ASA6 cases

[anbuitachi]

For organ harvests , especially after brain death. do you consent the HCP? do you even get a consent? the patient is dead..
ive done many of these in the past but not for a while. and i dont remember!

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[Lecithin5]

I just wait for them to arrive to the OR- I don’t recall obtaining any form of consent.

 

[Arch Guillotti]

No consent.

Donor services takes care of it all.

 

[coffeebythelake]

no consent

also someone told me no such thing as an ASA6E. thoughts?

 

[UscGhost]

Probably can't be an emergency if patient is dead

 

[anbuitachi]

Probably can't be an emergency if patient is dead

what about cardiac death donations but patient doesnt die. asa 5? 5e?

 

[nimbus]

what about cardiac death donations but patient doesnt die. asa 5? 5e?

Our group has a policy not to be involved in those. Too many ethical and legal land mines. Procurement organization brings their own people to reintubate and support the donor if the heart does indeed stop in a reasonable time. Often it does not.

 

[coffeebythelake]

what about cardiac death donations but patient doesnt die. asa 5? 5e?

if it is cardiac death donation... if patient heart doesnt stop then they arent dead and thedonation doesn't occur. We are not involved in these cases

 

[coffeebythelake]

Probably can't be an emergency if patient is dead

sometimes they ask for the case at odd hours of day, weekends, and we end up bumping other reasonably urgent but (nonemergent) cases to do it

 

[nimbus]

sometimes they ask for the case at odd hours of day, weekends, and we end up bumping other reasonably urgent but (nonemergent) cases to do it

They’re always coordinating with recipient centers.

 

[coffeebythelake]

They’re always coordinating with recipient centers.

yes, of course, multiple teams from all over and certain organs are very time sensitive to coordinate so i understand...

 

[Lecithin5]

Our group has a policy not to be involved in those. Too many ethical and legal land mines. Procurement organization brings their own people to reintubate and support the donor if the heart does indeed stop in a reasonable time. Often it does not.

Can you expand on this? Curious what the ramifications could be- or has anyone been involved in a sort of legal issue etc?

 

[anbuitachi]

Can you expand on this? Curious what the ramifications could be- or has anyone been involved in a sort of legal issue etc?

like if you give fentanyl and patient dies.

lot of potential issues.

 

[nimbus]

Can you expand on this? Curious what the ramifications could be- or has anyone been involved in a sort of legal issue etc?

One extreme example. There are competing goals to simultaneously minimize warm ischemia time while not hastening “cardiac death”.

An 8-year-old was taken off life support, his organs donated. Now, police are investigating

By the time Cole Hartman arrived at Ronald Reagan UCLA Medical Center, he was in grave condition.

www.latimes.com

 

[abolt18]

One extreme example. There are competing goals to simultaneously minimize warm ischemia time while not hastening “cardiac death”.

An 8-year-old was taken off life support, his organs donated. Now, police are investigating

By the time Cole Hartman arrived at Ronald Reagan UCLA Medical Center, he was in grave condition.

www.latimes.com

That's a few years ago. Did anything come of this?

Also, the ASA has a very good, very thorough article about DCD.

Statement on Controlled Organ Donation After Circulatory Death

www.asahq.org

 

[Shimmy8]

No consent obtained.

Stay far, far away from any DCD case with any type of involvement with those.

I hate the meds they give to “hasten” death for these patients after extubation and drips off.

In my state, if it’s DCD and they are harvesting lungs, they will terminal extubate patient and want them reintubated for lung ventilation and harvest. We have refused to do this as it’s asinine and filled with every sort of medico-legal risk imagineable.

 

[nimbus]

That's a few years ago. Did anything come of this?

Also, the ASA has a very good, very thorough article about DCD.

Statement on Controlled Organ Donation After Circulatory Death

www.asahq.org

I don’t know the outcome of that case.

FWIW, the last 3-4 attempted DCD donations at our hospital have been aborted due to patients lingering too long after withdrawal of support. Makes sense since they usually have healthy hearts and lungs.

