Improving the approach to organ donation: a review

Prothrombin Complex Concentrate Use in Coagulopathy of Lethal Brain Injuries Increases Organ Donation

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration ( P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10) patients. Of these seven patients, consent for donation was obtained in six patients and resulted in 19 solid organs being procured. The cost of PCC per patient was $1022 ± 544. PCC effectively reveres coagulopathy associated with lethal traumatic brain injury and enabled patients to proceed to organ donation. Although various methodologies exist for the treatment of coagulopathy to facilitate organ donation, PCC provides a rapid and cost-effective therapy for reversal of coagulopathy in patients with lethal traumatic brain injuries.

Patient-centered practices in organ donation

The opportunity for a critically ill patient to be an organ donor depends on a complex interplay of factors (the Donation Process), one of which is the treating medical team's perspective of the importance and priority of donation during end-of-life care. Medical providers frequently are hesitant to administer treatments to preserve organ function in patients whose death is imminent for fear of invoking a conflict of interest. The basis of the perceived conflict is that organ donation is a process done for the sole benefit of organ transplant recipients and not for the donor, and therefore care directed toward donation prior to death is not for the donor patient's benefit. In this report, it is argued that the Donation Process is indeed a patient-centered process for the potential organ donor and that organ donation serves the donor's best interests. In addition, key elements of the Donation Process are described.

A Single-Center Experience with an Intensivist-Led Brain-Dead Donor Management Program

Background

The aim of this study is to report our experience of brain-dead donor management by a dedicated intensivist who had wide experience in treatment of hemodynamically unstable patient and to suggest a role for intensivists in organ donation.

Material/Methods

The management of brain-dead donors was performed by experienced intensivists. The hospital medical records and data from the Korean Network of Organ Sharing from August 2013 to December 2016 were reviewed retrospectively.

Results

Fifty-four brain death patients (3.2% of KONOS nationwide data) donated organs in our institution during 41 months. Dedicated intensivists managed deceased patients for the whole duration (2.81±1.21 days) of management, not only with conservative therapies like fluid resuscitation, vasopressor, or hormonal replacement, but also with pulmonary artery catheter insertion for cardiac output monitoring (n=47, 87.0%) and continuous renal replacement therapy (n=22, 40.7%). The number of donors increased each year. The mean number of retrieved organs in each deceased donor was 3.98±1.55, more than the national average (3.26) and comparable to the higher level among the recent worldwide data. The number of donations by organ was: 23 hearts (4.9% of nationwide data), 17 lungs (7.5% of nationwide data), 102 kidneys (3.3% of nationwide data), 47 livers (3.1% of nationwide data), 6 pancreases (2.9% of nationwide data), 1 pancreatic duct (11.1% of nationwide data), and 1 small intestine (12.5% of nationwide data).

Conclusions

Management by dedicated intensivists will improve not only the number of actual organ donors, but also the number of harvested organs.

Medical Training and the Brain Death Exam: A Single Institution's Experience

BACKGROUND

Clinicians may have limited opportunities to perform neurological determination of death (NDD, or brain death) certification during their training. This study aimed to evaluate the level of resident exposure to the brain death exam at a large-volume donor hospital.

METHODS

In March 2014, we adapted a dual-physician model for NDD certification at our institution to improve resident education regarding NDD. To evaluate the incidence of resident exposure, we collected examiner information from all brain death exams conducted between January 2014 and July 2015. Organ procurement, family authorization, and brain death intervals were also collected to evaluate the impact of NDD timeliness on organ donation.

RESULTS

A total of 68 patients who met NDD criteria were included in this study. For these patients, 127 brain death exams were performed, 108 (85%) by a critical care attending physician or fellow, 9 (7%) by a neurology resident, and 7 (6%) by a neurosurgery resident. Exposure rates for neurology and neurosurgery residents were approximately 0.22 and 0.20 exams/resident/year, respectively. The median brain death interval between exams was 1.0 hours (interquartile range, 0.0-2.5) hours. Resident involvement, time between exams, and dual exams were all found to be nonsignificant correlates of organ authorization and family refusal.

CONCLUSIONS

Neurology and neurosurgery residents may be limited in their exposure to the brain death exam during training. High-volume donor hospitals may be able to complete 2 exams for NDD certification in a timely manner without detrimentally influencing organ authorization or family refusal rates.

