Organ and Tissue Donation

Reference Manual

Organ and Tissue Donation

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I. Conditions for Hospital Participation…………3 Conditions for Hospital Participation Clinical Cues for Referral

II. Collaborative Donation Process…………………5 The Collaborative Donation Process Supporting the Opportunity for Donation

III. Donation after Brain Death……………………….9 Declaration of Brain Death Donor Evaluation Adult Donor Management Goals Common Medications Common Pulmonary Interventions NEDS Order Set – Sample Organ Allocation

IV. Organ Surgical Recovery……………………………20 Organ Recovery – Preparing for Recovery Organ Recovery – Process Organ Recovery – Supplies OR Procurement Supply List DBD Preference Card DCD Preference Card Anesthesia Guidelines

V. Donation after Circulatory Death………………28 Donation after Circulatory Death DCD Flowchart Detailed Organ Evaluation – DCD

VI. Pediatric Donation……………………………32 Pediatric Donation

VII. Ancillary Support………………………………34 Respiratory Therapy Respiratory Therapy – Apnea Test Pulmonary Donor Management Donation after Circulatory Death Cardiology – Echocardiogram Cardiology – Cardiac Catheterization Pulmonology – Bronchoscopy Radiology Pathology Morgue Security

VIII. Tissue Donation……………………………….47 Tissue Donation – Referral Tissue Donation – Recovery Tissue Screening Worksheet

IX. FAQs…………………………………………………51Aftercare Services HOPE Act Myths & Facts National Donate Life Registry Hospital Partnership Campaign Religion and Donation Vascular Composite Allograft Donation

TABLE OF CONTENTS

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I. CONDITIONS FOR HOSPITAL PARTICIPATION

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The Center for Medicare & Medicaid Services (CMS) has mandated federal regulations, documented in the publication “Conditions of Participation for Hospitals Regarding Organ, Tissue and Eye Donation,” which define hospital requirements in working with Organ Procurement Organizations (OPOs). These requirements are specified further in a written agreement called a Memorandum of Understanding/ Agreement (MOU/MOA) between the hospital and their designated OPO (NEDS). The MOU/MOA addresses the following:

1. PolicyHospitals must have and implement written policies and procedures to address donation responsibilities.

2. Referral CriteriaHospitals must refer every death and every imminent death as defined by the designated OPO.

The referral criteria for imminent death, or potential organ donor, includes:

Any ventilated patient who has a non-recoverable injury or condition o Upon initiation of therapeutic hypothermia/TTMo Prior to discussion of DNRo Prior to discussion of DNE/CMO (limitation/removal of mechanical/pharmacological support)o Prior to initiation of brain death testing

The referral criteria for potential tissue donation is: o Within ONE hour of asystole

More information about the referral criteria and clinical cues for referral is included in this manual.

2. Medical SuitabilityThe OPO is responsible for determining medical suitability for organ and tissue donation. This is done incollaboration with the hospital, and final determination is made by the NEDS Medical Director.

3. Death Record ReviewHospitals must develop policies that allow NEDS to have timely access to death records to ensure alldeaths are being referred and to improve identification of potential donors.

4. Maintaining DonorsHospitals must maintain potential donors in a manner that preserves organ viability.

5. Donation RequestsHospitals and NEDS work collaboratively to determine the most appropriate time for NEDS to initiate thedonation discussion. NEDS’ staff are trained in addressing concerns, dispelling myths and engaging incomprehensive discussions about the donation process. CMS regulations require NEDS staff to engage indetailed training annually. Non-collaborative mention or unplanned hospital mention of donation is notconsistent with the CMS Conditions for Hospital Participation.

6. HIPAA Security and Privacy RulesHIPAA applies to Covered Entities (CE) (healthcare providers) and Business Associates (BA). NEDS, like allOPOs, is not a CE or BA under HIPAA. A specific exception in the HIPAA Privacy Rule allows hospitals andother healthcare providers to share protected information with an OPO to facilitate the donation andtransplantation of organs and tissues. NEDS maintains a robust privacy and security program based onthe HIPAA Security Rule and is constantly adjusting and reviewing its information security policies basedon external and internal risks.

CONDITIONS FOR HOSPITAL PARTICIPATION

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In order to determine initial medical suitability, specific information may be requested. Being prepared with the following information will allow for an efficient referral process.

o Admission course, including whether the patient had any downtime, surgeries since admission or if ahypothermia protocol was initiated

o Abnormal findings on imaging or any positive cultures

o Medical history such as cancer, hypertension, diabetes, kidney or liver disease

o Most recent neurological exam and vital signs, including the use of any vasopressors or vasodilators

o Recent lab values, including BUN and creatinine, AST, ALT, TBili, WBC, ABG

o Plan of care and if there are any planned family meetings

A timely referral occurs when NEDS is notified within 1 hour of a patient meeting the clinical cue(s).

CLINICAL CUES FOR REFERRAL

Saving lives through donation and transplantation is not possible without your help. Your identification of a potential organ and tissue donor and subsequent timely referral to New England Donor Services is the only way the over 100,000 people waiting for a life-saving organ transplant have a fighting chance.

The recipients are not the only ones to benefit from your call. Many donor families have reported that donation has provided them with comfort knowing that their loved ones helped save the lives of others.

Here’s how you can be an advocate for potential donor families and recipients:

Organ Donation

Identify and refer any patient who has a non-recoverable injury or condition and meets any of the following criteria:

Following the referral, a NEDS coordinator will come to the hospital to review the chart and briefly meet with you. During this time, there should be no mention of donation. A thorough evaluation and determination of medical suitability must be made by a NEDS coordinator prior to any donation discussion. Donation is only discussed with a potential donor family following a collaborative plan between NEDS and hospital staff.Once a patient is no longer hemodynamically maintained or if a patient is extubated, the opportunity to save lives through organ donation is no longer a possibility. A referral to NEDS must be made prior to any discussion of Comfort Measures Only (CMO) or Do Not Escalate (DNE) care.

Tissue Donation

Refer ALL patients within 1 hour of ASYSTOLE

When you make the initial referral, the NEDS coordinator will ask for information on the following:

Please have the medical chart available. Detailed information on the questions you will be asked as well as a screening tool are included in the Tissue Recovery section of this manual.

CLINICAL CUES FOR REFERRAL

o All fluids within last houro All transfusions within last 48 hourso Evidence of current infection/transmissible diseaseo Next of Kin contact information

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ll. COLLABORATIVE DONATION PROCESS

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The Collaborative Donation Process (CDP) NEDS data has demonstrated that when the CDP is implemented, more families authorize donation. The CDP is comprised of key components supportive of an effective donation process. These include:

1. Timely referral (see section on clinical cues for referral in this manual)2. Effective communication including use of “huddle”3. Donation discussion by NEDS

The U.S. Department of Health and Human Services recognized the vital role of hospitals in supporting organ and tissue donation and as a result established the CMS Conditions of Participation for Hospitals. Your institution has acknowledged the importance of the regulations through a Memorandum of Understanding/Agreement. The Collaborative Donation Process (CDP) is in alignment with the regulations.

The following is a summary of the hospital responsibilities:

1. Comply with criteria for making a timely referralA timely referral is the first step towards facilitating an optimal experience for both the family andthe medical team. When a referral is made within one hour of identifying a patient meeting aclinical cue, NEDS can respond to the hospital and complete a thorough evaluation in an organizedand unrushed manner. In addition, this allows for NEDS and hospital staff to work together onclear communication and plan for next steps.

2. Ensure all potential donor families are informed by an OPO representative of their donationopportunityEvery family has the right to make their own decision about donation at a time when they areemotionally able to learn about their options. Determining when a donation discussion is to occuris decided together with NEDS. The key conversation that supports this collaborative plan is donethrough a “huddle.” During this “huddle” NEDS and hospital staff discuss and agree on the besttiming for NEDS involvement, including transitional language for NEDS introduction.

3. Cooperate fully to support the organ donation processIt is only possible for potential donor families to have a thoughtful donation discussion with yourcommitment to supporting all possible end of life options. For proper evaluation of donationpotential, hemodynamic support may be indicated. Use of fluid resuscitation, vasopressor support,bicarbonate drip and increasing ventilator settings, when indicated, may give families the time tomake a donation decision. When patients are not maintained during the evaluation process, theopportunity for donation may no longer be possible.The gift of organ donation is extraordinary. It is our commitment to optimize each and everyopportunity we are trusted with on behalf of the donor and/or donor family. This responsibilityrequires thorough evaluation and management of the donor, often requiring the expertise ofcritical care staff and ancillary services. Specific information on common tests, procedures, andmedications used to optimize organ function is located in this manual.

THE COLLABORATIVE DONATION PROCESS

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Declaration of Death

When a patient is consistent with brain death, testing and declaration should be the next step. The diagnosis of brain death allows for compassionate end of life care for families as there is no decision regarding withdrawal of support. Brain Death is a diagnosis and is made independently of the decision to donate. When a referral is made after a family is informed that brain death has occurred, the time necessary for NEDS to conduct a thorough evaluation often delays the discussion of next steps and/or options, possibly resulting in a family declining donation due to timing.

Critical Care Guidelines Good critical care practice is essential to maintaining the opportunity for donation. The following are critical care guidelines which allow for proper evaluation and determination of donation potential.

Maintain SBP>100 (MAP>65) Consider invasive or noninvasive hemodynamic monitoring.

o Adequate hydration: Ensure adequate hydration to maintaineuvolemia.

o Vasopressor support: If hypotensive post adequate hydration,utilize Neosynephrine as the first pressor of choice at 40-60mcg/min, followed by Levophed if needed.

Maintain UOP 0.5 ml/kg/hr Goal <300 ml/hr Consider DI if UO > 400ml/hr x 2 hours.

o Treat Diabetes Insipidus: Vasopressin @ 1-3 U/hr, if UO still exceeds 400ml/hr, may give DDAVP0.5 mcg IVP q 2-3 hours.

o Note: Mix 10 units in 250cc D5W (yields 15cc = 0.6u hr).o If UOP falls below 0.5 ml/kg/hr, assess fluid status as patient may need rehydration or BP support.

Maintain PaO2 > 100 & pH 7.35-7.45 on least amount of FiO2 o Adequate ventilation with PEEP 5-8o Aggressive respiratory hygiene (q 2 hour suctioning and turning) if not contraindicated by

patient’s conditiono Beta agonist to prevent bronchospasm

Maintain temperature 36-37.5 C o Bair hugger/warming-cooling blanket/warm fluidso May consider ventilator circuit warming

SUPPORTING THE OPPORTUNITY FOR DONATION

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III. DONATION AFTER BRAIN DEATH

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When a patient has lost all neurological reflexes, brain death testing and declaration should be the next step. Brain death is a diagnosis and is independent of the decision to donate. This definitive diagnosis allows for the best end of life care for families as no decision has to be made by the family regarding whether to withdraw treatment. The diagnosis of brain death is made by the hospital physician and according to hospital-specific policy. NEDS staff refer to each hospital’s policy for specific testing, timeline and personnel requirements defined by the particular hospital.

The American Academy of Neurologists’ evidenced-based guideline for determining death by neurological criteria can be accessed at www.aan.com.