 

[psychbender]

I don’t know the outcome of that case.

FWIW, the last 3-4 attempted DCD donations at our hospital have been aborted due to patients lingering too long after withdrawal of support. Makes sense since they usually have healthy hearts and lungs.

I can't even remember the last DCD that actually made it to the OR. Our current policy is that the intensivist has to be at bedside during the immediate post-extubation period to minimize time from declaring death and getting into the OR. We move the patient and family to an isolation bay in the PACU, remove the tube, and they have 30 minutes to die. During that time, I'm usually parked at a computer in the PACU, writing notes, while one of my colleagues covers my unit for emergencies when we're down there. They never die during those 30 minutes.

 

[neutro]

No consent.

Donor services takes care of it all.

exactly, plus i do not think I want to be involved in these conversations explaining to the family that i will be giving anesthesia to their loved one who passed away a few hours ago.

 

[IMGASMD]

We were involved as residents, since usually we’re the one at night to turn off the vent. Thankfully I’ve only seen DDNC. From what I heard of DCD, that line is so thin, I won’t feel comfortable to be there.

 

[sanityonleave]

We aren't involved in DCDs at all. Donor services / organ bank brings them down to the OR (perhaps with an ICU RN) and then palliatively extubates them. Surgical teams are all outside the room until the patient is pronounced.

DBDs we will haul from the ICU and then stay with the patient until the aorta is XC'd. Donor services gets consent etc - I never meet the family unless they happen to be there when they're packing up the patient (though usually the ICU has coordinated goodbyes beforehand).

 

[anbuitachi]

We aren't involved in DCDs at all. Donor services / organ bank brings them down to the OR (perhaps with an ICU RN) and then palliatively extubates them. Surgical teams are all outside the room until the patient is pronounced.

DBDs we will haul from the ICU and then stay with the patient until the aorta is XC'd. Donor services gets consent etc - I never meet the family unless they happen to be there when they're packing up the patient (though usually the ICU has coordinated goodbyes beforehand).

im not sure why they cant do the same for dbd and why we are involved. not much is done in dbd by us...

 

[coffeebythelake]

im not sure why they cant do the same for dbd and why we are involved. not much is done in dbd by us...

They could easily have an ICU trained nurse do the DBD patients. These patients are dead. They don't need anesthesia.

 

[chocomorsel]

no consent

also someone told me no such thing as an ASA6E. thoughts?

Haven’t been here in a while but y’all are killing me! 😝😝

 

[chocomorsel]

what about cardiac death donations but patient doesnt die. asa 5? 5e?

Maybe I am getting old and dumb but this does not compute. How is it a cardiac death but the patient is still considered alive? Make it make sense for me.

 

[anbuitachi]

Maybe I am getting old and dumb but this does not compute. How is it a cardiac death but the patient is still considered alive? Make it make sense for me.

because if you staff the case, the patient comes in not dead yet. then you extubate and see if patient dies. if not patient gets reintubated and go back to ICU. in that case its not a cardiac death. but either way , ASA score is preop. and preop patient is not dead

 

[psychbender]

because if you staff the case, the patient comes in not dead yet. then you extubate and see if patient dies. if not patient gets reintubated and go back to ICU. in that case its not a cardiac death. but either way , ASA score is preop. and preop patient is not dead

Whoa, whoa, whoa. Why the **** are you reintubating a failed DCD patient? They're a comfort care only patient at that point, and should not be on the vent.

 

[chocomorsel]

because if you staff the case, the patient comes in not dead yet. then you extubate and see if patient dies. if not patient gets reintubated and go back to ICU. in that case its not a cardiac death. but either way , ASA score is preop. and preop patient is not dead

Thanks. Why isn’t this being done in the ICU? These patients take a while to go. I am used to this being done in the ICU and have never been involved in the OR.
And don’t they have to die within a certain amount of time anyway for the organs to be good? And if you reintubate then what? The process starts all over again? Seems counterintuitive.