Increasing the Quantity of Lungs for Transplantation Using High-Frequency Chest Wall Oscillation: A Proposal

The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.

Brain death and care of the organ donor

Brain death has specific implications for organ donation with the potential for saving several lives. Awareness on maintenance of the brain dead has increased over the last decade with the progress in the field of transplant. The diagnosis of brain death is clinical and can be confirmed by apnea testing. Ancillary tests can be considered when the apnea test cannot be completed or is inconclusive. Reflexes of spinal origin may be present and should not be confused against the diagnosis of brain death. Adequate care for the donor targeting hemodynamic indices and lung protective ventilator strategies can improve graft quality for donation. Hormone supplementation using thyroxine, antidiuretic hormone, corticosteroid and insulin has shown to improve outcomes following transplant. India still ranks low compared to the rest of the world in deceased donation. The formation of organ sharing networks supported by state governments has shown a substantial increase in the numbers of deceased donors primarily by creating awareness and ensuring protocols in caring for the donor. This review describes the steps in the establishment of brain death and the management of the organ donor. Material for the review was collected through a Medline search, and the search terms included were brain death and organ donation.

Families who previously refused organ donation would agree to donate in a new situation: a cross-sectional study

BACKGROUND

The limited supply of organs restricts the number of transplantations. Studying the families who refuse donation may help to increase the number of transplantations.

METHODS

This descriptive cross-sectional study used a questionnaire to obtain information from 61 family members who had refused to donate organs from January 1997 to December 2004. The exclusion criterion was donor death less than 1 year from the study. The mean age of subjects was 41 ± 12.7 years (range, 18 to 79 years) with 66% women.

RESULTS

More than half (36 of 69; 52%) of the families who refused donation would agree to donate in a new situation. The primary reasons for refusing donation were: disagreement among family members (25 of 128; 19%), lack of knowledge regarding the deceased's wishes (22 of 128; 17%), and previous request from the deceased not to be a donor (17 of 128; 13%). The most frequent suggestions to increase organ donation were to provide families with more information (43 of 149; 29%), initiate contact among the families (36 of 149; 24%), and involve a trusted physician (30 of 149; 20%).

CONCLUSION

Most family members who refused organ donation changed their minds and would agree to donate in a few situation. Most of the reasons for refusing to donate reflected a lack of information and discussion on the topic.

Critical care of the potential organ donor

Organ transplantation represents one of the great success stories of 20th century medicine. However, its continued success is greatly limited by the shortage of donor organs. This has led to an increased focus within the critical care community on optimal identification and management of the potential organ donor. The multi-organ donor can represent one of the most complex intensive care patients, with numerous competing physiological priorities. However, appropriate management of the donor not only increases the number of organs that can be successfully donated but has long-term implications for the outcomes of multiple recipients. This review outlines current understandings of the physiological derangements seen in the organ donor and evaluates the available evidence for management strategies designed to optimize donation potential and organ recovery. Finally, emerging management strategies for the potential donor are discussed within the current ethical and legal frameworks permitting donation after both brain and circulatory death.

Impact of compliance with the American College of Surgeons trauma center verification requirements on organ donation-related outcomes

BACKGROUND

In order to maximize organ donation opportunities, the American College of Surgeons (ACS) requires verified trauma centers to have a relationship with an organ procurement organization (OPO), a policy for notification of the OPO, a process to review organ donation rates, and a protocol for declaring neurologic death. We hypothesized that meeting the ACS requirements will be associated with improved donation outcomes.

STUDY DESIGN

Twenty-four ACS-verified Level I and Level II trauma centers were surveyed for the following registry data points from 2004 to 2008: admissions, ICU admissions, patients with a head Abbreviated Injury Score ≥ 5, deaths, and organ donors. Centers were also queried for the presence of the ACS requirements as well as other process measures and characteristics. The main outcomes measure was the number of organ donors per center normalized for patient volume and injury severity. The relationship between center characteristics and outcomes was determined.

RESULTS

Twenty-one centers (88%) completed the survey and referred 2,626 trauma patients to the OPO during the study period, 1,008 were eligible to donate, and 699 became organ donors. Compliance with the 4 ACS requirements was not associated with increased organ donation outcomes. However, having catastrophic brain injury guidelines (CBIGs) and the presence of a trauma surgeon on a donor council were associated with significantly more organ donors per 1,000 trauma admissions (6.3 vs 4.2 and 6.0 vs 4.2, respectively, p < 0.05).

