Final Critical Care Exam

Health Risks for LGBTQ+

§Higher depression and anxiety rates

§Increased Suicide attempts

§Higher abuse of alcohol, drugs

§Higher rates of obesity and cardiovascular disease (lesbian/bisexual women)

§Higher HIV infection rates, prostate, testicular and colon cancer (gay/bisexual/trans men)

§Delayed medical care

Gender Dysphoria

: Distress due to misalignment between gender identity and assigned sex

Hormone Therapy Transgender Women

▪Estrogen therapy

▪Softening of skin, testicular atrophy, decreased body strength, less hair loss on scalp, breast development

▪VTE risk, weight gain, HTN, gallbladder dz, infertility, high TG

▪Medications to reduce testosterone - PTE, HLD, mood change, muscle mass, male sexual dysfunction

Hormone therapy Transgender Men

First: Pre-treatment fertility preservation options

▪Testosterone therapy effects and risks: deepen voice, hair growth, HTN, acne, fertility considerations, lower HDL, elevated TG, sleep apnea, hepatotoxicity

▪Stop menses, increase muscle mass, increase sweating, weight gain, emotional changes

General criteria to be met before surgical consideration for gender re-assignment surgery:

General criteria to be met before surgical consideration:

1.Persistent, well documented gender dysphoria

2.Capacity to make informed decisions

3.Legal age of consent

4.Well Controlled medical/mental health conditions

5.12 months of hormone therapy

6.12 months living in congruent gender role

7.2 letters of support from physicians

Goal for Gender Re-assignment Surgery

Goal: Reduce gender dysphoria and improve quality of life by transitioning to a physical state that more closely represents their sense of themselves.

Male to Female Surgeries

·Facial reconstruction

·Breast augmentation

·Chondrolaryngoplasty and glottoplasty - voice feminization

·Hair removal

·Genital reassignment (orchiectomy, vaginoplasty)

Post-op care:

oHospital stay 8 days

oUrinary catheter

oDilator use, activity limited >pain

oVaginal dilation and cleansing for 3-6 months

oVTE Risk

oRestrictions on strenuous activity, baths, and intercourse

oWorsening anxiety, low mood temporary

▪Still need prostate screening, also mammogram

Female to male surgeries

·Mastectomy and Facial reconstruction

·Phalloplasty (penile reconstruction) (urologist and plastic surgeon)

·Stop smoking and stop hormone therapy prior to bottom surgery

·Lengthen urethra (buccal mucosa skin)

·Vaginectomy, Hysterectomy/ oophorectomy (GYN)

·Testicular implants and erectile implants

Phalloplasty

Penile reconstruction surgery

Chondrolaryngoplasty

Surgery to reduce size of adam's apple

Glottoplasty

CO2 laser and suturing used to create webbing in anterior portion of VFs. Raises pitch by shortening length of VFs.

Stages of Female to Male

1) Phalloplasty (phallus creation)

2) Urethral lengthening and scrotoplasty

3) Penile Prosthesis

Post Op: ICU then acute care: Phalloplasty

·Post-op considerations:

1-2 days in ICU

oSuprapubic urinary diversion and transurethral catheter

oRisk of complications (strictures, necrosis, infections)

oHourly checks of bleeding, color, cap refill, temperature

oDrain in scrotum and groin

oWound care - individualized

oWound VAC on arm 5 days, then splint and dressings

oPain management and support for recovery

oBed rest 5 days - risk for VTE

·Rooming patients according to gender identity

·Reducing anxiety with support groups and preferred family presence

·Managing pain and monitoring for:

oInfection

oHemorrhage

oVTE (administer enoxaparin)

oTissue necrosis (color changes, sensation loss, poor healing)

Etiology and Risk Factors for Lung Cancer

•Tobacco and cigarette smoking

-Longer period of smoking = higher risk

-Risk determined by pack-year history

•Passive smoke or Secondhand smoke (SHS)

•Radon

•Other (pollution, pesticides, etc.)

