Organ donation - Nursing Case Study

Pathophysiology

• Primary mechanism: Brain death determination - Brain death, a complete and irreversible loss of brain function, is a key requirement for organ donation. It is confirmed through clinical assessment, including absence of brainstem reflexes and apnea test. Some hospitals may use additional tests such as cerebral angiography or EEG.

• Secondary mechanism: Hemodynamic stability - Maintaining the donor's hemodynamic stability is crucial to preserving the viability of organs for transplantation. This involves careful monitoring and management of cardiovascular status, fluid balance, and electrolyte levels to prevent organ damage caused by hypoperfusion or hypoxia.

• Key complication: Ischemia-Reperfusion Injury - It occurs when the blood supply returns to the tissue after a period of ischemia or lack of oxygen. The return of blood flow causes inflammation and oxidative damage through the induction of oxidative stress rather than the restoration of normal function, which can impair the organ

Patient Profile

Demographics:

45, Male, Construction worker

History:

• Key past medical history: Hypertension, Diabetes, Chronic kidney disease

• Current medications: Metformin, Lisinopril, Amlodipine, Insulin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing fatigue, swelling in legs and abdomen, decreased appetite

• Key symptoms: Shortness of breath, weight gain, nausea, vomiting, confusion

• Vital signs: Blood pressure 160/95 mmHg, pulse 90 beats per minute, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 92% on room air.

Section 1

Change in patient status:

The patient's condition continues to deteriorate, exhibiting signs of sepsis, with a temperature spike to 102°F. His respiratory rate has also increased to 28 breaths per minute, and oxygen saturation has dropped to 88% on room air. His blood pressure remains alarmingly high at 170/100 mmHg, despite the administered antihypertensive medication. The patient is increasingly lethargic and confused, likely due to worsening uremia. The swelling in his legs and abdomen has also worsened, suggesting an increase in fluid retention and possible worsening of his kidney function.

New diagnostic results:

Lab results revealed increased BUN and creatinine levels (BUN: 65 mg/dl, Creatinine: 7.2 mg/dl) indicating worsening kidney function, while his blood glucose was 300 mg/dl despite insulin therapy. WBC count was elevated at 15,000 cells/µL, suggesting an infection. His hemoglobin level was also low at 10g/dl, contributing to his increasing fatigue. An arterial blood gas (ABG) test showed a pH of 7.30, indicating metabolic acidosis which is common in patients with chronic kidney disease. His urine output has decreased significantly to less than 20 ml/hr, further confirming the declining kidney function.

These changes indicate a progression of the patient's chronic kidney disease to end-stage renal disease (ESRD), with associated complications including sepsis and fluid overload. Given his current status, the healthcare team should consider the possibility of dialysis while continuing to manage his hemodynamic stability for potential organ transplantation. The patient's worsening condition will require critical clinical reasoning to manage the multiple organ complications and the potential for organ donation.

Section 2

New Complications:

The patient's condition, despite continuous medical interventions, continued to worsen. He developed difficulty breathing and required supplemental oxygen to maintain a saturation of 92%. His respiratory rate increased to 35 breaths per minute, with the use of accessory muscles noted. Auscultation revealed crackles in both lung bases, suggesting fluid overload. He also became increasingly somnolent and unresponsive to verbal stimuli.

In response to the worsening respiratory distress, the healthcare team initiated non-invasive ventilation (NIV) to help improve his oxygenation. However, the patient developed a sudden onset of tachycardia with a heart rate spiking to 145 beats per minute, and his blood pressure dropped to 90/50 mmHg. An electrocardiogram (ECG) showed changes consistent with myocardial ischemia. Troponin levels were elevated at 0.5 ng/mL, indicating possible myocardial injury. These findings suggest the possibility of acute coronary syndrome, complicating the patient's already critical status.

