuming anything is a key element of our DMGs and thereby, by extension, a key element.
Speaker: of our approach to these heroes when we take care of them.
Speaker: Beautiful.
Speaker: In terms of temperature, obviously post brain death, we lose a out of regulation of temperature.
Speaker: Any comments on how to treat hypothermia that can ensue and what should be our targeted temperature management goals?
Speaker: Absolutely.
Speaker: You know, the temperature is technically not a DMG, but it's just good critical care to get them back up to normal.
Speaker: So bear huggers, because of the fact that it takes at least a couple of days to match, usually three days, to match a hero with a recipient, we normally have enough time to actually warm the hero up with simple surface cooling, which generally works very effectively.
Speaker: I haven't really had to
Speaker: I very rarely have had to consider placing catheters in the, you know, cooling catheters or warming catheters or temperature modulating catheters in the femoral or any other access point.
Speaker: Usually the hero responds very well to forced air heating or cooling.
Speaker: But because of the coagulopathy we see from hypothermia, we absolutely try to get the heroes back up to normal temperature, which is really important.
Speaker: Particularly once they've lost that autonomic functionality, we can see substantial temperature changes.
Speaker: And this can become an issue even when patients, sometimes you have a hero that's
Speaker: We may do it as a hero that's on dialysis, for example, the hero that's on CRRT, for example.
Speaker: We've had to do that, and when you actually have those circumstances, temperature control becomes a very important part of our strategy.
Speaker: And to close up the discussion on the brain-dead organ donor management, any other aspects of general care or nutrition that you want to comment on?
Speaker: You know, one thing I'd like to comment on nutrition, that is an area of ongoing study.
Speaker: Right now, the OPOs really feel that the risk of a hero aspirating is to the point where, hey, we just don't want to t ake a chance.
Speaker: We'll do zero nutrition for the three days that they are awaiting their assigned recipients for the organization process.
Speaker: However, some of us in the organ donor management community do feel that nutrition is an important part
Speaker: and potentially a very important part of the heroes that we take care of, because we start changing all sorts of physiology when we actually have a hero.
Speaker: If we start starving the hero, then you're looking at increased catecholamine surging, which is certainly possible.
Speaker: You're looking at reduced glucose homeostasis, all those things that we take for granted.
Speaker: So even trickle feeds,
Speaker: in the near future.
Speaker: Some opios allow full tube feeding.
Speaker: Some opios have trickle.
Speaker: Some opios like ours have zero.
Speaker: So this is a right, this is right for study in terms of nutrition.
Speaker: Are there elements of good critical care that I would say that's important to keep in mind is the mindset of always investigating what your findings are.
Speaker: I'll give you an example.
Speaker: I remember when we first opened the DSU, I had a hero that came and there was no urine output or very low urine output.
Speaker: and we were resuscitated here well, there were off pressers, all the things we talked about a little earlier, and the foley, the urine in the foley didn't look particularly dark, it's just a very low volume.
Speaker: So I took the ultrasound and did a bladder ultrasound and noticed that the bladder was full,
Speaker: And that there was sediment around the Foley catheter.
Speaker: We replaced the Foley catheter, which upon further examination was occluded.
Speaker: And we replaced it.
Speaker: And then urine app was great.
Speaker: We were able to list those kidneys, for example.
Speaker: So, you know, just being attentive.
Speaker: Good general critical care, not taking anything for granted, and particularly when the OPO says, hey, look, they're kind of sick, and maybe we're not going to list the lungs.
Speaker: That doesn't mean you give up on the lungs.
Speaker: You try so that the OPO says, wait a minute, those lungs actually look pretty good after all.
Speaker: Maybe we can help someone.
Speaker: This is a process of both the OPOs and the intensivists growing into this new collaboration, this new role where intensivists are actively taking part in donor care.
Speaker: And so because of that, putting everything on the table, giving it a full court press every time as a general strategy can really benefit the recipients of these heroes.
Speaker: And another important aspect of this is that one hero can actually change the trajectory of the life of multiple patients, right?
Speaker: It's something that often we forget.
