Melanie Cole Host): Welcome to UAB Med Cast. I'm Melanie Cole and I invite you to listen as we discuss Catastrophic Brain Injury Guidelines and Organ Donor Management. Joining me, is Dr. Sam Windham. He's the Director of Surgical Critical Care and the Medical Director of Legacy of Hope at UAB Medicine. Dr. Windham, thank you so much. What an interesting topic that we've got here today. Thank you for joining us. Why don't you start for other providers, a little bit about catastrophic brain injury and the most common occurrence.

Sam Windham, III, MD (Guest): Well, thank you for having me today, Melanie. Catastrophic Brain Injury Guidelines, so they're really a simple set of parameters provided to healthcare providers to aid with the management of those patients who have sustained a very severe and sometimes, unfortunately quite often, a non survivable brain injury. Let me kind of back up a little bit to the need of why these guidelines were developed, because that does put an important framework of why we have them in place.

We know that organ transplantation has become a lifesaving procedure for many patients in organ failure. In fact, there's 120,000 people in the United States on the waiting list for a life saving organ. Unfortunately, many of those patients will die from their organ failure, never having received a transplant. And this is simply due to the fact that demand exceeds the supply. There are many people in the fields of organ donation as well as transplantation that are working on all aspects to try to help this problem with the waiting list. One particular interest of mine and that we're focused on, is that of preserving the chance for organ donation following brain death declaration.

In the United States, approximately 2.2 million people die every year, but less than 1% of those deaths occur in a manner to allow for organ donation following brain death. So, there's some key aspects that are important to allow for organ donation. Number one, is to capture the referral of every patient that might have the chance for donation. Number two, would be preserving the chance for donation once that patient is progressing towards brain death and after brain death, and then finally and an area of interest of mine is that management of the organ donor, after they have been declared to try to reverse all the negative effects that have happened to the body with the brain death process.

And so Catastrophic Brain Injury Guidelines, they were designed to really help with that second point that I just mentioned, and that is to preserve the chance for organ donation. Many healthcare providers take care of those patients that have catastrophic brain injuries and know just how unstable those patients get. And so, these guidelines help with the management and dealing with that instability.

Host: So then Doctor, what are the current guidelines for organ donor potential for these patients?

Dr. Windham: These guidelines were made to help support any kind of catastrophic brain injury. Some of these, the patients have trauma such as gunshot wounds to the head or car accidents, strokes, intracranial bleeds, a cardiac arrest. Overdose is becoming a lot more frequent here in the last few years. So, regardless what kind of injury has been sustained by the patients, these guidelines are made and developed to help support those patients. I guess, key to understanding the guidelines is to understand why the patients become unstable following the catastrophic brain injury. That gets to kind of the physiology of that catastrophic brain injury.

The first reason for the instability, is that often as patients progress with their catastrophic brain injury, their response is much like the septic patient in the intensive care unit. They have the same cytokines and inflammatory mediators that are released and then thus behave just like a septic patient. And this was described by Schwartz in the Journal of Cell Transplantation in 2018. So, just as the septic patient needs a volume resuscitation and hemodynamic support; so does that patient with a catastrophic brain injury. A second reason for the instability is that with the increased intracranial pressure from the catastrophic brain injury, ultimately the blood flow to the brain stops, which is the point of brain death. When that happens, all the central nervous system hormones are stopped being produced and that leads to instability from diabetes insipidus, as these patients will have large volume urine output and become hypovolemic really quickly, as well as they have adrenal insufficiency because the central nervous system no longer produces ACTH.

The third reason that the patients become unstable is that with the progression to brain death, the heart becomes stunned in up to 30 to 50% of the patients progressing to organ donation. And that just has to do with the physiology of that brain death process and the stunning of the heart. So, the guidelines were made to develop and overcome each of these three entities to help stabilize the patient. There are many iterations of the Catastrophic Brain Injury Guidelines, and I don't know that any one is better than another. And so we have typically adopted a very simple group of Catastrophic Brain Injury Guidelines at Legacy of Hope.