DECLARATION OF BRAIN DEATH

http://www.aan.com/

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Orders to Anticipate Post Consent

Monitor Vital Signs Q1hr:

o BPo HRo SaO2o CVPo I&0

All Potential Donors Potential Heart and/or Lung Donors

General

o Measured height and weighto CXR (upright) with readingo A-lineo Central lineo Blood type and screen

Labs (q 6 hours and prn) o CBC with differentialo Electrolytes/BUN/Creatinineo Glucose, Amylase, Lipaseo Mg, Phos, Ionized CAo LFTso Lactateo Albumino PT/PTT/INRo HgbA1Co Troponino ABGo Sputum for gram stain and cultureo Urine for UA/C&So Urine protein/creatinine ratio

o EKGo Echocardiogramo Cardiac catheterizationo PA line or non-invasive hemodynamic monitoringo O2 challenge (ABG post 30 minutes on 100% FiO2)o Bedside bronchoscopyo Chest CT

Trends in laboratory values are essential in determining the ability of organs to recover from initial insult. When an event occurs, such as a cardiopulmonary arrest (CPA) or severe hypotension, trending of labs and other post intervention studies provide needed information for the transplant physician to make an appropriate decision whether to accept the organ for their recipient.

DONOR EVALUATION

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Na < 160

MAP > 65mmHg

HR 50 - 100

CVP 4-12 Exclusion: renal failure

SaO2 > 95%

P/F ratio > 3.0Pre-existing conditions: COPD, asthma, emphysema, > 10ppyr smoking, chest trauma

pH > 7.3

U/O 1-3cc/kg/hr

Vasopressors < 1 Exclusion: vasopressin for DI Consider T3/T4 if patient requires > 2 vasopressors

Ventilator Goals ET size >7.5 Pplat< 30 cm/H2O P/F ratio > 300 on any FiO2 PaO2 100 torr on least FiO2 PaCO2 35-40 torr

ADULT DONOR MANAGEMENT GOALS

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Due to endocrine dysfunction as a result of brain death, the following medications may be used:

Order Dose/Management Rationale

Solumedrol 1g x 1 Corticoid Steroid Replacement a. Improves donor organ function and graft

survivalb. Increases tissue oxygenation and donor

lung recoveryc. Improves cardiac function following

transplantationd. Attenuates the effects of

proinflammatory cytokines released as aconsequence of brain death

T3 Protocol

T4 Protocol (may use T4 if patient requires >2 vasopressors)

Monitor electrolytes before and during T3 infusion.

1. Liothyronine (T3) bolus 4 mcq IV over 1 minute2. Then infuse at 20ml/hr (3 mcq/hour) for 5 hrs -

mixture: 15 mcq T3/Liothyronine in 100mL NS; ifnew bag required, mix 10 mcq T3 in 50 ml NS andinfuse at 15 mL/hr

3. Vasopressin 1 unit IV bolus over 1 minute, then0.5-4 units/hr IV infusion (titrate for SVR 800-1200and wean if UOP< 80 Ml/hr)

4. Solumedrol 2 gm IV bolus (if not already given)5. Insulin drip to maintain serum glucose 120-180

Monitor electrolytes (esp. K+ and glucose) before and during T4 infusion.

1. Levothyroxine (T4) bolus 20 mcq IV over 1 minute2. Infuse at 25 ml/hr (10 mcq/hr) - mixture: 200 mcg

T4 (50 ml ) in 500 mL NS)3. 1 amp (25 gm) Dextrose 50% IV Bolus4. 2 gm Solumedrol IV Bolus5. 20 units Regular Humulin Insulin IV Bolus

Reduce other pressors as tolerated while titrating T4 to maintain MAP > 65

Decrease in Thyroid Hormones a. Result of impaired TSH secretion and

peripheral conversion of T4 to T3i. Rapid decline in free T3

o Anaerobic metabolism andacidosis

o Progressive loss in CardiacContractility

Studies have demonstrated that the use of T4 improves tissue and organ perfusion with subsequent shift from anaerobic to aerobic metabolism due to:

a. Activation of cellular mitochondria tomaintain aerobic respiration with a shiftto normalize lactate and free fatty acidmetabolism

b. Increased arterial blood pressurec. Increased left ventricular function and

COd. Decreased inotrope requirements

Vasopressin 1. Replacing free water loss with hypotonic saline or2. Dextrose in water and electrolytes as needed3. Vasopressin 0.02-.04 units/min reduces UOP4. Goal UOP 100-200 ml/hr5. Severe cases UOP >1000 ml/hr may respond to

DDAVP 0.3 mcg/kg or vasopressin 0.1 U/min

Central Diabetes Insipidus (DI) a. Early depletion of ADHb. Characterized by inappropriate diuresis

leading to severe hypovolemiac. Hemodynamic and electrolyte instability

COMMON MEDICATIONS

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1. Standard care o ET cuff inflated to at least 25 cm H2O pressureo HOB up 30 degrees, frequent oral care/VAP protocolo NGT to suctiono Turn q 2 hours-consider positioningo Chest PT and suction q 2 hours - use VEST if availableo ABGs: baseline, q 2-3 hours and with all vent changes

2. Chest X-ray with interpretation

3. Bronchoscopy with sputum for gram stain and culture (right and left lobes) • prefer no lavage, minimal if necessary

4. Medications Antibiotics for specific organisms o Albuterol Nebso Solumedrol

5. Ventilation Considerations

Settings:

o Peep +5o Pressure Trigger with -4 cm/H2O• set trigger sensitivity to prevent auto trigger

o Inspiratory Time (Ti) 1.25 - 2 sec

Mode: VC: target Tidal Volume (Vt) of 8-10cc/kg with monitoring of Pplat. PCV: monitor Vt to assure 8-10 cc/kg APRV: monitor Mean Airway Pressure (PAW) and PaCO2

If P/F Ratio < 300, consider: o Extend Timing (If PC, monitor Vt; If VC, monitor I/E)o Larger Vt: assure Pplat < 30o Temporary increases in PEEPo Add Inspiratory Hold if availableo Add Sigh Maneuver if availableo Recruitment Maneuver followed by temporary increase in

PEEPset

Recruitment Maneuver: o CPAP 30cm x 30 sec, repeat in 2-4 min

COMMON PULMONARY INTERVENTIONS

Provider Signature: Print Name: _ Write in/check choice or preference. Provider Must Exercise Independent Clinical Judgment When using Order sets

New England Donor Services 60 First Avenue

Waltham, MA 02451 24-hour number: 800/446-6362

Known allergies/medication sensitivities:

Following authorization for organ donation, discontinue previous orders except as noted

Patient Identification Room No.

Date/Time New England Donor Services Orders

Patient Care Orders for All Donors

Measured HT /Admission Dry WT _ Blood Pressure, Heart Rate, Temperature, Input and Output every 1 hour and PRN Arterial Line/Central Line placement Transduce CVP hourly Maintain normothermia (36-37.5 C or 97-100 F.) Warming or cooling as indicated Maintain goal MAP >65; HR 60-120; UOP 100-300 cc/hr (1-3 cc/kg/hr); SaO2 > 95% Pulmonary Hygiene: Frequent suctioning; chest PT and turning q 2-4 hours and PRN VAP orders: HOB ^ 30 degrees; Oral care q 2 hours and PRN ETT cuff inflated to at least 25 cm H2O pressure NG/OG tube to intermittent low wall suction Other:____________________________________________________________

Donor Evaluation Orders: Order in collaboration with NEDS Coordinator Blood Type and screen x 1 Crossmatch 3 units PRBC and place on hold for the OR CBC with Differential Q6 Electrolytes, BUN/Creatinine, Glucose Q6 Mg, Ca+ (ionized), Phos Q6 AST/ALT/LDH/Alk Phos/T. Bili/D.Bili/ Total Protein/ Albumin Q6 PT/PTT/INR Q6 Amylase/Lipase Q12 Lactate Q12 HbA1C x 1 CPK with MB /Troponin x 1 Sputum -Stat Gm stain and culture, ideally from bronchoscopy (minimal lavage) Beta HCG (only if ICH as cause of death in females of childbearing age) O2 challenge ABG q 4 hours and PRN

Place pt on 100% FIO2 x 30 minutes prior to drawing ABG; return to previous settings post-draw UA Q12 Urine culture (if bacteria noted on UA) Urine albumin or protein/ creatinine ratio x 1 Portable Chest Xray Q24

NEDS Order Set - Sample








ORGAN SPECIFIC ORDERS:

Lung Donors: Bedside bronchoscopy

Obtain sample and send for stat gram stain and sputum culture Review all ventilator settings

Review all ventilator settings: Ventilate 8cc/kg of ideal body weight Goals: PaO2 >100 torr on least FiO2 possible, PaCO2 35-40 torr, pH > 7.3, P/F ratio > 300 Add at least 5 cm of peep on all patients

Recruitment maneuvers in collaboration with NEDS & RTT, as indicated Maintain CVP 4-6 if possible Assess Plateau Pressure and Peak Airway Pressure q 4 hours and PRN Chest CT (to assess trauma, emphysematous changes, r/o pneumonia, etc.) Other:___________________________________________________________

Heart Donors: EKG with physician interpretation BNP Q12 Trans-thoracic Echocardiogram (TTE) with reading If concern for endocarditis or poor images on TTE, perform Trans-esophageal Echocardiogram (TEE) Non-invasive cardiac monitoring device (Flo-Trac/CardioQ) or PA catheter placement

Monitor q 1 hour, CO/CI/SVR/PCWP/PVR except PCWP (at NEDS coordinator request) Cardiac Catheterization per NEDS or transplant surgeon request Other:___________________________________________________________

ALL DONORS: MEDICATIONS: Maintenance IV:

Please order fluid checked below at Rate of: ________cc/hr NS ½ NS D5 ¼ NS D5 ½ NS D5NS D5W

Electrolyte Replacement Protocol: Potassium Calcium Magnesium Phosphorus








MEDICATIONS: Methylprednisolone 1gm IV x 1 now Insulin Infusion per hospital protocol

Finger stick every hour, goal 120-180 mg/dl DI Treatment:

Vasopressin (10 units/250 ml) IV infusion titrate @ 1-3 units/hr titrate to goal UOP 1-3 cc/kg/hr DDAVP 1-2 mcg in 50 ml NS q 12 hrs

Pressors: Norepinephrine (4 mg/250 ml) IV infusion, titrate at 0-30 mcg/min to keep MAP > 65 Phenylephrine (20 mg/250 ml) IV infusion, titrate 1-300 mcg/min to keep MAP > 65 Dopamine (400 mg/250 ml) IV infusion, titrate at 2-20 mcg/kg/min to keep MAP >65 Dobutamine (500 mg/250 ml) IV infusion, dosing per NEDS coordinator

Anti-Hypertensives: Esmolol (2500 mg/250ml) IV Loading dose 500 mcg/kg/min over 1 min, begin at 50 mcg/kg/min titrate