Speaker: I mean, the organs may go to different people, different states, and really you are having a tremendous impact on several patients.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: I mean, on a bad day, if you only get kidneys, for example, you just change the lives of two patients.
Speaker: And on a good day, you're talking about pancreas, a small bowel, you're talking about lungs, you're talking about heart, you're talking about liver.
Speaker: I mean, the impact can be tremendous.
Speaker: And it is incredibly touching when we hear about families that have loved ones that have got a new lease on life.
Speaker: You know, adding one organ to that list, two organs to that list is a big deal.
Speaker: And it actually, if you think about it, it really changes the world.
Speaker: To have people that would have died now living, going home, and being productive citizens and loving parents and aunts and uncles and cousins, that's exactly, that's really staying true to our oath as physicians.
Speaker: Yeah.
Speaker: So we talked a lot about the management of the brain-dead organ donor, and you mentioned at the beginning that DCDO donation after cardiac death is increasing.
Speaker: Any particular points that you want to bring up to the management of donation after cardiac death?
Speaker: Yes, there's a couple of things that I think are very important.
Speaker: The donation at the cardiac death patient is relatively challenging because
Speaker: because they are still alive immediately prior to donation, it is...
Speaker: that hero to be does still remain under the care plan of trying to minimize the impact of their underlying disease.
Speaker: And so that can make things a little challenging in terms of being arrested with resuscitation or what drugs to use, things like that.
Speaker: So it's important to keep that in mind while still being respectful of that gift and keeping that
Speaker: quote-unquote line very clear that you're doing everything you can to save the potential hero while simultaneously doing everything we can to support that potential hero's wishes to donate.
Speaker: That being said, the DCT process is particularly effort-based
Speaker: laden for the intensivist team.
Speaker: It means you have to have someone who is going to, after removal of life support, be ready to declare that potential hero as having had cardiac death and being standing by for that for 60 to 90 minutes, depending on your institutional protocol.
Speaker: In hours, it is 90 minutes.
Speaker: And if they expire in that amount of time, you have to go with them to the operating room and still, excuse me, and still
Speaker: redeclare cardiac death five minutes later after that first cardiac death.
Speaker: So we're all the intensivists on the on the podcast are thinking the same thing.
Speaker: How am I going to have time to manage my ICU service and have my one person potentially who's in house doing that?
Speaker: It becomes an incredible logistical challenge.
Speaker: And so this is particularly like in my my field where I felt that anesthesiologists can help a lot because you usually have an anesthesiologist in the hospital
Speaker: Every anesthesiologist, if they're truly practicing as an anesthesiologist, can tell you if a patient is dead or not.
Speaker: And so they can easily function as part of that team after hours.
Speaker: And then, or whenever you have the opportunity during the daytime, making a clinical plan to make sure to have someone from your team ready to provide that support to declare that hero.
Speaker: The next thing I want to mention is
Speaker: is that DCD has gotten a whole new wave of complexity.
Speaker: And what I mean by that is
Speaker: One of the challenges with DC donation is that, well, the heart has stopped.
Speaker: So is the liver still good to donate?
Speaker: Is it still safe to donate the lungs or the heart?
Speaker: And we could have multiple podcasts on that topic.
Speaker: But the thing that your listeners may need to know or do need to know is the advent of NRP or normothermic regional perfusion.
Speaker: And what this really means is that you take a DCD donor,
Speaker: that has been declared dead.
Speaker: They come to the operating room.
Speaker: Now they've been confirmed dead five minutes later.
Speaker: They are a hero now.
Speaker: And the surgical team ligates a carotid artery, so there's no blood flow to the brain, cannulates to put the hero on effectively a cardiopulmonary bypass or an ECMO circuit,
Speaker: and reperfuses the organs that are there, reperfuses the heart and the lungs and the liver and the kidneys.
Speaker: But they're not reperfused in the brain because the brain has already been clamped off
Speaker: for the purpose of making sure that we're not reperfusing the brain and causing reanimation there.