Number one, is to maintain the systolic blood pressure greater than 90. If you're having trouble doing this, administer fluids, if they are behind. Add vasopressor support if needed to help achieve this goal. And that can come in any form, whatever the physician feels appropriate. Most commonly those are levophed or vasopressin or Neo-Synephrine.

And then third, if they're having trouble maintaining the blood pressure, is consider invasive monitoring and access to help achieve this goal. The second component of the Catastrophic Brain Injury Guidelines we have is to maintain the urine output between the range of half a cc to one cc per kilo, per hour and less than 300 ccs per hour. To help achieve these goals, first can administer fluid if they are behind and the urine output is low. And second, if the urine output is very high to start the vasopressin as this will help take care of the diabetes insipidus, which is likely to be present.

Third component of the CBIGs would be maintain a PAO2 greater than a hundred and fourth component is to maintain a normal pH between 7.35 and 7.45. So, these are the four guidelines that we encourage to be followed. They seem awfully simple, but believe it or not, just by performing these, the donation potential can be preserved in a tremendous way.

Host: Dr Windham, is there a point that the healthcare teams and sometimes families realize that the injury is not survivable and if the healthcare teams sense that, might they often direct less care, less resources to these patients? As you're giving us these guidelines, can you tell us steps in the process that will hopefully mitigate that?

Dr. Windham: First and foremost, these guidelines were really what would you do in order to get a patient better? In the case, that this is a survivable, so each one of these is good care. And in that case, that the patient can survive this, it gives them the best chance to survive. We do see very often, the care being decreased, we do know that it's non survivable and I don't think that's out of negligence or mal-intent but simply sometimes out of compassion for the patient to avoid unnecessary interventions if they're not going to be of any benefit and sometimes even in this last year, when we saw limited supplies, that played a role in I think limiting of resources of that, the limitations that COVID had to some of our very stretched medical staff and resources. But in general, if we can really aim to provide these simple interventions it really will afford better care for the patient all in all.

Host: Well, then tell us how you've been instrumental in increasing organ recovery rates at Legacy of Hope, directly impacting the number of transplants you've been able to do. Tell us about your role there, Doctor.

Dr. Windham: Well, I started in 2015, I joined the staff and then have since become Medical Director there. And actually, let me start by saying that it's really been a team effort. And I give credit to the team, all the way from our leadership that has really been living out our mission and providing the needs for our teams to do the work that we do. Our family support is also another group that's part of that team that they do such a tremendous and wonderful job working with the families to not only enhance the donor potential, but enhance the grieving process for the family as much as is possible. Our transplant coordinators is another member of that team. They work very long and hard shifts with all aspects of the donor management. And there's so many people behind the scenes on our team, such as our Perfusion Techs, quality department and others that work for this mission. So, the successes that have happened in the last few years are certainly not just what I've done, but my role in the part of this larger mission. I've tried to speak around the state to different groups and encouraging this management of the catastrophic brain injury in order to observe the potential, because I do you know that little steps done by anyone around the state can sure help our donor potential. And then we've also been able to implement several protocols to reverse the damage that is experienced with the brain death process and have been successful in those. In the first year, we were able to more than double the number of lungs able to be offered for transplant.

And then in the second year, as we rolled out new cardiac protocol that no one else in the country has been doing, we were able to have more than 150% increase in the hearts able to be transplanted. So, it's really been a wonderful opportunity to work with Legacy of Hope in developing these protocols.

Host: And what great work you're doing too, Doctor. So, tell us a little bit about how hospitals that have larger donor abilities and a great deal of experience in donor management before the development of these guidelines, are they the ones guiding and helping to expand the use of these CBIGs in the guidelines? Tell us a little bit, if you see this being used on a broader multicenter level where you might expect increases in successful attainment of donor management goals, that may be more pronounced.