CONCLUSIONS

Although the ACS trauma center organ donation-related requirements were not associated with improved organ donor outcomes, involvement of trauma surgeons on donor councils and CBIGs were and should be encouraged. Additionally, incorporation of quantitative organ donation measures into the verification process should be considered.

The Effect of Trauma Center Designation on Organ Donor Outcomes in Southern California

We sought to investigate the effect of trauma center designation on organ donor outcomes during a 5-year period. A retrospective study of the southern California regional Organ Procurement Organization database comparing trauma centers (n = 25) versus nontrauma centers (n = 171) and Level I (n = 7) versus Level II (n = 18) trauma centers between 2004 and 2008 was performed. A total of 16,830 referrals were evaluated and 44 per cent were from trauma centers. When compared with nontrauma centers (n = 171), trauma centers (n = 25) had a higher percentage of medically suitable eligible deaths (29 vs 16%, P < 0.001), total eligible deaths (22 vs 12%, P < 0.001), and eligible donors (14 vs 7%, P < 0.001). Trauma Centers had a significantly higher number of organs procured per donor (4.0 ± 1.6 vs 3.5 ± 1.6, P < 0.001), organs transplanted per donor (OTPD) (3.6 ± 1.8 vs 2.8 ± 1.8, P < 0.001), and higher organ yield (per cent 4 or greater OTPD [48 vs 31%, P < 0.001]). No significant differences were found between Level I and Level II trauma centers. Trauma centers demonstrate significantly better organ donor outcomes compared with nontrauma centers. Factors responsible for improved outcomes at trauma centers should be evaluated, reproduced, and disseminated to nontrauma centers to alleviate the growing organ shortage crisis.

Management of the heartbeating brain-dead organ donor

The main factor limiting organ donation is the availability of suitable donors and organs. Currently, most transplants follow multiple organ retrieval from heartbeating brain-dead organ donors. However, brain death is often associated with marked physiological instability, which, if not managed, can lead to deterioration in organ function before retrieval. In some cases, this prevents successful donation. There is increasing evidence that moderation of these pathophysiological changes by active management in Intensive Care maintains organ function, thereby increasing the number and functional quality of organs available for transplantation. This strategy of active donor management requires an alteration of philosophy and therapy on the part of the intensive care unit clinicians and has significant resource implications if it is to be delivered reliably and safely. Despite increasing consensus over donor management protocols, many of their components have not yet been subjected to controlled evaluation. Hence the optimal combinations of treatment goals, monitoring, and specific therapies have not yet been fully defined. More research into the component techniques is needed.

Development of donor yield models

Increasing donor yield, or the number of organs transplanted per donor, has been a focus of the transplant community in recent years. However, an exclusive focus on observed yield, unadjusted for the donor characteristics, ignores important differences between donors and donor case mixes in donation service areas (DSAs). We analyzed deceased donor registry data from the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients from January 2006 to December 2009 (N = 32 116 donors). Overall yields and kidney yields were modeled using ordinal logistic regression, and logistic regression was used to model heart, lung, pancreas and liver yields. Donor characteristics, including demographics, historical information and positive serology were related to overall and organ-specific yield. This study shows the potential value of the yield models as evaluation metrics and as tools that can inform DSA-wide practices in donor management and can improve organ utilization.

The pancreas allograft donor: current status, controversies, and challenges for the future

The pancreas allograft is a scarce resource that is currently underutilized. The selection of appropriate deceased donors for pancreas procurement is of paramount importance for minimizing technical failure and optimizing long-term outcomes in pancreas transplantation. Despite the increasing demand for pancreas transplantation, increases in overall organ donation rates and the evolution of criteria that constitute an "acceptable" pancreas donor, the number of deceased donor pancreas transplants being performed in the United States has actually declined in recent years. Although there are many factors that must be considered during evaluation of the potential pancreas allograft donor to minimize morbidity and graft loss, it is evident that there are transplantable organs that are not used. In this review, deceased donor pancreas identification, management, selection, allocation, assessment, preservation, and the problem of pancreas underutilization will be discussed.