Q5 mins. Dose range 50-200 mcg/kg/min to maintain HR<120 and SBP <180 Nicardipine (20 mg/200 ml) IV Titrate 2.5mg/hr Q5 minutes to max dose 15mg/hr for goal SBP <180 Sodium Nitroprusside (100mg/250 D5W) IV start at 0.25 mcg/kg/min, titrate to max 10 mcg/kg/min

for goal SBP <180 Labetalol Hydrochloride (400mg/250mL (1.6mg/ml)) titrate @ 0.5-2 mg/hr to keep SBP <180

Electrolyte Repletion: Magnesium Sulfate _____ gm x _____ IV Calcium gluconate 1gm/100ml x _____ IV Potassium Chloride (KCl) ____meq x _____ IV Other:______________________________

Nebulizers Ipratropium unit dose nebulizer (2.5 ml) inhaled per aerosol Q4 hrs and PRN Albuterol unit dose nebulizer (3 ml) inhaled per aerosol Q4 hrs and PRN Albuterol/Ipratropium (Combivent) metered dose inhaler 6 puffs Q4 hrs and PRN

T3 Protocol (see protocol below) T4 Protocol (see protocol below) Other: _______________________________________________________

ANTIBIOTICS/ Antifungals: Piperacillin/Tazobactam (Zosyn) 3.375 gm IV Q6 hours Vancomycin _ gram IV every hrs Cefazolin 1 gm IV Q8 hrs Ampicillin/sulbactam 1.5 gm IV Q6 hours Clindamycin 600 mg Q8 hrs (if donor has a penicillin allergy) Consult pharmacy for fungal coverage Other:________________________________________________________








THYROID HORMONE REPLACEMENT PROTOCOLS (T3 AND T4 )

NOTE: CLOSE MONITORING OF GLUCOSE & ELECTROLYTES REQUIRED, BEFORE & DURING

T3 Protocol: Liothyronine /Triiodothronine( T3) (Mixture:15 mcg/100 ml Normal Saline) Bolus 4 mcg IV over one minute, then 3 mcg/hour(20ml/hr) IV infusion x 5 hrs. Then mix 10 mcg/50ml

Normal Saline infuse at 15ml/hr (can bolus if needed) Vasopressin (Mixture:10 units/250 ml Normal Saline) Bolus 1 unit IV over one minute, then 0.5 – 4 units/hr IV infusion, titrate to SVR 800-1200 (wean if UOP

less than 80 ml/hr.) Insulin Infusion, titrate to serum glucose level 120-180 mg/dl Solumedrol 2 gm IV bolus (if not already given) Hemodynamic profile every hour or 30 minutes after each adjustment in above infusion rates Obtain repeat Echo portable after a minimum of 6 hours of T3 infusion and improved hemodynamic profile.

Check with NEDS Coordinator for timing

T4 Protocol: Initiation Phase 50 mEq 50% Dextrose (25 gm dextrose) IV bolus Solumedrol 2 gm IV bolus (if not already given) Regular Insulin 20 Units IV Bolus Levothyroxine (Mixture:200 mcg/500 ml), Bolus 20 mcg IV over one minute (50ml of mixture)

Maintenance Phase: Levothyroxine (T4) 200 mcg/500 ml, IV infusion at initial rate of 10mcg/hr (25 ml/hr). For donor weight

< 45 kg, set initial rate to 20 ml/hr Reduce levels of other pressors as tolerated while titrating T4 infusion to maintain adequate BP.

After 30 to 60 minutes, the donor heart rate, BP and temperature may increase. Monitor K+ level closely/q 1 hour--T3/T4 therapy may decrease K+ levels Insulin Infusion per Hospital Protocol

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More than 100,000 people in the U.S. are waiting to receive a life-saving organ transplant. As there are not nearly enough donated organs to transplant everyone in need, these factors are used to ensure fairness:

o justice (fair consideration of candidates' circumstances and medical needs), ando medical utility (increasing the number of transplants performed and the length of time patients

and organs survive).

How does organ matching work?

When transplant hospitals accept patients onto the waiting list, the patients are registered in a centralized, national computer network that links all donors and transplant candidates.

For each organ that becomes available, the national system matches available organs from the donor with people on the waiting list based on blood type, body size, how sick they are, donor distance, tissue type and time on the list. Race, income, gender, celebrity and social status are never considered.

Before an organ is allocated, all transplant candidates on the waiting list that are incompatible with the donor are automatically screened from any potential matches. Then, the computer application determines the order that the other candidates will receive offers, according to national policies.

FAQs Why is an organ sometimes not able to be transplanted? Matching a donor organ to a recipient is a complicated process. The “matches” generated by the computer are a good start, but don’t tell the whole story. Factors may be straight forward, such as size compatibility to the more complex issues around tissue antigens and immunologic response. Sometimes a recipient is ill and cannot undergo surgery, other times the weather may prevent transportation from the donor hospital to the recipient transplant center in a timely manner. Due to some of these varying factors, organs with similar function may be placed one day, but another day may not able to be transplanted.

Why do we attempt to allocate some organs when they are not functioning well? Research has indicated over 90% of organs that were traditionally deemed “not transplantable” (often due to the acute circumstances that have led to the donor’s death) may in fact function well after transplantation.* Successful transplantation of these organs is due, in large part, to more aggressive care of donors in the ICU prior to donation.

Other scenarios in which organs that appear “non-transplantable” may be used, are in situations where a recipient is so critically ill that a temporary organ is needed to save the recipient’s life by providing a “bridge” until a more suitable organ becomes available for long-term survival.

Why can it take so long to allocate organs from a donor? Factors complicating allocation can include everything from finding the correct ventilator strategy to maximize alveolar recruitment, to a potential recipient’s white blood cell count, to a storm affecting air travel outside. But the long hours and teamwork put into aggressive donor management and allocation of organs are always focused on one thing: maximizing the potential lifesaving impact of every organ donor, on their and their family’s behalf.

*DuBose and Salim, "Aggressive Organ Donor Management Protocol". Journal of Intensive Care Medicine, 23:6 (367-375). 2008.

ORGAN ALLOCATION

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IV. ORGAN SURGICAL RECOVERY

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Scheduling the Organ Recovery A number of factors must be considered when coordinating an organ recovery, including patient stability, donor hospital location, family needs, and the availability of hospital and NEDS’ staff. In the event a patient becomes unstable despite all stabilization efforts, it may be necessary to proceed directly to the OR to avoid any compromise to the organ recovery. The distance of the donor hospital from the transplant center, as well as that of the recipient’s residence can impact the timing of organ recovery. Not only does NEDS work with hospitals and transplant centers in all six New England states (as well as Bermuda), but NEDS also frequently work with transplant teams outside of New England. This can require additional coordination and adjustments to the OR time. It is clearly not possible to recover organs without OR staff. Your availability and that of the anesthesia staff are essential. NEDS will work with you as early as possible in the process to coordinate a time that will accommodate all requirements. At NEDS, we recognize the selfless gift donors and donor families make to allow potential recipients to have a second chance at life. Delays in recovery time can have a significant impact on donor families which may cause donor families to rescind authorization. It is our priority to work with hospital staff to enable a smooth and timely donation process for all donor families.

Travel to the Operating Room The clinical team on the unit will wait for OR notification that the room is open and ready before beginning travel to the OR. Communicating when the anesthesia team is expected to be on the way is helpful in coordinating our arrival. There is no need for anesthesia to review services or obtain consent from a donor family as the authorization for donation includes anesthesia services. The patient will travel in the bed or on a stretcher if available. The patient will require a travel monitor and any IV pumps must be maintained during transport.

ORGAN RECOVERY – PREPARING FOR RECOVERY

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The Organ Recovery Process Support from OR staff is essential to organ recoveries as opposed to tissue recoveries in which NEDS’ staff is self-sufficient.

o Both a circulator and surgical technician are necessary in all organ recoveries.o An anesthesiologist is needed in all Brain Death (DBD) cases and for lung recovery in Circulatory

Death (DCD) cases. A description of the role of the anesthesiologist is included in this manual.o If it is known that pathology is needed prior to the recovery, NEDS’ staff will contact pathology

and make a plan for them to be onsite.It is our practice to review the authorization and death note with you upon entering the OR. If you should have any questions about these documents, an NEDS clinical coordinator can address them.

NEDS and the transplant surgeons will participate in the time-out process led by OR staff. The patient is identified and the surgical process and hospital-specific requirements are discussed. After the time-out, the surgeon will prep and drape the patient from chin to pubis. In situations of Donation after Circulatory Death donation, NEDS staff will inform you whether the patient will be prepped and draped on the ICU or in the OR. Following the prep and before the incision is made, NEDS’ staff will conduct a moment of silence and read a statement that the donor family has prepared about their loved one. All OR staff, NEDS and surgeons participate in this respectful moment. The timing of recovery is critical and therefore we are in frequent communication with the recipient surgeons at the transplant hospital. On occasion, it might be necessary to hold cross-clamp to ensure the recipient and surgeon are ready when the organ arrives. The donor will be maintained on the ventilator until cross-clamp. Immediately prior to cross-clamp, heparin and mannitol will be given. NEDS’ staff will communicate the timing for the administration of these medications.

Safe Practices Recipient safety is a priority for us. We have a number of safe practices that must be observed.

o If a surgeon requests any patient information, including accessing information from electroniccharting, please refer them to a NEDS’ Coordinator. There are certain verification steps that mustbe followed.

o Cardiac paddles must be readily available in the OR. Please be sure they are charged!o NEDS staff, Donation Coordinator and Organ Surgical Recovery Coordinator, and surgeon(s) will

participate in a time-out with OR staff. In addition, NEDS will also have a separate time out toreview NEDS-specific documentation.

o It is essential that no tables are broken down without NEDS’ specific direction to do so. We maybe working on an organ on a different table before packaging another organ.

We recognize that post mortem care is not a routine practice for you and so we will always assist with this process.

ORGAN RECOVERY – PROCESS

New England Donor Services

Anesthesia Guidelines for Organ Donation

Anesthesia services for physiological support of brain dead organ donors include administration of fluids and blood, monitoring and maintenance of temperature, blood pressure, electrolytes, and ventilation/oxygenation, obtaining blood specimens, and administration of medications.

While the organ recovery procedure may last from less than one to more than five hours, on average, the interval of surgery will be approximately three hours, from incision to cross-clamp. At the time of aortic cross-clamping, cold preservation solutions are infused via cannulae inserted into the appropriate vessels, and the organs are subsequently removed for backtable dissection and packaging for transport. Anesthesia support is discontinued at the time of aortic cross-clamp. Specific guidelines and parameters for support of organ donors include the following:

1. Adequate monitoring of vital signs is critical to successful organ recovery • A radial arterial line is preferred for BP monitoring and obtaining blood specimens • Adequate venous access for CVP monitoring and rapid volume infusion is preferred • Core temperature should be maintained above 35° C using warming blanket and other means as needed.

It is helpful to keep the OR temperature at 75° F.

2. Adequate organ perfusion is critical • For adults, systolic BP > 100 mm Hg (MAP >60) should be maintained (consult with surgical team regarding

preferred means for maintaining BP) • In general, phenylephrine is the vasopressor of choice • Should you require additional access to infuse volume, please consult with the abdominal surgeon regarding

the insertion of a portal cannula • Urine output should be monitored closely. Goal is 0.5 to 3 cc/kg/hr.