•Cannabis

•Vaping

Staes of Non-Small Cell Lung Cancer (NSCLC)

-Stage I: Limited lungs & not spread to lymph nodes

-Stage II: Lung & nearby lymph nodes

-Stage III: Lung & lymph nodes in middle of chest

•IIIA- only to lymph nodes on same side of chest where cancer started

•IIIB- spread to lymph nodes on opposite side of chest, or above the collar bone

-Stage IV: Spread to both lungs, to fluid in the area around lungs, or to another part of the body

How to Calculate Pack-Year History

Packs per day X years smoked

Example: 2 pack per day for 10 years = 20 pack year

Where does lung cancer metastasize?

•Skeleton (35%)

•Brain (30%)

•Adrenal (20-40%)

•Liver (25%)

Clinical Manifestations of Lung Cancer

•Based on metastases site- brain, liver, bone, adrenal glands

•Cough- most common (dry, persistent; change in chronic cough)

•Hemoptysis

A nurse is assessing a 68-year-old patient with a 35 pack-year smoking history who quit smoking 10 years ago. Which action is most appropriate based on current CDC lung cancer screening guidelines?

A. Recommend a chest X-ray annually

B. Schedule a low-dose CT scan

C. Advise no screening is necessary due to smoking cessation

D. Refer for bronchoscopy

Correct Answer: B. Schedule a low-dose CT scan

•Rationale: CDC recommends annual low-dose CT scans for patients aged 55-80 with ≥30 pack-year history who currently smoke or quit within the past 15 years.

Caring for Patients POST-op Thoracic Surgery

•Positioning of patient

-Pneumonectomy

§Turn every hour to back and operative side

§NEVER un-operated side

§Allows fluid left in space to consolidate and prevents lung and heart from shifting toward operative side

-Lobectomy

§Turn every hour to either side

Chest Tubes

•Monitor for air leak

-sudden onset of air leak or large continuous leak>> bronchopleural fistula

•Measure drainage

-notify provider if >150 mL/hour

Management of Chest Tube complications

•If the chest tube becomes dislodged from the patient: immediately cover the insertion site with sterile dressing taped on 3 sides & notify the provider

•If the drainage system becomes damaged or cracked: place uncontaminated end of the connective tubing into sterile saline or water until new system can be obtained

Chest Tube Removal

•No air leak in a 24 - 48-hour period.

•Minimal drainage in a 24-hour period.

•Must be removed by a physician or authorized provider.

•After removal -occlusive sterile dressing, taped on 4 sides, is placed over the insertion site to prevent air from entering the pleural space.

Who Should Get Screened for Lung Cancer?

*Low dose CT Scan*

CDC Recommendations

1.Patients between 55 and 80 years old, and

2.Current smoker or have quit in past 15 years, and

3.>/= 30 pack year smoking history

•What if I have a nodule (spot) when being screened?

We may recommend:

-Follow up scan in 3-6 months

-Further testing such as a PET scan

-Referral to a lung specialist for possible biopsy

Diagnostic Studies Steps for Potential Lung Cancer

•X-ray (initial)

•CT scans (lungs and metastasis sites)

•PET scans (metastasis)

•Pathology

-Provides tissue dx and tumor type

If lung cancer is suspected. . .

Fine-Needle Aspiration Biopsy of the Lung - removal of tissue or fluid from the lung using a thin needle.

•CT scan, ultrasound, or other imaging used to locate the abnormal tissue.

•*Perform chest x ray after procedure to rule out a pneumothorax!*

Bronchoscopy -bronchoscope inserted through the nose or mouth into the trachea and lungs to look for abnormal tissue.