Movements in brain death: a systematic review

Brain death is the irreversible lost of function of the brain including the brainstem. The presence of spontaneous or reflex movements constitutes a challenge for the neurological determination of death. We reviewed historical aspects and practical implications of the presence of spontaneous or reflex movements in individuals with brain death and postulated pathophysiological mechanisms. We identified and reviewed 131 articles on movements in individuals with confirmed diagnosis of brain death using Medline from January 1960 until December 2007, using 'brain death' or 'cerebral death' and 'movements' or 'spinal reflex' as search terms. There was no previous systematic review of the literature on this topic. Plantar withdrawal responses, muscle stretch reflexes, abdominal contractions, Lazarus's sign, respiratory-like movements, among others were described. For the most part, these movements have been considered to be spinal reflexes. These movements are present in as many as 40-50% of heart-beating cadavers. Although limited information is available on the determinants and pathophysiological mechanisms of spinal reflexes, clinicians and health care providers should be aware of them and that they do not preclude the diagnosis of brain death or organ transplantation.

Does the use of pulmonary artery catheters increase the number of organs available for transplantation?

Aggressive donor management, including the placement of a pulmonary artery catheter (PAC) to monitor hemodynamic status and tissue perfusion, has been associated with a significant increase in the number of organs recovered for transplantation. Nonetheless, there has been growing scrutiny over the use of PACs because of their known complications and lack of therapeutic effect. The purpose of this study is to evaluate the use of PACs in the management of organ donors. The records of all patients who successfully donated organs between January 1, 2002 and December 31, 2005 were reviewed. A total of 96 patients underwent successful organ donation during the four-yr study period. Of these, 49 (51.0%) were managed with a PAC. Compared with donors managed without a PAC, there were significantly more hearts recovered from donors managed with a PAC (71.4% vs. 44.7%; p = 0.0079) with no difference in the daily administration of fluids and vasopressors between the two groups. The management of organ donors with a PAC can help maximize cardiac procurement.

Aggressive organ donor management protocol

As of August 2007, 96 900 people are awaiting organ transplantation in the United States, while only 28 930 transplants were performed in 2006. With such a large gap between organ need and organ availability, it is inevitable that many will die while awaiting transplantation. This organ shortage has become a national public health crisis, and as a response, the United States Department of Health and Human Services launched the Organ Donation Breakthrough Collaborative, an ambitious campaign to dramatically increase the number of transplantable organs. One of the suggested strategies involves maximizing the number of organs obtained from the available cadaveric "brain dead'' donor pool by using donor management protocols that optimize and treat the profound physiological disturbances that are associated with brain death. The use of these standardized and aggressive donor management protocols has been shown to increase the number of transplanted organs and prevent the number of donors lost due to medical failures. A protocol-driven approach by a dedicated organ donor management team should be considered a key component of any program designed to bridge the gap between organ supply and demand.

[Organ donation]

For patients with end-stage organ disease transplantation of human organs is a well-established therapy, and in most cases it is the only life-saving one. But the lack of available organs is a big problem. The legal basis in Germany is the transplantation law (TPG). According to this law, every ventilated patient with diagnosed brain death is a potential organ donor. However, brain death may lead to strong reactions in the patient's cardiovascular system as well as disturbances in thermoregulation, water and electrolyte balance, and the endocrine and haemostatic systems. Thus, protecting the organs of the organ donor and, furthermore, caring for his or her relatives are great challenges for every physician and nurse in the intensive care unit.

Improving Consent Rates for Organ Donation: The Effect of an Inhouse Coordinator Program

BACKGROUND

The inability to obtain consent remains one of the major obstacles to organ donation. The presence of in-house coordinators (IHCs) from organ procurement organizations (OPOs) might substantially improve donation rates.

OBJECTIVE

To review the preliminary results of the effect of the presence of an IHC on organ donation rates at our center.

METHODS

This is a retrospective analysis of patients referred to the regional OPO for possible organ donation. An IHC program was started at our hospital in late 2001. Data regarding organ donation demographics and family consent rates were compared before (Pre-IHC, 1998-2001) and after (Post-IHC, 2002-2005) the institution of an IHC program. The conversion rate was calculated as the number of actual donors divided by the number of potential donors and is represented as a percentage. The function of the IHC was to assist in donor surveillance, ensure timely referral, provide hospital staff education, assist with family consent and donor management, and provide family support.