3. Oxygenation

• Please verify the current ventilator settings with the Donation Coordinator as these patients may often be ventilated at higher tidal volumes

• Arterial PaO2 should be maintained at > 100 mm Hg, while FiO2 should be kept at 40% unless otherwise indicated (e.g., progressive arterial hypoxemia). PEEP of 5 cm H20 is preferred. • Arterial blood gases should be obtained once the chest is open and periodically at the discretion of the

surgical team. 4. Administration of blood products and medications

• In general, the patient's hematocrit should be maintained at 27. Three units of PRBCs should be typed, crossed and available. Other blood products (platelets, FFP) should be given in consultation with surgical team.

• Heparin 30,000 Units and Mannitol 25 gm should be given at the direction of the surgical team. Other medications e.g. Amphotericin B or neuromuscular blockage may be requested on occasion.

ORG-96 (4) 011017

23

The following documents include detailed lists of necessary supplies to be provided by both the donor hospital and NEDS. These are reference tools used during cases to assist you in preparing for the surgical recovery. We will need a large amount of unsterile ice to package the organs in boxes for transport. Obtaining the ice from the kitchen is usually most efficient.

In general, NEDS will provide: o Sterile Retractoro Frozen salineo Infusion lineso Preservation Solution

ORGAN RECOVERY – SUPPLIES

24

Brain Dead Donors

Donor Name: _____________________________ DOB: ___________ MRN: ________________________ Donor’s Location: ___________________ Date of Procurement: ______________ Time: _____________ Onsite Coordinator: __________________________________ Phone: ________________________ Case Type: Brain Death DCD *Consent for anesthesia and surgical process included in NEDS authorization for donation

ALL Organ Donors Additional items based on specific organs Large Operating Room

Staffing: - RN and Scrub

Supplies:- Major Abdominal instrument set- Coronary dilators / lacrimal probes (hold)- Unsterile Ice (approx. 2 gallons of ice per organ)- Split sheets to drape, Chlora/Dura prep, Ioban- Large capacity suction (Neptune)- Defibrillator with STERILE internal paddles- Sternal Saw- Vascular Clamps (hold)- Room temp Saline Irrigation- 4 prong IV pole- Large backtable for NEDS- Sponges, instruments, sharps count per hospital policy

Medication:- 25 grams of Mannitol

Suture:- 0, 2-0, 4-0 silk ties open. Silk suture available,3-0,4-0 Chromic SH availableTeams will request additional suture as needed

Lungs - 1 additional back table (med)- 1 sterile large basin- FLEXIBLE bronch with video- 1 additional IV pole

Heart- 1 additional back table (med)- 1 sterile large basin- 2 1 liter pressure bags- If PEDI - chest retractor

Intestine- 1 additional small back table- GIA staplers available

Pancreas- 250 mL D5W- Catheter tip syringe- 250-500 mL sterile bowl / pitcher- GIA / TA Staplers available

Arm / Face Grafts- Arm table- Osteotomes- Tourniquet machine / cuffs- Marks Needles- Heparinized Saline (dose per team)- Additional back table- Separate back table for scrub – we will bring ALL

instruments for this portion

Staffing: - Anesthesia team

Supplies:- 2 Cautery Machines / 2 grounding pads- 2 Liters IV Saline- Bone wax- Med / Lg Hemoclips (hold)

DCD Donors - NO cautery

- Might do case ON a stretcher- May drape PRIOR to coming to OR

ORGAN PROCUREMENT SUPPLY LIST

Operating Room Guide Organ Donation after Brain Death (DBD) (Multi or Single)

NEDS: 800-446-6362/800-874-5215

Please note: Recovery procedures are NOT complete upon removal of the organs. The recovery process is continued on the back table for the evaluation and prepping of the organs. NEDS staff will notify you when it is permissible to break down the back tables.

General Needs: • Largest Operating Room available • 25 grams of Mannitol for Anesthesia• 2 Bovie machines w/ grounding pads• 3 Suction devices, w/ extra canisters (largest possible)• 2 - 4 one liter bags of Lactated Ringers (room temperature)• 2 large bins of non-sterile wet ice for packing (do not add alcohol)• 1 - 4 prong IV pole• 1 - 2 prong IV pole• 2 Kick buckets• 6 Bottles of Saline (on ice)

Important Notes: • Grounding pads, EKG pads and other devices should be placed on the

posterior side of the patient away from the sterile field.• Visiting teams may bring sterile items to be opened for the scrub or

onto the back tables • NEDS staff will bring chest/abdomen retractors (either sterile or that to

be flashed), and at the end of the case staff will ask to have the retractors wrapped in a large biohazard bag

• Anesthesia team will be asked to draw blood and fill several blood tubes.

• The cross-clamp time is the start of organ preservation not the time ofdeath.

Extras: • Blankets (if needed for the floor)• Have headlights available• 2 - one liter pressure bags available• Flexible Bronchoscope, if lungs are to be recovered• Defibrillator with external & internal paddles in room (Crash Cart)

Positioning of Patient: • Supine w/ arms tucked at the

side

Prepping of Patient: • Shave chest and abdomen• Betadine Scrub and Solution

or Chloraprep from sternalnotch to pubis

Draping of Patient: • 8 Sterile towels• 6 Towel clips or skin stapler• 2 Split Sheet

• Drape sheets (hold)• Extra-Large Ioban Steridrape

(hold)

Ties/Sutures/Blades: • 0, 2-0, 3-0 silk ties• #1 silk ties• 2-0 silk, cutting needle• 3-0 silk, pop-offs taper needle• 3-0 chromic gut, taper needle• 4-0 & 5-0 prolene, taper needle• #10, #15, #11 blades

Supplies: • Vessel loops• Umbilical tapes• Bone wax • Long bovie tip• 5-10 gowns • Lap sponges

Instruments: • Major laparotomy tray • Assorted vascular clamps• Sternal saw (w/ batteries)• 2 Suction tubings• 2 Yankeur suction tips• 2 Poole suction tips• 2 Large metal basins

Instruments to have available in OR: • Coronary or Gall Bladder dilators• Sternal retractor (if pediatric case)• Balfour retractor (if pediatric case)• 1 Large metal basin for each organ • Mallet

Other supplies to have available in OR: • Skin stapler• Specimen cups• Back table covers

• Vascular staplingdevice

• Bowel stapling device• Lg. & Sm. Hemoclips

Dressing:

• Shroud with toe tags

Developed by New England Donor

Services Rev. 4/13/2017

RECOMMENDED OPERATING ROOM SET-UP Organ Donation after Brain Death (DBD)

(Multi or Single)

OR Table

Anesthesia Team

1

3

Liver &

Kidney Table*

Heart &

Pancreas Table*

Lung Table*

4

S

S S

S

BoBo

T Mayo Stand

Back Table

N

N

2

Depending on the size of the OR, tables will be arranged as needed to keep sterile tables together.

Key:

= Tx MD = Scrub = NEDS Staff

= Kick Bucket = Suction = Ring Stand

S T N IV Poles 1- Anesthesia2- Anesthesia3- Perfusion (4-prong)4- Perfusion (2-prong)

Operating Room Guide Organ Donation After Circulatory Death (DCD)

NEDS: 800-446-6362/800-874-5215

Please note: Recovery procedures ar e NOT complete upon removal of the organs. The recovery process is continued on the back table for the evaluation and prepping of the organs. NEDS staff will notify you when it is permissible to break down the back tables.

General Needs: • Largest Operating Room available • 3 Suction devices, w/ extra canisters (largest possible)• 1 large bin of non-sterile wet ice for packing

(do not add alcohol)• 1 - 4 prong IV pole• 1 - 2 prong IV pole• 2 Kick buckets• 6 Bottles of Saline (on ice)

Extras: • Warm blankets• Have headlights available• 2 - one liter pressure bags available• 1 Medium Table for hallway

Transport: • If withdrawal is to take place in the ICU or PACU ideally

the patient would be moved to a stretcher for transport.The surgical recovery can proceed while the patient is on the stretcher.

Important Notes: • If prepping and draping occurs in the ICU, the OR or Central Supply

will need to send items to the ICU:

o 2 Split Sheets o 1 Skin Staplero 10 Drape Sheets o 3 Chloraprepo 8 Sterile Towels o 1 Medium Tableo 2 Medium Loban Drapes o 4 Bath Blanketso 1 Large Gown o 2 Sets Sterile Gloves

• If withdrawal of support occurs in the OR, with the family present, the family will need scrubs or coveralls. o If patient positioning, prepping or draping occur before withdrawal,

sterile drapes will be placed over the sterile field. Then blankets ontop of the sterile drapes, to allow family/patient contact.

o The sterile back tables with instrumentation/equipment will becovered with sterile drapes to be out of view.

• NEDS staff will bring chest/abdomen retractors (either sterile or thatto be flashed), and at the end of the case staff will ask to have theretractors bagged in a big biohazard bag.

Positioning of Patient: • Supine w/ arms at the sides• Pillow under head

Prepping of Patient: • Shave chest and abdomen

Betadine Scrub and Solution or Duraprep from sternal notch topubis

Draping of Patient: • 2 Split Sheets• Drape sheets (have

available)• 8 Sterile towels (have

available)Ties/Sutures/Blades: • 0, 2-0, 3-0 silk ties• #1 silk ties• 2-0 silk, cutting needle• 3-0 silk, pop-offs taper needle• 3-0 chromic gut, taper needle• 4-0 & 5-0 prolene, taper needle• #10, #15, #11 blades

Supplies: • Bone Wax • Vessel loops• Umbilical tapes• 5-10 gowns • Lap sponges• Back table covers

Instruments: • Major laparotomy tray • Major vascular tray• Assorted vascular clamps• 2 Suction tubings• 2 Yankeur suction tips• 2 Poole suction tips• 2 Large metal basins

Instruments to have available in OR: • Coronary or Gall Bladder dilators• Sternal saw• Sternal retractor (if pediatric case)• Balfour retractor (if pediatric case)

Other supplies to have available in OR: • Extra drape sheets• Extra back table covers• Bowel stapling device

• Lg. & Sm. Hemoclips• Specimen cups• Vascular stapling device

Dressing: • Shroud with

toe tags Developed by

New England Donor Services Rev. 3/9/2017

RECOMMENDED OPERATING ROOM SET-UP Organ Donation After Cardiac Death (DCD)

OR Table

Anesthesia Area

1

3

Liver &

Kidney Table*

IV Poles: 1-Anesthesia Area2-Anesthesia Area3-Perfusion (4-prong)4-Perfusion (2-prong)

4

S S

Key:

S = Tx MD

T = Scrub

N = NEDS Staff

= Kick Bucket = Suction = Ring Stand

T Mayo Stand

Back Table

N

2

Cart w/ Kidney Pumps

*Depending on the size of theOR, tables will be arranged asneeded to keep sterile tablestogether.

N

27

New England Donor Services

Anesthesia Guidelines for Organ Donation

Anesthesia services for physiological support of brain dead organ donors include administration of fluids and blood, monitoring and maintenance of temperature, blood pressure, electrolytes, and ventilation/oxygenation, obtaining blood specimens, and administration of medications.