• perform biopsies of suspicious areas

Clinical Complications of Lung Cancer

•Phrenic nerve paralysis

•Upper extremity paresthesia

•Horner's syndrome (face/eyelid)

•Pulmonary embolism

•Superior vena cava (SVC) syndrome

Leading cancer killer in men and women in US and worldwide

Lung Cancer

Long Term Survival w/ Lung Cancer

•Long term survival rate low

-spread to lymphatics or metastasized by time of diagnosis in 48.5% of patients

-5 year survival rate 21.7%

Treatment Modalities for Lung cancer

•Surgery

Preferred curative modality

-Lobectomy -gold standard for NSCLC

-SCLC: only if in one lung and no metastasis

-Wedge or segmental resection

-Pneumonectomy

•Radiation

-Used to reduce tumor size or relieve symptoms

-Monitor for fatigue, anemia

•Chemotherapy

•Palliative care

-Consider early in the course of illness

All patients with NSCLC (i.e. adenocarcinoma, squamous cell carcinoma, and others) tested for biomarkers. T/F

True-Biomarkers predict response to treatment

Pneumonectomy

•Procedure in which the entire lung is removed

•Usually the most complex/ longer recovery time

HIV 1

§Common in US

§Causes most HIV infections worldwide

§More rapid progression to AIDS; more virulent

HIV 2

§Isolated in West Africa

§Rare in the US

§Slower rate of disease progression

HIV

-RNA Virus

-Called retroviruses because they replicate in "backward" manner going from RNA to DNA

-Replicates using CD4+ cells

-CD4+ T cell is the target cell for HIV entry

Life cycle of HIV

1. Binding and entry - seeks out CD4 cell>attaches>fuses>releases RNA enzymes

2. Reverse Transcription- Converts RNA into DNA using enzyme reverse transcriptase

3. Integration- integrates into CD4 nucleus using enzyme integrase

4. Replication - builds new copies >variations and mutations

5. Budding and maturation - HIV migrates to outer membrane. Protease helps convert into mature infections virus > push out bud >repeat

-Kills host T cell

-Understand life cycle to understand ART Tx

HIV Transmission

•HIV can be transmitted thru contact with certain body fluids

•HIV is not spread thru casual contact

What may increase risk for HIV?

-Unprotected sex

-Anal sex

-STI's

-Foreskin

Indications for HIV Screening

-13 -75 should be tested at least once.

-Sexually active gay and bisexual men consider testing every 3-6 months.

-Test positive for STD's or Hepatitis

-Unprotected vaginal, oral or anal sex with more than one sexual partner since last screening

-Frequent testing is particularly important for men who have sex with men (MSM) aged 13 to 24 years

-Use IV drugs

-Exchange sex for money or drugs

-Have unprotected sex with someone in the above categories

-Have been sexually assaulted

-Pregnant women - tested

HIV Testing

§4th Generation HIV Test (ELISA)- 1/2 Antibody Antigen test

-Antigen turns positive about day 13

-Antibody positive after 30 days ( 2-6 weeks)

§Rapid HIV antibody test

What if that test is positive? Confirmatory testing

-HIV viral load test (HIV RNA) ordered as HIV Nucleic Acid Amplification Test (NAAT or NAT), CD4+ count and HIV genetic testing (to assess for transmitted drug resistance)

§Ongoing Monitoring:

-CD4+ - frequency based on last CD4+ count

-Normal CD4+ range: 500 - 1500 cells/mm3 of blood

-Monitor q3 months if CD4+ count <300 cells/mm3

-Less frequent monitoring if CD4+ count >300 cells/mm3 and taking ART

§Viral Load - every 3-6 months

Stages of HIV Infection

•Stage 0 - Early infection

•Stage 1 - Asymptomatic

•Stage 2 - Symptomatic

•Stage 3 - AIDS or AIDS Condition

Stage 0 - Early infection

•40 - 80% develop symptoms of nonspecific viral illness (rash, fever, muscle/joint pain, fatigue, sore throat, headache, swollen lymph nodes) for 1-2 weeks

•Highly contagious, includes Window period

•Viral load very high in blood

Stage 1 - Asymptomatic

•Destruction of CD4 T cells > drops CD4 count (500 or greater)

•Other immune cells like CD8 increase killing of infecting virus

•Viral set point - equilibrium between HIV levels and immune response

•A chronic inflammatory stage persist cannot rid body of virus.