Speaker: So by doing that, that, as you can imagine, is very complex and it can raise a lot of technical, even ethical issues until all the questions are answered.
Speaker: And so knowing that NRP is out there and it's being done in different ways, but with that fundamental mindset in place is a very important thing for the intensives to be aware of.
Speaker: Perfect.
Speaker: And I think that, like you said, a lot of times for if you're the single intensivist at a busy ICU and you have a potential DCD patient, it becomes, like you said, a time poverty issue.
Speaker: But what I would always encourage people to think is that that probably...
Speaker: Or very well could be the most important thing you do on that shift in terms of saving lives.
Speaker: So try to think of the families that you're trying to impact.
Speaker: And also a topic that we didn't touch yet, which I think is also important, is that there's also literature, I understand, George, on the value for grieving families of the hero.
Speaker: Knowing that they have impacted our lives a lot of times can have a very positive and salutary effect on that grieving process.
Speaker: Gosh, Sergio, thank you for bringing that up.
Speaker: That is absolutely an important part.
Speaker: The literature is quite clear on this.
Speaker: When you look at grieving families, the fact that they were able to donate organs—
Speaker: is a tremendous benefit in the grieving process.
Speaker: This is, every time it's been studied, it's shown the same thing.
Speaker: You are helping not only the recipients of those organs, and we should do everything we can in that respect,
Speaker: but also you're helping the families because no one ever wants to be in the position to where they're deciding to donate organs.
Speaker: That means that their loved one has died or they are in the process of dying.
Speaker: So it's a way for us as intensivists to actually care for the families by ensuring that their gift is maximized.
Speaker: When we're talking about a family that was able to give the kidneys versus giving the kidneys a heart and the lungs, that's a huge impact.
Speaker: You can
Speaker: tell that family that their loved one is helping sustain life with these four or five or six different people.
Speaker: And that makes a tremendous positive difference.
Speaker: I just want to say real fast, Sergio, you know, one thing we do is
Speaker: at Herman is that we actually raise a flag, a donate life flag or an organ donation flag every time there's a hero in our unit.
Speaker: And when the hero goes to donate organs in the operating room, as much as is possible, we have what's called an honor walk where the staff stand along the walk to the operating room to honor and recognize the donation, the gift that person is giving.
Speaker: And then we have a moment of silence in the operating room that we take very seriously.
Speaker: And then after that, the flag is taken down and given to the family to support the family.
Speaker: The first thing we did when we designed the DSCU was make sure that we have a family space in DSCU.
Speaker: So supporting the family and meeting the needs of the family was.
Speaker: are an incredibly important part of why intensivists and getting involved in the management of heroes is so important because we're helping families all the time.
Speaker: We know how to support families.
Speaker: This is another element of providing great care to our patients before they become a hero and after they become a hero.
Speaker: That is very moving.
Speaker: And I've been part of some of those marches.
Speaker: And really, I mean, I think it's a very important way of helping the family also recognize how important, how much value, what their loved one, their hero has done for others.
Speaker: Now, as we close, I think there's a lot of topics around the organ transplant that we could talk about.
Speaker: We're not going to dive deep into the ethical issues because that could be a whole other podcast and maybe we'll do that next time.
Speaker: But as we close our discussion on the management of the organ donor, could you talk a little bit about how best to work with our local organ procurement organization and
Speaker: historically what's been encouraged is decoupling, right?
Speaker: The ICU team takes care of the patient and the OPO representative talks to the family about potential donation.
Speaker: But the studies have been very clear that having the right people do that and timing can have a tremendous impact on our success and getting the organs from these donors, from these heroes.
Speaker: Any thoughts or tips there?
Speaker: Absolutely.
Speaker: I would say the first thing is this is a the OPO world has been managing heroes alone for since this is where they started.
Speaker: And so this is new for them, just like it's new for us.
Speaker: And so it's important to approach this with an open mind, listening to what they can tell you about what they have historically done or routinely do, and making sure that we provide a evidence-based medicine approach.
Speaker: a appropriately critical yet receptive eye to all things that we learn in that process.
Speaker: And furthermore, be ready to communicate and create.