While the organ recovery procedure may last from less than one to more than five hours, on average, the interval of surgery will be approximately three hours, from incision to cross-clamp. At the time of aortic cross-clamping, cold preservation solutions are infused via cannulae inserted into the appropriate vessels, and the organs are subsequently removed for backtable dissection and packaging for transport. Anesthesia support is discontinued at the time of aortic cross-clamp.

Specific guidelines and parameters for support of organ donors include the following:

1. Adequate monitoring of vital signs is critical to successful organ recovery.o A radial arterial line is preferred for BP monitoring and obtaining blood specimens.o Adequate venous access for CVP monitoring and rapid volume infusion is preferred.o Core temperature should be maintained above 35° C using warming blanket and other means

as needed. It is helpful to keep the OR temperature at 75° F.

2. Adequate organ perfusion is criticalo For adults, systolic BP > 100 mm Hg (MAP >60) should be maintained (consult with surgical

team regarding preferred means for maintaining BP).o In general, phenylephrine is the vasopressor of choice.o Should you require additional access to infuse volume, please consult with the abdominal

surgeon regarding the insertion of a portal cannula.o Urine output should be monitored closely. Goal is 0.5 to 3 cc/kg/hr.

3. Oxygenationo Please verify the current ventilator settings with the Donation Coordinator as these patients

may often be ventilated at higher tidal volumes.o Arterial PaO2 should be maintained at > 100 mm Hg, while FiO2 should be kept at 40%.o Unless otherwise indicated (e.g., progressive arterial hypoxemia). PEEP of 5 cm H20 is

preferred.o Arterial blood gases should be obtained once the chest is open and periodically at the

discretion of the surgical team.

4. Administration of blood products and medicationso In general, the patient's hematocrit should be maintained at 27. Three units of PRBCs should

be typed, crossed and available. Other blood products (platelets, FFP) should be given inconsultation with surgical team.

o Heparin 30,000 Units and Mannitol 25 gm should be given at the direction of the surgicalteam. Other medications e.g. Amphotericin B or neuromuscular blockage may be requestedon occasion.

28

V. DONATION AFTER CIRCULATORY DEATH

29

In situations where a patient has suffered a devastating and irreversible brain injury or other condition where the family has decided to withdraw treatment, Donation after Circulatory Death (DCD) gives patients and families an option for organ donation when brain death has not occurred.

The suitability of a donor for DCD is determined by NEDS and is dependent on age, medical history, cause of death and likelihood of deterioration to circulatory cessation within a specified timeframe following extubation.

In DCD donation, the recovery of organs follow declaration of death by circulatory cessation – asystole or Pulseless Electrical Activity (PEA) – as dictated by hospital policy. Due to potential hypoxia, resulting ischemic organ damage, and poor outcome on transplantation, organ recovery only occurs when the patient deteriorates to circulatory cessation within a specific timeframe (commonly 60 – 90 minutes) defined in your hospital policy. DCD allows for the recovery of kidneys, liver, lungs and heart.

No invasive testing or donor management is done with DCD donors. It is necessary however, to conduct an evaluation of individual organ function. This is done through blood work, including ABGs, urinalysis and other non-invasive testing such as CXR.

The DCD process is shown here both as an overview and in detail.

DONATION AFTER CIRCULATORY DEATH

If consent has been obtained, Heparin is administered per NEDS request at extubation

Following a moment of silence and family statement, Organ recovery begins, declaring physician may leave the OR

Family escorted to changing room and given scrubs

Transplant surgeons, NEDS clinical responder enter OR

Authorization is obtained for DCD donation

Ongoing patient care to maintain MAP>60, UO 100cc/hr, PaO2 100

OR and OR staff are ready, NEDS staff and transplant team in OR

Plan for OR extubation

Patient made DNR and family has consented to CMO

Make a referral to NEDS

Blood samples are collected and sent to NEDS lab for tissue typing and serology testing

Move patient to OR, prep and drape as appropriate

Usual comfort measures given per hospital policy, patient extubated, IVF/vasopressors discontinued

Circulatory cessation

Family escorted into OR

Family members are encouraged to say “goodbye”

Hospital physician writes death note in patient’s chart

NEDS evaluates potential donor for Donation after Circulatory Death (DCD)

Family meeting with hospital staff to discuss DNR and CMO

NEDS staff is introduced to the family to offer option of DCD donation

Patient has been given grim prognosis and there is a plan for a family meeting to discuss the plan of care, possibly including DNR and withdrawal of support/comfort measures only (CMO)

Patient’s family members are escorted out of the room and supported by NEDS Family Services Coordinator. Transport patient to OR if in ICU.

Circulatory cessation (PEA)* maintained on monitor for full 5 minutes, exam must be done by hospital physician and declared dead by cardiac-pulmonary criteria

Family declines DCD donation

Plan for ICU extubation

Transfer to OR stretcher or prep and drape as appropriate

Patient remains in ICU room

Patient remains with a heart rate > 60 mins or *

Family escorted back into ICU room

Treatment is withdrawn

Case aborted, patient brought back to ICU / designated bed if in OR

*Per hospital policy

A moment of silence is held and family statement is read, NEDS staff and transplant team escorted out of room

31

A Donor after Circulatory Death (DCD) is a donor who has suffered devastating and irreversible brain injury and may be near death, but does not meet formal brain death criteria. In such cases, where the family has decided to withdraw treatment DCD may be an option. When circulatory cessation has occurred and the patient is declared dead, the organs are recovered in the operating room. The surgeons involved in transplantation cannot be part of the end of life care or in the declaration of death. This type of donation does not cause or hasten death. The following tests will assist to determine and monitor organ function.

For ALL ORGANS:

Broad spectrum antibiotics Arterial Line Central Line

Yes/No If No: Reason Why

Organs Being Evaluated Tests/Procedures Lab Work

Yes No

Lungs o Chest X rayso Chest CTo PT/Recruitmento Pulmonary Toileto Inhalation Therapy

o ABGs q 2 hrs

Yes No

Liver o CMP q 6hrso PT/INR q 6 hrso CBC q6 hrs

Yes No

Kidneys o UA q 24 hrso Random urine Protein x 1o Random urine Creat x 1o CMPq6hrs

ORGAN EVALUATION - DCD

32

VI. PEDIATRIC DONATION

33

NEDS works in tandem with the medical team to care for the pediatric donor.

NEDS will seek input from the medical team regarding specific interventions, medications and/or tests most appropriate to meet the goals for optimal organ function.

NEDS uses the following guideline recommend by Dr. T.A. Nakagawa (Critical Care Medicine; June 2015) for management of the pediatric donor.

Age Heart Rate SBP Urine

Output CVP

Infant <160 >80

1-3cc/kg/hr

N/A

Toddler <140 >85 3-6School Age (7) <120 >90 3-6

Adolescent <110 >110 3-6

Drug Dose Comments

Dopamine 2-20mcg/kg/min Titrate to desired B/P

Dobutamine 2-20mcg/kg/min Titrate to desired B/P

Epinephrine 0.1-1mcg/kg/min Titrate to desired B/P

DDAVP 0.5mcg/hr ½ life 75-120 minutes

Vasopressin 0.5milli-units/kg/hr ½ life 10-35 minutes

Esmolol 50-250mcg/kg/min Loading dose 500mcg/kg

Labetalol 0.4-3mg/kg/hr Bolus 0.2-1 mg/kg

Bicarbonate 1meq/kg Monitor labs

Insulin 0.05-0.1units/kg/hr Monitor for hypoglycemia

Levothyroxine T4 0.8-1.4mcg/kg/hr Refer to T4 guidelines

Bolus 1-5 mcg/kg No insulin or D50 bolus

riiodothyronine T3 0.05-0.2 mcg/kg/hr Refer to T3 guidelines

No bolus No insulin or D50 bolus

Methyprednisolone 20-30 mg/kg IV May be repeated in 8-12 hrs-monitor for fluid retention and glucose tolerance

Ampicillin 100-200mg/kg/day Q6hrs

Gentamicin <30days 4mg/kg/dose Q24 hrs >30days 2.5mg/kg/dose Q8hrs

Adjust dosing to levels

Ancef 25mg/kg/dose Q8 hrs

Ceftriaxone 50-75mg/kg/day IV/IM Can be given IM if no IV

Tham Base Deficit x wt = IV CC of 0.3 molar solution

No increase in CO2 or OSM used instead of bicarb a lot in peds

Fluid Maintenance

1st 10kg= 4cc/kg (ex..4kg X 4cc = 16cc/hr fluid) 2nd 10kg= 2cc/kg >20kg= wt(kg)+40

Fluid Resuscitation

20cc/kg of LR, NS or 5% Albumin repeat x2 (Never use dextrose solutions for resuscitation)

Blood Products

PRBC 10-15 cc/kg (blood is leukocyte reduced CMV negative and irradiated usually) FFP 10cc/kg over 2-4 hrs Platelets 6 units (can be spun to reduce volume)

Hypoglycemia Bolus 2cc/kg of D10

PEDIATRIC DONATION

34

Vll. ANCILLARY SUPPORT

35

The role of the Respiratory Therapist is essential in managing the potential organ donor. Your partnership to accomplish the following will allow for a successful donation.

How You Can Help o Assist with bronchoscopyo Administration of nebulizerso Ventilator changes based on ABGso Lung recruitment as neededo Prevent de-recruitment by using transport ventilator when travelling with patient

Goals for all potential organ donors: 1. Pplat< 30 cm/H2O2. PIPs < 303. P/F ratio > 300 on any FiO24. PaO2 100 torr on least FiO25. PaCO2 35 - 40 torr6. pH 7.35 - 7.45

General care goals for all potential organ donors: o ETT size >7.5o ETT cuff inflated to at least 25 cm H2O pressureo HOB up 30 degreeso NGT/OGT to suction

RESPIRATORY THERAPY

36

Donation after Brain Death Donation after Brain Death (DBD) is the recovery of organs for transplantation from patients who have been declared dead by neurological criteria. The apnea test is commonly required in the declaration process.

APNEA Test The apnea test is an essential component of the brain death diagnosis. Please refer to your hospital policy for specifics to your institution.

General process: o PRE-Test

o pH > 7.25o PaCO2 35 – 45 mmHgo Off sedation/paralyticso Normothermic (> 97F/35C)o Normotensive (vasopressors as needed)o Hyperoxygenate FiO2 100% for 5 minutes

o APNEA Testo Remove patient from ventilatoro Provide 6 – 8 liters passive O2 into ETTo Expose chest/abdomen and observe for movement indicating spontaneous respirationso Observe for approximately 10 minutes or per hospital policyo If patient becomes hypotensive or hypoxic prior to 10 minutes, test may need to be

abortedo Draw ABG at 10 minutes or per hospital policyo PaCO2 > 60 or increase of > 20 torr = apneic and supportive of brain death

RESPIRATORY THERAPY – APNEA TEST

37

Ventilator Management Common Ventilator Goals and Settings

PEEP +5 Pressure trigger with -4 cm/H2O (set trigger sensitivity to prevent auto trigger) Inspiratory Time (Ti) 1.25—2 sec

Mode: VC: target Tidal Volume (Vt) of 8-10cc/kg with monitoring of Pplat. PCV: monitor Vt to assure 8-10 cc/kg APRV: monitor Mean Airway Pressure (PAW) and PaCO2

If P/F Ratio < 300, consider: Extend timing (if PC, monitor Vt; if VC, monitor I/E) Larger Vt: assure Pplat < 30 Temporary increases in PEEP Add Inspiratory hold if available Add Sigh maneuver if available Recruitment maneuver followed by temporary increase in PEEPset

Recruitment Maneuver CPAP 30cmH2O x 30 sec, repeat in 2-4 min May need to increase PEEP temporarily following maneuver

PULMONARY DONOR MANAGEMENT

38

Donation after Circulatory Death (DCD) is the recovery of organs for transplantation from patients who have been declared dead after circulatory cessation following withdrawal of treatment and extubation.