•May last 8-10 years fairly asymptomatic.

Stage 2 - Symptomatic

Symptomatic and CD4+ T lymphocyte are between 200 and 499.

Stage 3 - AIDS or AIDS Condition

CD4+ counts less than 200 cells/mm3 of blood. Considered to have Acquired Immune Deficiency Syndrome (AIDS) or an AIDs condition is present

Treatment for HIV

-use of antiretroviral drugs from 2 or more drug classes

-Combination Therapy Utilized

-Compliance with medication

-Monitor Viral load - evaluate effectiveness

-HAART (Highly Active Antiretroviral Therapy)

Immune Reconstitution Inflammatory Syndrome (IRIS) after Starting ART

•Occurs in initial months of treatment, significant morbidity, hospitalized

•Paradoxical inflammatory response - Worsening of preexisting infectious processes following initiation of ART

•Associated with many organisms: mycobacteria, herpes viruses, fungal infections

•Fever, Respiratory, Abdominal symptoms, and Opportunistic infections

•Treated with anti-inflammatories

Clinical Manifestations of HIV: Respiratory

-SOB, dyspnea, cough, chest pain, fever

-Consider: Pneumocystis jirovecii, TB, cytomegalovirus, Legionella

-Pneumocystis pneumonia (PCP) caused by Jirovecii

-Acute onset of dyspnea, fever, non-productive cough, pain

-Tachypnea, tachycardia, rales/crackles with exertion

-Oral thrush is a common co-infection

-If low CD4+ less than 200 > prophylactic Bactrim

-Plan of Care: TC&DB, IS, vibropercussion, fluids

Clinical Manifestations HIV: Gastrointestinal

-Loss of appetite, N/V, oral and esophageal candidiasis, CHRONIC DIARRHEA, hairy leukoplakia

-HIV Wasting Syndrome

Clinical Manifestations HIV: Cancer

-Kaposi Sarcoma

-cutaneous lesions to disseminated disease involving multiple organs

-Cervical Carcinoma

-AIDS-Related Lymphoma

-Hodgkin & non-Hodgkin

Clinical Manifestations HIV: Neurological

-Direct effects of HIV on nervous tissue by chronic inflammation

-Atrophy, demyelination, degeneration and necrosis

-Peripheral Neuropathy

-HIV encephalopathy - progressive decline in cognitive, executive function, visual memory and motor function from HIV infection

-Depression and apathy - neuropsychiatric complications of HIV

Strategies to Protect Against HIV Infection

§Abstinence

§Use latex condoms for every sex act, and do not reuse

§Choose less risky sexual behaviors

§Avoid/minimize tissue trauma during sex

§Limit the number of sexual partners

§Get tested and treated for sexually transmitted infections

§Do not inject drugs

§Avoid sharing needles, razors, toothbrushes, sex toys or blood contaminated items

§Needle exchange, bleach to clean needles/syringes

§Consider post-exposure prophylaxis (PEP) for recent HIV exposures (within <72 hours)

§Consider pre-exposure prophylaxis (PrEP) if regularly engage in high-risk behaviors

§If HIV seropositive, take ART regularly to achieve and sustain viral suppression

ZERO risk of sexual HIV transmission when virally suppressed on ART

Pre-exposure prophylaxis (PrEP)

-Use of ART to prevent HIV

-Up to 99% effective in preventing HIV infection via sexual exposure and at least 74% effective in preventing HIV infection via injection drug use, when taken correctly

-Currently, three FDA approved PrEP medications

-Tenofovir disoproxil fumarate/emtricitabine - Truvada

-Tenofovir alafenamide/emtricitabine - Descovy

-Cabotegravir - Apretude (long acting injectable)

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-Time to maximum protective levels for oral PrEP:

•~7 days of daily use for receptive anal sex

•~20 days of daily use for receptive vaginal sex and injection drug use (Truvada only)

-Time to protective levels for injected PrEP: 7 days

-PrEP does not protect against other sexually transmitted infections

-Requires regular HIV testing (q3 months)

Health Care Workers use Standard Precautions for HIV

1. Gloves

2. Gown

3. Mask

If an occupational HIV exposure occurs:

-Alert your supervisor, initiate reporting

-Determine the HIV status of exposure source. Use rapid testing if HIV status of patient is unknown

-Counseling: use contraceptive precautions (barrier contraceptives, avoid blood/tissue donations, avoid pregnancy and breast feeding during 6-12 weeks after exposure

-3 drug PEP may be prescribed

-Reevaluation of exposed provider within 72 hours after exposure

-HIV testing at baseline and 6 weeks and 4 months after exposure

-CBC, renal and hepatic function tests at 2 weeks after exposure

Incidence Brain & CNS tumors

•Most common solid tumors in children (0-14)

•Age 85+ = Highest for all

•Median age at diagnosis for all primary brain and other CNS tumors was 61 years

•LOW IMMUNITY

Risk factors for Brain Cancer

•Cause of brain tumors is unknown

•Exposure to ionized radiation

•Environmental

•? Familial patterns

-Neurofibromatosis

Brain Tumor Type

•Non-malignant

•Malignant

-Primary

-Metastatic

•2x common as glioma

•Lung, breast, melanoma, renal, colon

•Blood-brain barrier = Chemotherapy to cross

•Survival from primary cancer improves = incidence of brain metastases increases

Classification of type of brain cancer is based on what?

histopathology (cell of origin)

Histological Grading

•Grade I: relatively circumscribed, non-infiltrating, low proliferative potential

•Grade II: atypical cells, well differentiated, infiltrating, low proliferative potential

•Grade III: (anaplastic) diffusely infiltrating, nuclear atypia, significant proliferative activity

•Grade IV: (glioblastoma) poorly differentiated, presence of necrosis and/or microvascular proliferation

Most brain tumors are malignant or non-malignant?

Non-malignant

Survival Rates Brain Tumors

•Overall 5-year survival rate = 33.72%;

•The 10-year survival rate = 27.92%

-Glioblastoma = 5-year =4.7%

= 10 year =2.32%

•In general-

*12-18 mo with tx.

*6 mo or < without tx

Causes of Brain Tumor Symptoms

- directly infiltrating tissue

- producing adjacent edema

- compressing adjacent structures

- irritating surrounding tissue

- blocking flow of CSF

- creating new blood vessels that hemorrhage.

Peritumoral Edema

-swelling around the tumor

-common at presentation and is the cause of most initial symptoms = significant contributor morbidity & mortality

Of all headaches associated with brain tumors, what percentage are related to edema and increased ICP?

33%-71% are related to edema and increased pressure and traction on pain-sensitive structures

Peritumoral Edema Treatment

•Corticosteroids

-Dexamethasone preferred (increase BS (diabetics))

•A common dosage is 16 mg/day.

-Oral absorption is excellent.

-Improvement in symptoms often can be seen within 24-72 hours after initiation.

Tumor Angiogenesis

the proliferation of a network of blood vessels which supplies a tumor with a supportive microenvironment rich with oxygen and nutrients to sustain optimal growth.

Vascular endothelial growth factor (VEGF)

Stimulates endothelial cells to multiply and restore endothelial lining. Caused by tumor.

