Page 782 - ACCCN's Critical Care Nursing

Organ Donation and Transplantation 759

Case study
Day 1 Receiving regular physiotherapy treatments: change of position
Ms Wright, a 25-year-year-old woman, was found lying on the floor and suctioning.
of her bathroom in the early hours of the morning after falling Day 4
off a horse the previous day. She was admitted to a country 0400: Difficulty with ventilation: asynchronous breathing with
hospital via ambulance (and was able to walk to the ambulance). ventilator, bradycardic, systemic hypertension: Cushing’s response
On arrival at hospital her vital signs included: GCS 7–8, BP was queried as the cause. Sedation was increased, metoprolol and
165/85 mmHg, pulse rate (PR) 45, O 2 saturation 98%, spontaneous clonidine given with no effect; SNP was started to control the
movement of all limbs, no verbal response. Her weight was esti- marked hypertension, with a profound drop in BP; given metara-
mated at 65 kg. She was intubated and ventilated for a cerebral minol bolus and noradrenaline infusion commenced.
CT, which revealed extensive frontal contusions, skull fracture, SAH
and subdural with mass effect. She was retrieved to a metropolitan 0530: GCS 3 both pupils 5 mm and fixed, nil gag reflex or sponta-
hospital by air. neous breathing, sedation ceased, noradrenaline titrated to keep
MAP >60–80 mmHg, polyuric.
1345: On arrival, pupils are unequal and unreactive, sinus rhythm,
normotensive, GCS 3, morphine and midazolam infusion changed 0800: Morning round: probable brainstem failure noted after
to propofol. Taken immediately to theatre for bifrontal craniectomy sympathetic storm. Plan to perform set of brain death studies at
and insertion of an extraventricular drain (EVD). 1700, 24 hours after thiopentone ceased. Family conference: events
overnight discussed, probable brain death, and time planned to
1645: Admitted to critical care: intracranial pressure (ICP) 46, conduct tests. Organ donor coordinator contacted to notify of
pupils unequal, fully ventilated (SIMV, RR 20, Tv 400 mL, PEEP 5), potential donor.
sedated and paralysed, hypertensive: given stat dose of clonidine
with effect, sinus rhythm, febrile 39.5°C and active cooling 1200: Patient moved to side room for privacy, also enabling more
commenced. family members to visit at a time. Routine care including physi-
otherapy treatment continues. During this time, the family
2200: Thiopentone infusion commenced: low dose, pupils unequal broaches the subject of organ donation with the nursing staff and
and unreactive, ICP 30–35 mmHg, EVD opened when ICP social worker, who advise them that this will be discussed after
>25 mmHg. Cerebral perfusion pressure (CPP) 50–60 mmHg, brain death testing. DonateLife organ donor coordinator notified
systolic blood pressure (SBP) 120–145, mean arterial pressure of offer of organ donation by family, and asked by the medical staff
(MAP) >70 mmHg. to contact the coroner for permission to seek consent from the
Day 2 family.
0405: Clinical deterioration: ICP 44 mmHg, PR 60, BP 170/ 1430: Coroner grants permission for organ and tissue retrieval.
90 mmHg, taken for urgent CT scan: more extensive bifrontal
contusions, significant mass effect from frontal contusion. 1700: First set of brain death tests conducted: clinical brainstem
reflex testing performed by critical care senior registrar. All reflexes
0900: During morning medical round: GCS 3, no cough on suction, absent: PCO 2 64 mmHg after 10 minutes of apnoea.
pupils unequal and non-reactive, normothermic, good gas
exchange, paralysis ceased, low-dose thiopentone infusion 1750: Second set of brain death tests conducted: clinical
continues, mannitol, insulin infusion titrated for blood sugar level brainstem reflex testing performed by critical care consultant.
(BSL). Nasogastric tube (NGT) feeds commenced. Family All reflexes absent. Tests performed with family present at their
conference involving parents, intensivist, senior registrar, social request.
worker and nursing staff. Family is told that the head injury is 1800: Formal approach to family by critical care consultant to seek
life-threatening. consent for organ and tissue retrieval; family agrees.
2200: Left pupil 2 mm and reactive, right pupil 4 mm and non- 1830: Introduction of State DonateLife organ donor coordinator
reactive, spontaneous extensor response in upper limbs, GCS 5, to family to clarify consent and explain process. Blood collected
ICP 38 mmHg. Sedation increased. and sent for virology, tissue typing and cross-matching. Infor-
mation collected for referral. DonateLife organ donor coordinator
Day 3 provides written material to family which outlines process of
0830: ICP 45 mmHg, EVD open, left pupil reactive, right pupil donation, support and counselling options and grief and bereave-
non-reactive, normothermic, BP 145/75 mmHg, PR 72, strong ment information. Contact details are confirmed for follow up.
cough on suction, breathing spontaneously.
2000: Referral to transplant teams.
1600: Repeat head CT: unchanged, effaced ventricles, anterior
herniation through craniectomy, brainstem viable. CT neck: no 2015: Family completes formal identification with police for the
fracture. Thiopentone ceased. coroner.
1900: Family conference: prognosis noted as very poor, sub- 2100: Acceptance of offer by the transplant teams and identifi-
optimal neurological state with residual impairment at best, cation of potential recipients for heart, lungs, liver, kidneys and
progression to brain death a possibility. Sedation decreased. pancreas.