RESULTS

There were a total of 495 potential donors and 195 actual donors during the 8-year time period. Post-IHC was associated with a significantly higher consent rate (52% vs. 35%, p < 0.01), a significantly higher conversion rate (50% vs. 34%, p < 0.01), and a 17% increase in organs donated compared with Pre-IHC.

CONCLUSION

The presence of an IHC program significantly improves consent and conversion rates for organ donation. An IHC program should be considered as a viable option to bridge the gap between organ supply and organ demand.

The Effect of a Protocol of Aggressive Donor Management: Implications for the National Organ Donor Shortage

BACKGROUND

The disparity between the number of people awaiting organ transplantation and the number of organs available has become a public health crisis. As many as 25% of potential donors are lost as a result of cardiovascular collapse (CVC) before organ harvest. A policy of aggressive donor management (ADM) may decrease the number of cadaveric donors lost as a result of CVC.

METHODS

Retrospective analysis of potential brain-dead donors evaluated from January 1995 to December 2003 at nine American College of Surgeons-verified Level I trauma centers covered by a regional organ procurement agency. One center (Los Angeles County + University of Southern California Medical Center [LAC]) had an ADM protocol in place instituted January 1999; the remaining eight centers with no ADM protocol were grouped as Center A. The incidence of CVC and organ donation demographics were compared between centers and within LAC before (LAC-Pre) and after (LAC-Post) adoption of ADM. ADM consists of early identification of potential organ donors, a dedicated team that provides medical management, and aggressive fluid resuscitation as well as hormone replacement therapy with solumedrol and thyroxin.

RESULTS

The incidence of CVC was significantly higher in LAC-Pre (odds ratio [OR] 15.0, p < 0.001) and Center A (OR 5.8, p < 0.001) compared with LAC-Post. The number of organs harvested per potential donor for LAC-Post (2.4) was significantly higher than LAC-Pre (2.0, p = 0.02) and Center A (2.1, p < 0.01).

CONCLUSION

An aggressive donor management protocol decreases the number of donors lost as a result of cardiovascular collapse and increases the number of harvested organs per potential donor.

Complications of brain death: frequency and impact on organ retrieval

Brain death is associated with complex hemodynamic, endocrine, and metabolic dysfunction that can lead to major complications with the potential donor. Untreated, this can progress to cardiovascular collapse with loss of valuable organs for transplantation. We hypothesized that brain death-related complications would have no effect on the number of organs donated if an aggressive donor management protocol was in place. We identified all successful organ donations between January 2000 and December 2003 and evaluated them for brain death-associated complications (defined as vasopressor requirement, coagulopathy, diabetes insipidus, cardiac ischemia, lactic acidosis, renal failure, and acute respiratory distress syndrome) and donated organs per donor. Sixty-nine organ donors were identified. Complications identified were as follows: intravenous vasopressor requirement in 97.1 per cent, coagulopathy in 55.1 per cent, thrombocytopenia in 53.6 per cent, diabetes insipidus in 46.4 per cent, cardiac ischemia in 30.4 per cent, lactic acidosis in 24.6 per cent, renal failure in 20.3 per cent, and acute respiratory distress syndrome in 13 per cent. There was no significant effect of complications on the average number of organs harvested, with the exception of an increase in organs harvested in the presence of diabetes insipidus. With the implementation of an aggressive organ donor management protocol, these complications can be effectively managed with no impact on the number of organs harvested for transplant.

Hemodynamic Monitoring of Organ Donors: A Novel Use of the Esophageal Echo-Doppler Probe

The esophageal Doppler monitoring (EDM) technology is well described in the literature. As it evolved over the last several years, the use of EDM has found expanded indications in various clinical settings. One of the areas where EDM has not been studied extensively is its use during optimization of organ donors before organ procurement. Close hemodynamic monitoring has become essential in the era of increasing use of extended organ donors. We present six cases of successful EDM use during preorgan procurement resuscitation of organ donors. Despite labile hemodynamics in the majority of these cases, EDM-guided optimization of resuscitative end-points allowed successful organ procurements and transplants, including 12 kidneys, 6 livers, 3 hearts, 2 pancreases, and 2 lungs. The EDM technology is noninvasive, technically easy, and less expensive than the traditional pulmonary artery catheter. Other potential benefits of the EDM include its portability and possibility of deployment in any setting by trained organ procurement personnel or critical care nursing staff. In conclusion, successful organ procurement can be facilitated by the use of EDM technology in hemodynamically labile organ donor patients.