 

[anbuitachi]

Whoa, whoa, whoa. Why the **** are you reintubating a failed DCD patient? They're a comfort care only patient at that point, and should not be on the vent.

im not but i think when i was a resident we did one.

 

[anbuitachi]

Thanks. Why isn’t this being done in the ICU? These patients take a while to go. I am used to this being done in the ICU and have never been involved in the OR.
And don’t they have to die within a certain amount of time anyway for the organs to be good? And if you reintubate then what? The process starts all over again? Seems counterintuitive.

they want it in OR so they can open asap and take organs.

 

[abolt18]

because if you staff the case, the patient comes in not dead yet. then you extubate and see if patient dies. if not patient gets reintubated and go back to ICU. in that case its not a cardiac death. but either way , ASA score is preop. and preop patient is not dead

Why would you be staffing said case? Intensivist is supposed to be in charge of their care during withdrawal of care.

@chocomorsel to get the best understanding of how this is supposed to go, read this:

Statement on Controlled Organ Donation After Circulatory Death

www.asahq.org

 

[woopedazz]

DCDs take up an OR and surgical/scrub team(s); but otherwise exist outside of our mind's eye.

We're a trauma/neuro centre, so we do a lot of DBDs. Normally leave after x-clamp.

 

[chocomorsel]

Why would you be staffing said case? Intensivist is supposed to be in charge of their care during withdrawal of care.

@chocomorsel to get the best understanding of how this is supposed to go, read this:

Statement on Controlled Organ Donation After Circulatory Death

www.asahq.org

I just write the order to withdraw care and the comfort order sets and walk away. And then inevitably get the call from the OPO that the patient is not dying fast enough and that the mission is to be aborted. Oops.

 

[chessknt]

because if you staff the case, the patient comes in not dead yet. then you extubate and see if patient dies. if not patient gets reintubated and go back to ICU. in that case its not a cardiac death. but either way , ASA score is preop. and preop patient is not dead

Absolutely have never seen reintubation ever. These people are going to die and the family (if there is one) understands the care is going in one direction only and does not get escalated again. Have you seriously re intubated a dcd patient???? I've definitely seen many not die fast enough once extubated but then we just move them to a comfort care room to die.

 

[nimbus]

Absolutely have never seen reintubation ever. These people are going to die and the family (if there is one) understands the care is going in one direction only and does not get escalated again. Have you seriously re intubated a dcd patient???? I've definitely seen many not die fast enough once extubated but then we just move them to a comfort care room to die.

No personal experience since we are not involved. But the ones who become actual donors are apparently reintubated.

I’ve read that potential lung donors are reintubated after a 2-10 min “no touch period”, so they can get bronchoscopy to be sure there was no aspiration after extubation, and to assist in dissection of donor lungs. The “no touch period” is there to make sure they don’t come back from the dead on their own with spontaneous ROSC.

Even further, I guess these donors are sometimes put on partial/regional CPB (excluding the brain) after death to minimize warm ischemia time.


From the ASA link posted above.

1. Organ Recovery
   1. If applicable, antemortem placement of femoral or other large vessel cannulas and/or administration of pharmacologic agents for the sole purpose of optimizing donor organ function must be detailed in the consent for donation process.
   2. Once death is documented, the donor’s lungs will require reinflation if they are being considered for retrieval. This may necessitate reintubation of the donor. (See 3d above)
   3. Once there is a declaration of death, an incision to recover organs should be performed immediately. The transplant surgeons will initiate perfusion of the organs with cold preservation solution and proceed with the donor operation.
   4. As stated in section 3d. above, any team members actively involved in the initiation and/or maintenance of circulatory support for NRP cannot participate in the guidance or administration of end-of-life care or the declaration of death.

 

[abolt18]

No personal experience since we are not involved. But the ones who become actual donors are apparently reintubated.

I’ve read that potential lung donors are reintubated after a 2-10 min “no touch period”, so they can get bronchoscopy to be sure there was no aspiration after extubation, and to assist in dissection of donor lungs. The “no touch period” is there to make sure they don’t come back from the dead on their own with spontaneous ROSC.