Speaker: Because this is an evolving role of the intensivist, this is a frontier where we have a chance to
Speaker: to define an area of medicine in all the right ways and all the positive aspects for all the right reasons.
Speaker: And so this is a great chance for us to, when we interact with an OPO or we interact with that donor care specialist who may be a nurse, who may be a respiratory therapist, who may have very limited medical background,
Speaker: Take that as an opportunity to educate them about why you're thinking the way you are and take an opportunity to learn about how they are going through their process and where they're getting their perspective from.
Speaker: This is a great chance to grow and develop together.
Speaker: And so I really strongly consider having a big dose of humility going into starting something like this.
Speaker: Perfect.
Speaker: We like to close every episode of the podcast, George, with a couple of questions that are unrelated to the clinical topic, but tap into the wisdom of our guest.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: Sure.
Speaker: Absolutely.
Speaker: The first question relates to books.
Speaker: Is there any book in particular that has influenced you significantly or a book that you have gifted often to others?
Speaker: Yeah, well, I have to answer that question.
Speaker: Honestly, for me, that book is the Bible.
Speaker: You know, it's it's it there's there's things that speak to every situation in life.
Speaker: And and I genuinely have gifted that book the most to others.
Speaker: And so it's not a medical book, but we're human beings first.
Speaker: And I think that that spiritual component is very important.
Speaker: Perfect.
Speaker: What do you believe to be true in medicine or in life that most other people don't believe, or maybe they don't behave like they believe?
Speaker: You know, I'll quote one of my professors from medical school and this, and I actually tell this to families.
Speaker: You know, when we have a difficult conversation, I say, look, I'm just a doctor.
Speaker: You know, all I've got are needles and machines and tubes and
Speaker: But you are his or her family.
Speaker: You know their hopes and dreams.
Speaker: You're the most empowered person.
Speaker: You're the most important person in this conversation because you are standing in that person's shoes helping make decisions for them.
Speaker: And I think that is incredibly true in medicine.
Speaker: Our role of being physicians is incredibly important, but it's extremely humbling.
Speaker: I'm going to the point to where we're really, if we really all think about it, we're not really qualified to be where we are in terms of sitting in these rooms and helping human beings in their last moments of life.
Speaker: That is it.
Speaker: We have to really always incredibly respect that.
Speaker: And I think in medicine, it's very possible for that to happen so often that it becomes part of the job.
Speaker: for lack of a better term, it becomes routine.
Speaker: So we have to really remember that, yes, we have this role and it's very special and it's been hard fought and a lot of effort goes into it, but simultaneously, it's very important for us to make sure we minimize ourselves in our role and the power that we have so that we can empower the people that can really carry out the patient's wishes.
Speaker: And to close, George, what would you want every listener, intensivist, or clinician listening to us to know?
Speaker: Boy, you know, I would say that as we practice and as we're intensivists, let's actually, it's going to sound a little redundant, but let's actually make sure we're maximally humble.
Speaker: That we have humility, not just in terms of how we talk to patients, but how we deal with each other.
Speaker: how an intensivist of one background may interact with another intensivist of a different background.
Speaker: Consulting services, answering that phone call where you ask for help.
Speaker: You know, as intensivists,
Speaker: People come to us for help a lot.
Speaker: It kind of makes us like the apex physician in a few ways in the hospital, because by the time people come to you, they need help.
Speaker: And so just making sure that we stay humble in that, I think is very important because it's very easy to lose that.
Speaker: And the moment we lose that, we become dangerous.
Speaker: So I say just make sure as antithesis that we know to keep ourselves humble as we go about our daily work and doing our very best to save lives.
Speaker: I think that's a perfect place to end.
Speaker: I really appreciate your willingness to spend your time and your expertise with us.
Speaker: Enjoyed the conversation, learned a lot, and hope to have you back on the podcast to talk about this and other critical care topics.
Speaker: Thank you so much, Sergio, for having me.
Speaker: I've had a great time talking to you, and I really appreciate the incredible work that you and your team do.
Speaker: Thank you so much.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