Maintain ventilator settings until time of extubation o Continue current therapies (nebs, Chest PT, etc.) until directed otherwiseo Determine plan for ventilatory support if extubation to occur in ORo In compliance with hospital policy, establish with team who will perform extubationo Participate in time-out prior to extubation (to be facilitated by NEDS)o Extubation to occur in collaboration with NEDS and done only when NEDS, ICU, OR staff and

patient’s family are ready for withdrawal of support to occur

DONATION AFTER CIRCULATORY DEATH

39

A comprehensive evaluation of cardiac function is essential for the determination of organ suitability. An EKG with a formal reading and an echocardiogram are needed.

An echocardiogram provides transplant surgeons necessary information regarding cardiac function, cardiac abnormalities, ejection fraction, wall motion abnormalities, valvular function, and indications of vegetation.

A HARD COPY of the echocardiogram report is needed for NEDS to share the information with transplant surgeons.

Prior to obtaining an echocardiogram, donor management strategies will be implemented to hydrate appropriately and wean the patient off as many vasopressors as possible.

Due to the criticalness for a thorough assessment of cardiac function, more than one echocardiogram may be required. In situations where the patient is on the thyroid hormone protocol, a second, and at times a third echocardiogram is necessary in approximately 12 hour intervals following the initial administration of Liothyronine or Levothyroxine. A change in ejection fraction on follow up testing can save a life.

A trans-thoracic echocardiogram may be requested if certain images are unable to be read or there is concern for certain conditions (i.e. vegetation).

When echocardiograms are requested, please:

o Complete the evaluation form provided by NEDSo Provide a copy of the test on a disc in DICOM formato Ask the NEDS clinical coordinator any questions!

CARDIOLOGY - ECHOCARDIOGRAM

40

It is NEDS practice to obtain a cardiac catheterization on any potential donor >40 years old unless history or medical decision to not pursue heart donation is made. An echocardiogram and determination of preliminary suitability is made prior to the request for a cardiac catheterization.

No separate consent is needed for the test as the NEDS authorization and disclosure encompass all tests and procedures related to donation.

The patient will travel with a monitor to the cardiac catheterization suite with ACLS medication.

In general, a right-sided heart catheterization will be requested. The intent is to evaluate coronary arteries and plaque if present, PA pressures, PWCP and CVP. On occasion a ventriculogram may also be requested. The swan-ganz catheter is left in place when there is the ability for monitoring in the ICU setting.

On occasion a Transplant Surgeon/Cardiologist may wish to speak with the Interventional Cardiologist if plaque is found or there are further questions regarding the findings.

When cardiac catheterizations are requested, please:

o Complete the evaluation form provided by NEDSo Provide a copy of the test on a disc in DICOM formato Ask the NEDS clinical coordinator any questions!

CARDIOLOGY - CARDIAC CATHETERIZATION

41

A comprehensive evaluation of pulmonary function is essential for the determination of organ suitability.

A bronchoscopy is necessary for thorough lung evaluation. Evaluation of anatomy, secretions, and bronchus lining are important information when determining organ suitability. NEDS will provide a form to be completed.

A sputum sample to be sent for gram stain and culture will be requested as a part of our evaluation. Please use minimal lavage if necessary; no lavage is preferred.

A bronchoscopy may also be requested for therapeutic purposes.

PULMONOLOGY - BRONCHOSCOPY

42

Radiological studies are an important adjunct to proper evaluation of organ suitability for transplantation. The following describes radiology tests and services that may be requested by NEDS.

Plain Films It is not uncommon for NEDS to request chest x-ray films every 6 hours, particularly when lung donation is being considered and ventilator strategies are being implemented.

Abdominal films are not commonly requested.

X-rays of the extremities may be requested during the evaluation of potential arm or leg donation fortransplant/research.

CT

NEDS may request a chest CT when evaluating potential for lung donation. Important observations include evidence of emphysema/COPD, atelectasis, infiltrate, lymphadenopathy, pneumothorax, hemothorax.

NEDS may request an abdominal CT to assess anatomy or obtain measurements of abdominal organ size (primarily liver measurements – A/P, lateral, craniocaudal) if there are concerns for recipient size compatibility. In addition, reported history of hepatic steatosis, lymphadenopathy, kidney stones, or renal/hepatic cysts may indicate a need for a CT. An abdominal CT is often indicated when evaluating for small/large bowel donation.

A pelvic CT may be requested when past medical history mentioned by the family indicates a need for further work-up such as mention of ovarian cysts. A pelvic CT will be necessary for the determination of suitability if uterine transplant is being considered.

CT with Contrast/CTA A contrast enhanced chest CT may be requested to assess for PE or any other vascular related questions that a transplant surgeon may have.

A contrast enhanced abdominal CT may be requested to assess liver vasculature to determine replaced vessels. It may also be requested to assess the extent of vascular disease or aneurysm throughout the abdomen.

Ultrasound

NEDS will occasionally request an ultrasound of the abdomen to assess steatosis of the liver or to evaluate the kidneys if there is a history of kidney problems reported by the family, such as cysts or masses.

Interventional Radiology

NEDS will occasionally request interventional radiology to perform a bedside liver biopsy. The purpose of this is to assess liver steatosis, fibrosis, and chronic inflammation. All bedside liver biopsies that are performed will be sent for frozen section. NEDS will coordinate with pathology for specimen preparation and review.

Occasionally, hospital staff may request interventional radiology to perform a 4 vessel cerebral angiogram to aide in the determination of brain death. This request will come from the medical team, not NEDS.

RADIOLOGY

43

MRI

NEDS does not routinely request MRI evaluation on donors. On rare occasions, if a CT shows concern for a solid mass that requires further evaluation, after consultation with NEDS Medical Directors and transplant programs, NEDS may request an MRI.

Doppler Ultrasound NEDS may request doppler ultrasound to assess vascular flow in any potential donor who is being considered for upper or lower extremity transplant or genitourinary transplant.

NEDS may request additional studies as determined by history provided by the donor family or established in the medical record. NEDS may also request additional studies if requested by a transplant program or a medical director.

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In some circumstances, a thorough evaluation of organ suitability requires pathology services. When it is known that pathology services will be needed, the NEDS coordinator may contact the on-call pathologist to determine availability and requested lead time. In other situations, an unexpected finding intraoperatively requiring pathology examination may occur.

Kidney biopsies Kidney biopsies are generally done for older donors or when there is a history of hypertension, diabetes mellitus or an unexplained rise in serum creatinine. Additionally, a biopsy may be requested by a recovery surgeon if the appearance of the kidneys is poor – suggesting cortical scarring or damage. If there are dark cysts or a suspected mass on either kidney, it will likely need to be biopsied to rule out cancer or another disease process. It is recommended that each kidney biopsy contain at least 50 glomeruli. The NEDS coordinator will provide you with a form to complete.

Liver biopsies Liver biopsies are generally requested when there is a history of suspected liver disease or the appearance of the liver is steatotic and/or yellow. The pathologist will be asked to determine to the best of their ability the percentage of macro/micro steatosis, inflammation, and fibrosis. The NEDS coordinator will provide you with a form to complete.

When biopsies are requested, please: o Complete the evaluation form provided by NEDSo Provide prepared slides for both kidneys and 2 slides for the livero Ask the NEDS clinical coordinator any questions!

Please note: o A phone call to the NEDS coordinator in the OR will be requested to provide an immediate

response for determination of organ suitability for transplant.o The recovery surgeon may come to the pathology department to view the slide directly.o Due to circumstances beyond our control, some organ donor recovery cases occur in the middle

of the night as opposed to daytime hours.

Situations of non-routine evaluation include: o Whole heart if concern for vegetation on valves or concern for mass on valveo Lung nodules that may have been previously identified on Chest CT and located during surgeryo Any suspicious nodules or masses noted during surgeryo Suspicious moles

To ensure the safety of recipients, NEDS may request a consult when a suspicious finding is noted during the physical examination. Suspicious findings may include moles, rashes, or skin lesions.

No separate consent is needed if excision is required as the NEDS authorization and disclosure encompass all tests and procedures related to donation.

Please note: o Time is of the essence – dermatology findings may impact donor suitability and appropriateness

to move forward with donation.o A detailed written report will be necessary for transplant center and NEDS review.

PATHOLOGY

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Following donation, NEDS staff will provide assistance with post mortem care per hospital protocol (toe tags etc.) whenever possible.

In the event that the patient is a medical examiner case, all tubes, lines and foley catheters will be kept in place. Frequently the Medical Examiner will request blood tubes – these will be sent to the morgue with the patient.

When the patient is to be a tissue donor, NEDS will be escorted by hospital security to obtain custody of the body. Please note:

o A copy of the medical record should be completed by admitting prior to transfer to morgue orper hospital protocol.

o All patient belongings should be provided to the family or prior arrangements have been madeas to avoid losing any belongings.

o Document time patient leaves room.o Donor is escorted to morgue by security staff or per prior arrangements/hospital policy.

MORGUE

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In situations where NEDS responds to the hospital for a tissue donor, NEDS’ staff will report to Security Staff upon arrival to report their presence on all cases and provide adequate NEDS ID. Security staff may be requested to escort NEDS’ staff to copy machines or other areas of hospital as needed, including the morgue. NEDS’ Tissue staff will notify security upon departing premises.

SECURITY

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Vlll. TISSUE DONATION

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The Many Uses of Tissue Donated human tissue can be used in many surgical applications, saving and healing lives on a daily basis. Tissue donation can benefit patients in a number of serious or life-threatening medical situations, including saving patients with severe burns, allowing athletes with torn ligaments or tendons to heal and regain strength, restoring hope and mobility to military men and women who have been injured in combat, and repairing musculoskeletal structures such as teeth, skin, and spinal components. Each year, approximately 30,000 tissue donors provide lifesaving and healing tissue for transplant. Approximately 1.75 million tissue transplants are performed each year and 48,000 patients have their sight restored through corneal transplants.

Referral Process Potential Tissue Donors: Any patient who has died has the potential to donate tissue. However, tissue donation is time sensitive. It is essential that every death is referred to NEDS within one hour of asystole. This timeframe allows NEDS the necessary time needed for screening and assessing the patient’s suitability for donation prior to a donation discussion with the legal next of kin. Time is of the essence as the maximum timeframe for the recovery of most tissues is 24 hours after asystole. Corneas are no longer able to be donated after 16 to 20 hours.