Symptoms of Brain Cancer

•General symptoms

-Seizures

-Cognitive-behavioral deficits

-Decreased level of responsiveness

-Fatigue

•Intracranial pressure (ICP)

-Headache

-Vomiting

-Papilledema

•Cluster unique to brain tumor population

-Focal neurologic symptoms

-Seizures

- Headache

*LOCATION, LOCATION, LOCATION*

Visual Field Test

measurement of the entire scope of vision (peripheral and central) can help identify location of tumor

QOL in Adults with Brain Tumors

• ^ Symptom burden

• v Physical Fxing

• v Social Fxing

• v Ability to carry out normal activities w/o restriction

• ^ Fatigue

• v Cognitive

• ^ Emotional/mood alterations-fear & anxiety

• ^ Depression-serotonin binding sites

• ^ Sleep disturbance

Treatment -Surgery/Chemotherapy

•Surgery

-Seizures postop

-Meningitis

-Hydrocephalus

•H/A, decreased LOC, N/V, Pupillary abnormalities

-VTE

•Chemotherapy

-Temozolomide (oral)

-Bevacizumab (IV)

-Lomustine

-Methotrexate (CNS lymphoma)

Treatment-Radiation

-Radiation + chemotherapy

•SOC in high-grade gliomas

-External beam

-Intensity-modulated RT

-Whole-brain

-Stereotactic radiosurgery

-Proton therapy

*Peritumoral edema

-*fatigue

-h/a

-n/v

-anorexia

-alopecia

-attention deficit

-short-term memory loss

Factors Contributing to Overall Prognosis of Brain Cancer

•Age

•Karnofsky Performance Status (KPS) Scale

•Extent of resection

•Volume of residual disease

•Presence of necrosis

•Preoperative MRI findings

•Enhancement

•Therapy used

•Tumor size

•Non-central tumor location

•Albumin level

•Genetic factors

Post Mortem Care

•Handle the body with respect

•Ask family if they want to participate

•Prepare family for removal of the body from room/home

•Home death - Durable medical equipment (DME) meds, documentation

•Assess family/caregiver needs/bereavement, emotional support

Cultural Considerations When Death is Imminent

•Death rites/ rituals

•Encourage time with the body

•Ask who needs to view of attend the body

•Interpret/normalize post mortem changes

•Provide emotional support

Pain with Death

•Requires frequent assessment

•Not always present at end of life

•May not be able to rate pain & must rely on behavior cues

•Rule out / think about other causes of distress

•Use of oral/transdermal medications

Dyspnea with Death

•Is a distressing symptom for patients and families

•Be proactive

•Oxygen

•Positioning

•Fan/cool environment

•Calming environment/provide reassurance

•Use of opioids

•Benzodiazepines

Respiratory Secretions with Death

•Avoid "death rattle"

•Distressing and frightening to family, friends, healthcare providers

•Can cause agitation and fear of suffocating

•Assessment

Interventions/Management of Respiratory Secretions

•Elevate head of bed

•Begin anticholinergic drug(s)

•Reduce or stop IV fluids/enteral feedings

•Provide reassurance and education

•Provide peaceful, calming environment

•Role model comforting

Restlessness with Death

•Access for reversible causes (i.e. constipation, distended bladder)

•Provided a calm, comforting environment

•Use medications as ordered

Delirium with Death

•Hyperactive -restlessness, calling out, agitated, disoriented, crawling out of bed, delusions

•Hypoactive -lethargic, somnolent, appear to be in a stupor

•Causes of delirium include changes in the sleep/ wake cycle /ICU psychosis/ restraints

•Can have both - hypo and hyper active delirium

•Treatment - environmental/use of antipsychotics (if indicated)

•Benzodiazepines may worsen delirium (especially in the elderly)

Other Signs of Imminent Death

•Cardiovascular - cold extremities/mottling, change is vital signs

•Respiratory - change in breathing pattern (apnea, panting, cheyne-stokes, mandibular breathing), audible secretions

•Metabolic - fatigue, surge of energy, temperature changes/diaphoresis

•Gastrointestinal- decreased intake, nausea, vomiting, diarrhea, constipation, incontinence

•Urinary - decreased urine output

•Communication - decrease interaction with others (i.e. withdrawn, using metaphors, expressing emotional and/or fears)