Even further, I guess these donors are sometimes put on partial/regional CPB (excluding the brain) after death to minimize warm ischemia time.


From the ASA link posted above.

1. Organ Recovery
   1. If applicable, antemortem placement of femoral or other large vessel cannulas and/or administration of pharmacologic agents for the sole purpose of optimizing donor organ function must be detailed in the consent for donation process.
   2. Once death is documented, the donor’s lungs will require reinflation if they are being considered for retrieval. This may necessitate reintubation of the donor. (See 3d above)
   3. Once there is a declaration of death, an incision to recover organs should be performed immediately. The transplant surgeons will initiate perfusion of the organs with cold preservation solution and proceed with the donor operation.
   4. As stated in section 3d. above, any team members actively involved in the initiation and/or maintenance of circulatory support for NRP cannot participate in the guidance or administration of end-of-life care or the declaration of death.

He's saying, never seen reintubation for someone who did not die, because anbuitachi described someone not dying then getting reintubated and taken from the OR. Reintubation for lung transplant is standard.

 

[anbuitachi]

He's saying, never seen reintubation for someone who did not die, because anbuitachi described someone not dying then getting reintubated and taken from the OR. Reintubation for lung transplant is standard.

thats what i remember. i could be wrong i guess? case was from when i was in residency which was a longggggggggggggg time ago

 

[PTPoeny]

No personal experience since we are not involved. But the ones who become actual donors are apparently reintubated.

I’ve read that potential lung donors are reintubated after a 2-10 min “no touch period”, so they can get bronchoscopy to be sure there was no aspiration after extubation, and to assist in dissection of donor lungs. The “no touch period” is there to make sure they don’t come back from the dead on their own with spontaneous ROSC.

Even further, I guess these donors are sometimes put on partial/regional CPB (excluding the brain) after death to minimize warm ischemia time.


From the ASA link posted above.

1. Organ Recovery
   1. If applicable, antemortem placement of femoral or other large vessel cannulas and/or administration of pharmacologic agents for the sole purpose of optimizing donor organ function must be detailed in the consent for donation process.
   2. Once death is documented, the donor’s lungs will require reinflation if they are being considered for retrieval. This may necessitate reintubation of the donor. (See 3d above)
   3. Once there is a declaration of death, an incision to recover organs should be performed immediately. The transplant surgeons will initiate perfusion of the organs with cold preservation solution and proceed with the donor operation.
   4. As stated in section 3d. above, any team members actively involved in the initiation and/or maintenance of circulatory support for NRP cannot participate in the guidance or administration of end-of-life care or the declaration of death.

Everyone should only be involved in organ donation to the point that they are comfortable. But just to put out there I think DCD is an amazing thing for families. I know peds is different but my experience is we do DCD on the kids that have a horrific event but aren't quite brain dead because they keep one single cranial nerve reflex. As an intensivist my hospital has my group accompany the patient to the OR with family in bunny suits. We do the palliative extubation with family at bedside just like upstairs. Then if they die in time we declare and the family is escorted out during the do-not-touch time before the surgeons come in. We also don't do DCD lungs in kids where I have been so the consideration of re-intubation has never been part of my experience.

I'm sure it feels a lot different because we are the ones having conversations with the OPO about when and if to approach families about DCD rather than being consulted after a decision is made but I have found families to be incredibly appreciative of the opportunity to feel like they made a difference and made something good come out of a horrible tragedy.

 

[PpfSuxTube]

They could easily have an ICU trained nurse do the DBD patients. These patients are dead. They don't need anesthesia.

Well...
Have you done many of these? Sounds like you havent

 

[nimbus]

Well...
Have you done many of these? Sounds like you havent

If ICU nurses were familiar with the anesthesia machine and hand ventilating the lungs, they could do it. They can give heparin, lasix and steroids as well as we can.