Fetal Deaths: The following must be reported to NEDS:

o All cases >36 weeks gestation and weigh 5.5 lbs. (2500 grams)o Any gestational age where there was a heartbeat and/or breath present at the time of delivery

Patients at this age may have the opportunity to donate heart valves and corneas. Please do not approach the parents of the potential donor regarding the opportunity for tissue donation, as NEDS will conduct a thorough evaluation to determine medical suitability and need before any discussion.

Making the Referral: The following information will be required when making the referral:

o All IV fluids received within the last hour of lifeo All transfusions received within the last 48 hourso Evidence of current infection or transmissible diseaseo Next of Kin contact information

The tissue screening worksheet is a helpful tool to use as you prepare to make the referral. The Tissue Screening Worksheet is included in this manual.

Preparing for Tissue Recovery In order to facilitate the wishes of the patient and/or patient’s family, it is essential that the recovery process occurs in a timely and efficient manner. Please adhere to all “HOLD” body requests. In the event that tissue donation will not occur, NEDS will call the hospital to release the body.

Tissue recovery may occur either in the NEDS’ Tissue Recovery Center (TRC) in Waltham, at a satellite office or in the hospital. The following describes the process for each location.

TISSUE DONATION - REFERRAL

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TRC Recovery: o The NEDS Operations Department will notify the RN Supervisor, Admitting, and/or Security of the

following information:o Transport/Funeral Service company name (employee name if available)o ETA to hospital

o The NEDS Operations Department will fax the authorization/disclosure form to the RN Supervisorand/or Admitting/Medical Records

o Once the Transporter arrives; they will proceed to the applicable department/location where theycan retrieve the donor’s paperwork (admitting/security office, medical records, etc.). Applicablepaperwork may include Death Certificate or Attestation Sheet (may not be available if MEO case)and/or copy of hospital chart or medical record (if not already faxed to NEDS Operations).

o The Transporter will be escorted to the morgue (or other specified location if no morgue on-site)according to hospital/security policy.

o The donor is released to the transporter once ID is verified and all applicable paperwork has beencollected.

o Any bags with the donor’s belongings should remain at the hospital so that the family mayretrieve them.

In-hospital Recovery: o Notification from NEDS Operations Department that authorization has been obtained for tissue

donation and recovery at the hospital.o NEDS requests to continue “hold” on donor’s bodyo NEDS notifies RN Supervisor of pending recovery and ETA of Recovery Teamo NEDS contacts OR Supervisor to request OR time for recovery, if applicable (recovery

may take place in pathology department or morgue)o The NEDS Operations Department will fax the authorization/disclosure form to the RN Supervisor

and/or Admitting/Medical Records.o NEDS will request that a copy of the hospital chart or medical record be faxed to NEDS or made

available to the Recovery Team upon arrival.o Upon arrival, the Recovery Team will be escorted to applicable clinical areas as per hospital

policies.o The hospital will arrange for the donor to be brought to the OR, if applicable.o Hospital staff is not required to be present during tissue recovery. NEDS will bring their own

supplies.o Upon completion of the tissue recovery, the NEDS Recovery Team notifies RN Supervisor and/or

applicable department.o NEDS will clean the room following recovery.

TISSUE DONATION - RECOVERY

TBS-141 (4) 081117

If you answered YES to any of these questions, OR if this patient has been reported to NEDS previously during this admission,

please inform the NEDS Specialist at the beginning of your call.

Age 96 or over YES ___ No ___ <36 weeks gestation YES___ No ___ HIV+ YES ___ No ___ Hepatitis B or C+ YES ___ No ___ IV drug use within 5yrs YES ___ No ___ Age 75+ with metastatic cancer YES ___ No ___ Current leukemia or lymphoma YES ___ No ___

Is sepsis COD on death certificate YES ___ No ___

Tissue Screening Worksheet

ALL deaths must be reported to NEDS within 1 hour of cardiac death. 1(800) 446-6362

If all answers in the top box are checked NO, the patient is still a potential tissue donor. Please have the patient’s chart and the information listed below readily available.

Clinical Course Leading to Death Admitting Diagnosis, Evidence of Infection, Antibiotic Coverage, and Surgical Procedures

Lab Results Daily WBC’s & Daily Temperatures (most recent, 3 days of results) and Culture Results this admission

Medical History Past Medical History Current Medical Diagnoses Patient’s Regular Home Medications

Physical Assessment Trauma, Deformities, Amputations Skin Integrity (rashes, breakdowns, ulcers, etc.), Tattoos, or Body Piercings Documented Height and Weight

Blood/Fluid Received (Need to have colloids and crystalloids accurately documented in the chart to determinewhether or not there is a suitable blood sample available for serology testing)

Next-of-Kin Contact information (Provide # to where family/NOK can be reached & any additional contacts) If ED Death we will also need the name of the EMS company, any cardiac rhythm (PEA, VFIB, est. downtime)

Tissue donation may include corneas, heart valves, aortoiliac graft, bone, vein, and skin. We ask that the potential for donation NOT be mentioned to the families at the hospital.

Thank you for the time you have committed to participate in the screening process on behalf of the potential donor families that wish to give these healing gifts and the potential recipients that receive them with hope.

The following information will be needed for EVERY referral: Phone # to Unit/Unit where patient died Name of Patient Medical Record # Date of Birth Preliminary COD/admission diagnosis Date of Admission Cardiac Death Date/Time

Was the patient mechanically ventilated within 24 hours of death?

TBS-141 (4) 081117

How to use this Screening Worksheet

This Screening Worksheet is designed to streamline the information required when you call to report a death. Taking a few moments to look this information now,

will make the process more efficient and save you time the next time you call!

ALL Deaths must be called in within 1 hour of asystole whether or not the family has been notified of the death.

We define 1 hour, 2 ways:

1. On a coded patient, 1 hour starts at the completion of the code. (Youwill have pronouncement on these cases before you call).

2. On a DNR patient, 1 hours starts at the time you find the patientasystolic – not when you have pronouncement.

Demographic & PHI will be shared with NEDS: HIPAA specifically permits disclosure of a potential donor's personal health information (PHI) to organizations like the NEDS for the purposes of coordinating organ and tissue donation.

If any of these are YES:

The patient will not be able to be a TISSUE donor however, the referral must still be called in to NEDS and you will still provide basic demographic information. Start the call with any of the ‘YES’ responses: “Hi, I’m calling from Franklin Regional Hospital with a 73 y.o. patient with a HX of Hepatitis”

If there is potential for at least 1 tissue to be donated:

NEDS will ask you for NOK information and will coordinate with you & your hospital to preserve that opportunity for the family. The patient can go to the morgue but should not be released from the Hospital until we have spoken with the family.

NEDS staff are the only authorized requestors trained to have a donation discussion with families:

Please do not discuss donation with a family unless specifically requested to do so by NEDS. Tissue donation is a rare opportunity that cannot be offered to most families once the patient’s medical history and clinical circumstances are evaluated. We partner with your hospital to preserve this opportunity for those few families for whom donation is a possibility. Donation offers donor families a chance to find comfort & solace and recipients & their families a gift to begin to heal. We want to ensure that only the families that are medically able to donate are offered this opportunity by NEDS.

If all of these are NO:

The patient may be a potential tissue donor who can help many people.

We need your help to review some additional information about their admission.

Depending on their cause & manner of death, we will ask various questions including why they were admitted, their clinical course, labs, medical history, physical assessment observations and crystalloids & colloids received. You can help by starting off with anything that is remarkable –‘hit the highlights.’

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lX. FAQs

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Support: All families are automatically enrolled in the Aftercare program following their loved one’s donation. Families are sent mailings and helpful resources including memorial cards and grief resources as well as a donation outcome letter. In addition, Aftercare Specialists are available to listen and help answer questions.

Connections: Connecting donor families with recipients, other donor families, volunteer services, and more!

Grief Resources/Memorialization: Through caringconnectionsneds.org families can access resources any time, day or night, as well as create memorial tributes in honor of their loved one.

The mission of Aftercare Services is to guide families through the first year after the donation by providing easy access to relevant resources, opportunities to share the legacy created by donation and create pathways for making meaningful connections.

These services include:

AFTERCARE SERVICES

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On March 30, 2016, surgeons at Johns Hopkins University School of Medicine in Baltimore, Maryland, successfully transplanted a liver and kidney from an HIV positive donor to HIV positive recipients under a new research protocol. This was the first time HIV positive organs have been transplanted in the US. The liver transplant was the first in the world and was facilitated by the New England Donor Services.

Both recipients have been HIV positive for over 25 years. “For patients living with both HIV and end-stage organ disease… this could mean a new chance at life,” said transplant surgeon Dr. Dorry Segev.

The HIV Organ Policy Equity (HOPE) Act

This transplant was made possible due to the HOPE Act, legislation that was signed into law by President Obama in 2013.

The HOPE Act lifted a twenty-five year federal ban on the use of organs from HIV positive donors, and allows transplants of HIV infected organs into HIV infected patients.

People infected with HIV are now living longer due to major advances in antiretroviral therapies. However, both the HIV infection as well as the therapies used to treat it can cause liver or kidney failure. Others suffer from end-stage organ disease for other reasons.

There are currently more than 100,000 Americans on the transplant waiting list, and may die waiting for an organ. An estimated 500 to 600 potential HIV positive organ donors die each year, and allowing their organs to be transplanted into HIV positive patients can save up to a 1000 lives annually.

What does this mean for you? HIV patients are no longer medical rule-outs for donation. Each individual case will be reviewed for medical suitability. Please contact your Hospital Relations Coordinator with any questions.

HOPE ACT

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The quality of my medical care will be compromised if I want to be a donor. If you are injured or sick and taken to the hospital, the number one priority of the healthcare team is to save your life. Organ and tissue donation is considered only after all life-saving efforts have failed.

I can't donate organs and tissues because of my past medical history. Anyone can be a potential donor regardless of age, race or medical history. Your medical condition at the time of death will determine what organs and tissues can be donated.

My family will be charged for donating my organs and tissues. All costs for the purposes of donation are the responsibility of New England Donor Services. All charges associated with medical care provided to the patient prior to declaration of death and usual and customary funeral expenses remain the responsibility of the family and/or descendant's estate.

Rich or influential patients receive special consideration in organ and tissue distribution. When you are on the waiting list for an organ, what really counts is the severity of your illness, time spent on the waiting list, blood type, and other important medical information, not your financial or celebrity status.

My religion does not support organ donation. All major religions in the United States support organ, eye and tissue donation and see it as the final act of love and generosity toward others.

I can't be a donor because I want an open casket funeral. New England Donor Services will make every reasonable effort to minimize any visual change to the body and any delay in funeral arrangements. Organ and tissue donation does not preclude an open casket viewing if desired by the family.

MYTHS & FACTS

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What is the National Donate Life Registry?

The National Donate Life Registry is a computer database of individuals who have made the decision to save lives through organ and tissue donation. It allows organ and tissue donation professionals to determine at the time of death if someone had registered to be a donor so that their wish to donate could be fulfilled.