Dr. Windham: Yes, we do have certain hospitals in our coverage area that do have a higher amount of organ donors that are referred to us. And that's mainly due to the volume of patients that they take care of and the type of patients that they see. Certainly, the patients from stroke centers and trauma centers do have a higher donation potential. And so the hospitals do play a role with respect to the size and the volume that they refer to us. I would say probably more importantly is the individual healthcare worker. And that is, there are certain doctors, nurses, respiratory therapists, chaplains, all people involved in the care of patients with critical brain injuries that are donor champions. You know, they seem to be the ones to capture the potential that the patient has. They really offer good care and for the patient and then support for the family as that patient is progressing through a non survivable injury. And so, I've found it's probably less so the hospital, as opposed to those people that are our donor champions. And we're really trying to cultivate that relationship with individuals from each hospital so that we can really optimize the referral from every hospital.

Host: Doctor, we just to have a few more questions. And can you tell us some of the goals you're achieving and even some of the goals that were met less often in the post CBIGs and what you would like to see happening in the future?

Dr. Windham: I think importantly in the next few years, the government's going to be holding us to certain statistics about our donation rate and our transplantation rate. And so we have been meeting weekly with our leadership team to help prepare ourselves to really function at the highest level. One of those components will be to roll out and really have the buy-in or the implementation of CBIGs throughout our hospitals. I've been, like I mentioned, I've been trying to go around the state to emphasize the CBIGs and other elements of donor management to these hospitals. And at each place, I really try to stress, how much a difference it can make.

There are two articles in the literature illustrating that. In Critical Care Medicine in 2012, there they took 360 donors and they managed them with a certain group of guidelines or goals, just like I mentioned. And they found that if they could meet those goals in the management, they increased the number of organs per donor from 3.6 organs per donor, to greater than four organs per donor. This was then repeated in JAMA Surgery in 2014, in which they took 671 donors who had even greater degree of sicknesses and co-morbidities and found that meeting the early guidelines and goals, they could increase the donor potential from 2.1 to three organs per donor.

Now neither one of those seems like a lot, but just to give a framework, what that would mean for our organ procurement organization, is that with the number of referrals and donors that we managed last year, that would mean 220 to 260 more organs for donation in last year alone. And that's incredible to think about how much more that would be available for those people that are on the waiting list in lifesaving gifts. Really, we're trying to stress that importance to the hospitals. And that's one of our major focuses around the state, currently.

Host: That's an incredible focus. Dr. Windham, as we wrap up, what would you like other providers to know about how the use of Catastrophic Brain Injury Guidelines before brain death has led to more stable donors, maximizing transplantable organs, your Legacy of Hope and what you're doing there at UAB Medicine.

Dr. Windham: Yes, the first off, these guidelines are really simple and they can make a tremendous difference. Number one, that if the patient has a chance of survival, it gives him the best chance of survival. But when that chance disappears and they are not going to survive, then it gives the best chance to preserve the gift of donation.

And then second is that each individual can make a difference. You know, so often in medicine we get part of bigger schemes and sometimes don't necessarily feel we can make a difference. But each individual can make a wonderful difference just by implementation of these. When you implement them, each physician and caregiver is giving the best care they can to the patient.

Also implementing them, they give the best chance for the recipients on that waiting list to receive the gift of life. And then lastly, implementation of them really helps the families. You know, if the patients get better, then wonderful, those patient's families are eternally grateful for those healthcare providers for what they've done for their loved one. But if that's not possible, then it gives the best opportunity possible for our family support and resources that we have to work with the families in their grieving process. I just can't imagine what those families are going through. And they're really remarkable families that can take their worst moment in time and think of other people.

And having that opportunity to work with our family support gives them help and aid in going through that grief process. We do have a yearly picnic when we're not under COVID isolation and where the donor families can get to meet the recipients and it is truly an amazing event to see the opportunities for healing and compassion that happens. So, the implementation of the CBIGs by anyone out there certainly helps in all aspects of the donor, the recipient, as well as the family and gives us a chance to help turn around those organs for organ donation.

Host: Wow. I got chills, Dr. Windham. What a remarkable program that you are running there at UAB Medicine. It's just, that's just amazing what you're doing there. So, thank you so much for joining us today. And a community physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember, as always to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.