Signs Death has Occurred

•Absent - pulse, blood pressure, respirations, response to stimuli blinking/corneal reflex

•May see - bowel/bladder incontinence, eyes slightly open, jaw relaxed, mouth open, waxy, pasty appearance to skin

The Healthcare Professional's Role for Organ Donation

+ Identification and referral

+ Support of the family considering donation

+ Assist with the family approach

+ Provide information to Legacy of Hope and Advancing Sight Network

+ Assist with the evaluation and support of organ donors

The Donation Process

+ After all attempts are made to save the person's life, donation is considered

+ Legacy of Hope is called on EVERY in-hospital death

+ Evaluation for medical suitability

+ Family approached as appropriate

+ Coordination of donation

+ Family follow-up after donation

DETERMINING ORGAN DONATION OPTIONS

Is the heart beating or is pt. ventilated> if yes> potential organ and tissue donor

If the heart is not beating or the pt. is not ventilated then potential eye or tissue donor

Brain Death

+ The irreversible cessation of all brain function, including the brain stem

+ A person who is brain dead is dead and has no chance of revival

+ In Alabama, two physicians, not affiliated with donation or transplantation, independently assess the patient and agree there is no brain function

+ The date/time of death is when the second brain death note is written

+ Patient maintained on mechanical until organ recovery

Donation after Circulatory death (DCD)

+ A pathway to organ donation which can occur when a patient dies from cardiac arrest in the hospital under very specific circumstances

+ A patient is determined to have a non-survivable injury or medical event and family wishes to withdraw life sustaining therapies

+ Organ donation opportunity is presented to the family after the decision to withdraw life-sustaining therapies

+ The patient is maintained on the ventilator during the donor evaluation and organ allocation process

+ At a mutually agreed upon time with the family, the primary care team and Legacy of Hope, life-sustaining therapies are discontinued. End-of-life care will be provided by the primary care team.

+ When the patient cardiac arrests, death is pronounced by the primary care team

+ If the patient arrests within the current timeframe for organ suitability, the organs may be recovered for transplant

+ If the patient does not arrest, end-of-life care will be maintained by the primary care team

Evaluation for Medical Suitability

+ Determine donor suitability before approaching the family + Enable the requestor to answer family questions

+ Prevents asking families who don't have donation options

+ Medical Examiner / Coroner's Consent

The Family Discussion - The 4 R's

-Right time

-Right people

-Right place

-Rigth information/options presented

Family Approach

+ Done by Legacy of Hope staff or a hospital staff member trained by Legacy of Hope

+ Primary focus - the needs of the donor family

+ Approached in a sensitive manner

+ Ensure family received necessary information to make an informed decision

Authorization and Donor Risk Assessment Interview (DRAI)

+ Donor Designation / Authorization

+ Important to get medical/social history from next-of-kin and others who may have known the donor

+ Screen for increased-risk behavior

Additional Evaluation

+ Basic labs

+ Organ specific labs

+ Serology, i.e. Hepatitis, HIV, etc.

+ Blood type

+ Cultures

+ Consults

Organ Allocation

+ The donor's information is entered in the national sharing system (UNOS) via DonorNet

+ Organs are matched by blood type, body size, waiting time and patient's medical status

+ Legacy of Hope coordinator electronically notifies transplant centers, based on the generated list, of the organ offer

+ Multiple offers are made at once

+ Cannot move through the list until the primary center accepts or declines the organ offer

+ Can take hours!

Organ and Tissue Recovery

+ The OR is scheduled when all organs are allocated

+ Treat the donor with respect, be a good steward of the gift + Organ recovery takes place in our Donor Recovery Center or the hospital's operating room

+ Tissue recoveries may occur in our Donor Recovery Center, other outside facility or hospital operating room

What to Expect in the OR

+ Visualization of organs

+ Organ dissection

+ Insertion of flush cannulas

+ Aortic cross-clamp

+ Flush

+ Organs removed to back-tables for individual organ flushing and packaging