Is registering through the National Donate Life Registry similar to signing up to be a donor at the DMV? Yes. Registering with the National Donate Life Registry is simply one more way to make donation decisions known. Many donors may even wish to register through both the National Donate Life Registry and their state motor vehicle office.

If someone changes their mind, can they remove themselves from the registry? If someone registers online through the National Donate Life Registry website, they can change their registration status at any time by visiting www.RegisterMe.org. If they registered through the state’s driver’s license process, they must remove themselves through the state’s motor vehicle department.

Can people make specific decisions about what organs and tissues they wish to donate? Yes. Once enrolled, there is an opportunity to change one’s profile and designate specific organs or tissues they do not wish to donate.

Will their decision to donate be kept private? Identifying information in the donor registry is only accessible to designated donation professionals. The information on the donor registry cannot be shared with or sold to companies or government agencies. Next-of-Kin will be informed of a donation decision and about the donation process to follow.

Do people receive a donor card? No. Federal regulations require all hospital deaths to be reported to the local organ procurement organization. This makes it possible for the computerized National Donate Life Registry to be checked each and every time a death is referred. No donor card is necessary. We recommend that everyone who registers as a donor talk to their family about their decision to donate.

Does next of kin have the authority to override the registry? No. Families cannot override the decision to donate as it is the legal right of individuals to make the donation decision for themselves.

What happens if a family is opposed to their loved one's donor designation? Most families support their loved one's wish to save lives. When a family is opposed, NEDS staff will work to help them understand donor designation and work with staff to provide continued support to families and honor the wishes of the donor.

NATIONAL DONATE LIFE REGISTRY

http://www.registerme.org/

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The Hospital Campaign, a national initiative by the Workplace Partnership for Life (WPFL) of the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) was launched in 2011. This initiative encourages hospitals to work with Organ Procurement Organizations (OPOs) to promote organ and tissue donation in their hospitals and communities by conducting activities such as donation awareness and registry events. Each completed activity earns points towards platinum, gold, silver, or bronze recognition from HRSA. Any hospital can join this initiative that has collected 443,427 donor registrations since 2011.

More information on the WPFL campaign can be accessed at: https://www.organdonor.gov/awareness/workplace/hospital.html

HOSPITAL PARTNERSHIP CAMPAIGN

https://www.organdonor.gov/awareness/workplace/hospital.html

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All major religions in the world view organ donation as an act of charity or make it clear that it is a decision to be left up to the individual or family.

AME & AME Zion (African Methodist Episcopal) Organ and tissue donation is viewed as an act of neighborly love and charity, and members are encouraged to support donation to help others.

Amish The Amish consent to donation if they know it is for the health and welfare of the transplant recipient. They believe that since God created the human body, it is God who heals. However, they are not forbidden from using modern medical services, including surgery, hospitalization, dental work, anesthesia, blood transfusions, or immunization.

Assembly of God Donation is supported though no official policy has been stated. The decision is left up to the individual.

Buddhism Buddhists believe organ and tissue donation is a matter that should be left to an individual’s conscience. Reverend Gyomay Masao Kubose, president and founder of The Buddhist Temple of Chicago said, “We honor those people who donate their bodies and organs to the advancement of medical science and to saving lives.” The importance of letting loved ones know your wishes is stressed.

Catholicism Organ and tissue donation is considered an act of charity and love, and transplants are morally and ethically acceptable to the Vatican.

Christian Church (Disciples of Christ) The Christian Church encourages organ and tissue donation, stating that we were created for God’s glory and for sharing God’s love. A 1985 resolution, adopted by the General Assembly, encourages “members of the Christian Church (Disciples of Christ) to enroll as organ donors and prayerfully support those who have received an organ transplant.”

The Church of Christ, Scientist Christian Scientists do not take a specific position on transplants or organ donation. They normally rely on spiritual, rather than medical means for healing. Organ and tissue donation is an issue that is left to the individual church member.

Episcopal The 70th General Convention of the Episcopal Church recommends and urges “all members of this Church to consider seriously the opportunity to donate organs after death that others may live, and that such decision be clearly stated to family, friends, church and attorney.”

Greek Orthodox The Greek Orthodox Church supports donation as a way to better human life in the form of transplantation, or research that will lead to improvements in the prevention of disease.

Gypsies Gypsies tend to be against organ donation. Although they have no formal resolution, their opposition is associated with their belief in the afterlife. Gypsies believe that for one year after a person dies, the soul retraces its steps. All parts of the body must remain intact because the soul maintains a physical shape.

RELIGION AND DONATION

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Hinduism Hindus are not prohibited by religious law from donating their organs, according to the Hindu Temple Society of North America. In fact, Hindu mythology includes stories in which parts of the human body are used for the benefit of other humans and society. The act is an individual decision.

Independent Conservative Evangelical Generally, Evangelicals have had no opposition to organ and tissue donation. Donation is an individual decision.

Islam Based on the principles and the foregoing attributes of a Muslim, the majority of Islamic legal scholars have concluded that transplantation of organs as treatment for otherwise lethal end-stage organ failure is a good thing. Donation by living donors and by deceased donors is not only permitted but encouraged. Muslim scholars of the most prestigious academies are unanimous in declaring that organ donation is an act of merit and in certain circumstances can be an obligation.

Jehovah’s Witnesses Jehovah’s Witnesses do not believe that the Bible comments directly on organ transplants; hence: decisions made regarding cornea, kidney, and other tissue transplants must be made by the individual. The same is true regarding bone transplants. Jehovah’s Witnesses are often assumed to be opposed to donation because of their belief against blood transfusion. However, this merely means that all blood must be removed from the organs and tissues before being transplanted.

Judaism In principal Judaism sanctions and encourages organ donation in order to save lives. Rabbi Elliott N. Dorff wrote that saving a life through organ donation supersedes the rules concerning treatment of a dead body. Transplantation does not desecrate a body or show lack of respect for the dead, and any delay in burial to facilitate organ donation is respectful of the decedent. Organ donation saves lives and honors the deceased.

The Conservative Movement’s Committee on Jewish Laws and Standards has stated that organ donations after death represent not only an act of kindness, but are also a “commanded obligation” which saves human lives.

Lutheran Church The Lutheran Church passed a resolution in 1984 stating that donation contributes to the well-being of humanity and can be “an expression of sacrificial love for a neighbor in need.” They call on “members to consider donating and to make any necessary family legal arrangements, including the use of a signed donor card.”

Mennonite Mennonites have no formal position on donation, but are not opposed to it. They leave the decision to the individual or his/her family.

Moravian The Moravian Church has made no statement addressing organ and tissue donation or transplantation. Robert E. Sawyer, President, Provincial Elders Conference, Moravian Church of America, Southern Province, states, “There is nothing in our doctrine or policy that would prevent a Moravian pastor from assisting a family in making a decision to donate or not to donate an organ.” It is, therefore, a matter of individual choice.

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Mormons The Church of Jesus Christ of Latter-day Saints believes the donation of organs and tissues is a selfless act that often results in great benefit to individuals with medical conditions. The decision to will or donate one’s own body organs or tissue for medical purposes, or to authorize the transplant of organs to tissue from a deceased family member is made by the individual or the deceased member’s family.

Pentecostal Pentecostals believe the decision to donate should be left to the individual.

Presbyterian Presbyterians encourage and endorse donation. It is an individual’s right to make decisions regarding his or her own body. The resolution states, “the Presbyterian Church (U.S.A.) recognizes the life-giving benefits of organ and tissue donation, and thereby encourages all Christians to become organ and tissue donors as a part of their ministry to others…”

Seventh-Day Adventist The Seventh-day Adventist Church does not have an official statement on organ donation, however, donation and transplantation are strongly encouraged. In fact, there are numerous Seventh-day Adventist transplant hospitals.

Southern Baptist Convention The Southern Baptist Convention (SBC) has no official position on organ donation. “Such decisions are a matter of personal conscience,” writes Dr. Steve Lemke, provost of the New Orleans Baptist Theological Seminary and fellow of the Research Institute of The Ethics and Religious Liberty Commission.

Shinto In Shinto, the dead body is considered impure and dangerous, and thus quite powerful. Injuring a dead body is a serious crime. It is difficult to obtain consent from bereaved families for organ donation or dissection for medical education or pathological anatomy because Shintos relate donation to injuring a dead body. Families are concerned that they not injure the itai, the relationship between the dead person and the bereaved people.

Society of Friends (Quakers) Quakers do not have an official position. They believe that donation is an individual decision.

Unitarian Universalist Organ and tissue donation is widely supported by Unitarian Universalists. They view it as an act of love and selfless giving, according to the Unitarian Universalist Association.

United Church of Christ “United Church of Christ people, churches and agencies are extremely and overwhelmingly supportive of organ sharing,” writes Rev. Jay Litner, Director, Washington office of the United Church of Christ Office for Church in Society.

United Methodist “The United Methodist Church recognizes the life-giving benefits of organ and tissue donation and thereby encourages all Christians to become organ and tissue donors,” reports a church policy statement. In a 2000 resolution the church also “encourages its congregations to join in the interfaith celebration of National Donor Sabbath …another way that United Methodists can help save lives.”

Sources: https://unos.org/donation/facts/theological-perspective-on-organ-and-tissue-donation

https://unos.org/donation/facts/theological-perspective-on-organ-and-tissue-donation

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What is VCA Transplantation? Vascularized Composite Allograft (VCA) transplantation is the transplantation of full facial, partial facial, genitourinary, upper or lower extremities to persons with significant deformities and loss of function as a result of injury or illness. The transplantation provides the recipient with near-normal appearance and use of face, genitourinary and/or limbs.

ICU VCA donation is a rare event. The following may occur with a potential VCA donor:

o Multiple photographs will be taken of the donated tissueo Molds may be done in preparation for the prostheticso For hand(s) donation:

o Vein mapping ultrasoundso AP and lateral radiographs

How You Can Help o Remove IV lines in limb being donated and insert new lines as indicatedo Shave patient’s face if donating full or partial faceo Travel to CT (head CT may be warranted for facial recovery)

OR The recovery process of VCA occurs PRIOR to organ recovery. The following are estimates in additional time required for the recovery:

o 3 – 5 hours for facial recoveryo 2 – 3 hours for limb recoveryo 3 – 4 hours for genitourinary recovery

Other changes that occur with VCA donation: o 2 authorization forms to reviewo Anesthesia will be set up at patient’s feet during facial recoveryo Reconstruction will follow the face recovery and prior to organ recoveryo Extremity prosthetic will be applied following organ recovery or at funeral home

How You Can Help o Schedule largest OR to accommodate additional surgeons and tableso Limit traffic to essential staff only

NEDS and/or recovery surgeon will communicate with the OR in advance if any additional instruments are needed.

Privacy and Respect All donation events are confidential. It is the responsibility of NEDS and hospital staff to maintain professionalism, privacy and respect the donor and donor’s family. Due to the heightened attention as a result of the unique nature of VCA donation, these cases require more vigilant confidentiality.

VASCULAR COMPOSITE ALLOGRAFT DONATION

Documents

Organ and Tissue Donation