 

[PpfSuxTube]

If ICU nurses were familiar with the anesthesia machine and hand ventilating the lungs, they could do it. They can give heparin, lasix and steroids as well as we can.

You would let an icu nurse that says they're familiar with the machine run an OR anesthetic?

 

[nimbus]

You would let an icu nurse that says they're familiar with the machine run an OR anesthetic?

No I wouldn’t allow it based on what they said. But if they get oriented to it and showed competence, then sure, why not? It’s not rocket science and it’s not more complicated than a lot of things they already do.

As @coffeebythelake says, they can easily be trained to do it.

 

[coffeebythelake]

Well...
Have you done many of these? Sounds like you havent

I work at a large academic center so I do these cases occasionally. Probably 10 or 15 of them over the years. I reiterate my previous statement that dead patients do not need anesthesia, and an ICU nurse can be trained to adjust vent settings or run infusions. The organ procurement team has a handout with all the relevant management goals. They don't even need to use an anesthesia machine. They can use an ICU vent

 

[Shimmy8]

I’ve prob done 100 or so of these between residency and current position. The VAST majority of these do not need more than a critical care nurse.

However…every once in awhile you get a super sick one who needs very hands-on critical care management that requires a higher level of training.

 

[PpfSuxTube]

I’ve prob done 100 or so of these between residency and current position. The VAST majority of these do not need more than a critical care nurse.

However…every once in awhile you get a super sick one who needs very hands-on critical care management that requires a higher level of training.

Finally.

 

[nimbus]

I’ve prob done 100 or so of these between residency and current position. The VAST majority of these do not need more than a critical care nurse.

However…every once in awhile you get a super sick one who needs very hands-on critical care management that requires a higher level of training.

Are you talking about DBD or DCD? What kind of high level critical care do these patients with healthy donor organs require?

At our hospital, when a patient becomes a DBD donor, our intensivists sign off and stop rounding on them. They are managed by the organ procurement organization and the icu nurse. Sometimes this goes on for 2-3 days.

 

[coffeebythelake]

I’ve prob done 100 or so of these between residency and current position. The VAST majority of these do not need more than a critical care nurse.

However…every once in awhile you get a super sick one who needs very hands-on critical care management that requires a higher level of training.

This must be digging bottom of the barrel cases. Management of DI, hypotension, hypo/hyperglycemia, fluid management all pretty protocol driven. You know.. the typical things that you may expect to see with brain death.. If a DBD is so unstable they are probably not a suitable organ donor. What type of "super sick" are you talking about?

 

[Shimmy8]

Are you talking about DBD or DCD? What kind of high level critical care do these patients with healthy donor organs require?

At our hospital, when a patient becomes a DBD donor, our intensivists sign off and stop rounding on them. They are managed by the organ procurement organization and the icu nurse. Sometimes this goes on for 2-3 days.

Exactly. The real people managing acute problems sign off. Again, the vast majority are fine. But 2-3 days of zero real intervention on a minority of these patients can be seen as they near end of life.

Their disease process is often still unfolding. Polytrauma, massive stroke, anemic, on pressors, increasing FiO2 requirements, ARDS, etc.

Nothing we can't and don't handle on a very routine basis, but nothing that an ICU nurse is used to managing ON THEIR OWN while surgeons are barking at them.

And you all are exactly right that some of these are NOT good donors. They are often borderline about to have circulatory collapse, but we're trying to do the best we can to preserve organs.

 

[dabears505]

These cases of brain death donations definitely need anesthesia management. I've even had to give blood during one. Pressors are not uncommon. Yea you can say a critical care nurse can manage that, but then you can say they can manage most intraop cases.

Also what legal liability could you have for a patient you reintubate after cardiac death? That doesn't make sense. They are dead dead at that point. Unless somehow they become alive again after the tube goes in and they are oxygenated.

 

[nimbus]

I've even had to give blood during one. Pressors are not uncommon. Yea you can say a critical care nurse can manage that, but then you can say they can manage most intraop cases.

I’ve seen OPO and ICU nurse do all the above.