This new development necessitates a rapid reassessment of the patient's overall condition and management plan. The healthcare team needs to balance the management of the patient's multiple organ failure, potential sepsis, and now the possible acute coronary syndrome. This case presents a significant challenge for clinical reasoning, where multiple organ systems are involved, and the patient's condition is rapidly deteriorating. The patient's suitability for organ donation may also need to be reassessed in light of these new developments.

Section 3

New Diagnostic Results:

Further diagnostic tests were ordered by the physician in charge due to the sudden onset of tachycardia and hypotension. The patient's arterial blood gas (ABG) showed a pH of 7.28, a PaCO2 of 55 mmHg, and a PaO2 of 68 mmHg, indicating respiratory acidosis. Additionally, his serum lactate levels were markedly elevated at 5 mmol/L, suggesting tissue hypoperfusion. The complete blood count (CBC) revealed a white blood cell count of 18,000 per microliter and a platelet count of 100,000 per microliter, suggesting a possible infection and increased risk of bleeding respectively. The kidney function tests showed a creatinine level of 3.0 mg/dL and a blood urea nitrogen level of 35 mg/dL, suggesting acute kidney injury.

These new diagnostic results underscore the severity and complexity of the patient's condition. The respiratory acidosis indicates the patient's lungs are unable to adequately remove CO2 from the bloodstream, likely due to the fluid overload and worsening respiratory distress. The elevated serum lactate level suggests that the tissues are not receiving enough oxygen, which could be a result of the acute coronary syndrome, sepsis, or both. The increased WBC count, in addition to the patient's fever and hypotension, supports the suspicion of sepsis. The impaired kidney function indicates another organ system is now involved in this multi-organ failure. With these findings, the healthcare team must reassess the patient's suitability for organ donation and adjust the management plan accordingly.

Section 4

In light of the new diagnostic results, the patient's status has significantly deteriorated. The patient's Glasgow Coma Scale (GCS) score has dropped to 8, indicating severe impairment of consciousness. The patient's pulse has increased to 130 beats per minute, and the blood pressure has fallen further to 85/50 mmHg. His oxygen saturation levels have also dropped to 88% on 4L of oxygen via nasal cannula. The patient's respiratory rate has escalated to 30 breaths per minute with decreased breath sounds on the right lung field, suggesting possible consolidation or pleural effusion.

These new clinical findings necessitate an immediate response to manage the evolving sepsis and multi-organ failure. The healthcare team decided to start the patient on broad-spectrum antibiotics, continue aggressive fluid resuscitation, and commence vasopressors to manage the septic shock. The worsening respiratory distress may require intubation and mechanical ventilation to ensure adequate oxygenation. The team also plans to involve a nephrologist for the management of acute kidney injury, which might require renal replacement therapy. The team must also consider discussing with the family about the prognosis and the possibility of transferring the patient to the intensive care unit for more specialized care.

Section 5

The patient's status continued to deteriorate, despite aggressive interventions. His oxygen saturation levels further dropped to 85% on 5L of oxygen via nasal cannula. His blood pressure remained hypotensive at 80/45 mmHg, despite the initiation of vasopressors. The increased work of breathing was evident by his respiratory rate of 35 breaths per minute. A follow-up chest x-ray revealed an increasing opacity in the right lung field, suggestive of pneumonia, correlating with the diminished breath sounds noted during the physical assessment. The laboratory results showed a further increase in creatinine levels to 3.2 mg/dL, indicating worsening renal function.

Considering the patient's deteriorating condition, the healthcare team decided to proceed with intubation and mechanical ventilation. The nephrologist was consulted and recommended initiating renal replacement therapy due to the patient's persistent acute kidney injury and to manage the fluid overload. The team also decided to escalate the antibiotic therapy based on the new chest x-ray findings, suggesting pneumonia. Meanwhile, the patient's family was informed about the worsening condition and the need for more aggressive measures to manage the multi-organ failure. The possibility of transferring the patient to the intensive care unit was discussed with them for a higher level of care and continuous monitoring.