Brain death: recent ethical and religious considerations in Iran

The Islamic Republic of Iran has a long history of medicine. The principles derived from core Islamic teachings provide a comprehensive moral, ethical, and legal framework for the practice of medicine. The issue of brain death has significant impact on the procurement of organs from cadavers. It is a major subject of debate and interest to bioscientists, legal experts, religious scholars, and the general public. Laws related to the ethical and legal aspects of cadaver organ donation from the brain dead have not been defined in many Muslim countries. This report presents recent advances in Iranian law with regard to the ethics of organ transplantation and the definition of brain death.

Aggressive organ donor management significantly increases the number of organs available for transplantation

BACKGROUND

The shortage of transplantable organs has become a national crisis. Despite various attempts to expand the donor pool, the difference between organ supply and organ demand continues to widen. With no foreseeable increase in the number of donors, it is necessary to maximize the utilization of organs from the existing donor pool.

METHODS

Records of all patients referred to the regional organ procurement organization for possible organ donation over an 8-year period (1995-2002) were reviewed. A policy of aggressive donor management (ADM) by dedicated physicians was instituted in January 1999 involving intensive care unit admission, pulmonary artery catheterization, aggressive fluid resuscitation, early use of vasopressors, prevention and treatment of complications associated with brain death, and liberal use of thyroid hormone in hemodynamically unstable donors. Data regarding referrals for organ donation, actual organ donors, organs recovered, and donors lost due to cardiovascular collapse before organ donation were compared before (January 1995- December 1998) and after (January 1999- December 2002) ADM.

RESULTS

There were 878 patients referred for organ donation during the 8-year period. Of those, 469 (53.4%) were confirmed as potential donors, but only 161 (34.3%) became actual donors. When compared with the period before ADM, the period after ADM showed a 57% increase in total referrals (p < 0.001), 19% increase in potential donors (p = 0.01), 82% increase in actual donors (p < 0.001), 87% decrease in the number of donors lost due to hemodynamic instability (p < 0.001), and a 71% increase in the number of organs recovered (p < 0.001).

CONCLUSIONS

A policy of ADM increases the referral pool for organ donation and reduces the number of organ donors lost due to cardiovascular collapse. The net result is a significant increase in the number of organs available for transplantation.

The effect of a thyroid hormone infusion on vasopressor support in critically ill children with cessation of neurologic function

OBJECTIVE

To determine the impact of a thyroid hormone infusion (T4) on the vasopressor requirements in children with cessation of neurologic function (i.e., brain death) during evaluation for organ recovery

DESIGN

Retrospective cohort study.

SETTING

The 1998-2002 database of a regional organ recovery program.

PATIENTS

Children </=18 yrs with cessation of neurologic function during evaluation for organ recovery (n = 171) were included. The treated group (n = 91) received a weight-based bolus and continuous infusion of T4 according to the organ procurement agency protocol. All other children (n = 80) were considered untreated.

INTERVENTIONS

T4 was administered at the clinician's discretion. All children (treated and untreated) had identical goals for fluids, blood pressure, and organ function criteria. Vasopressor score ([dopamine x 1] + [dobutamine x 1] + [epinephrine x 100] + [norepinephrine x 100] + [phenylephrine x 100]) at the time of the program's involvement (T0) and at organ recovery (TOR) were recorded. The Wilcoxon rank sum and Student's two-sample t-test were used to compare the average vasopressor score at T0 vs. TOR. The Wilcoxon signed rank test was used to analyze the difference in median vasopressor score at T0 vs. TOR. Multivariable linear regression was used to assess the impact of T4 on the ability to wean vasopressor support while accounting for the effects of several potential confounders.

MEASUREMENTS AND MAIN RESULTS

One hundred seventy-one subjects were included in the final analysis. T4 administration was associated with an unadjusted decrease in the vasopressor score of 32 (95% confidence interval, 12-53; p = .002). After adjusting for steroid administration, fluid balance, and baseline vasopressor score, T4 administration was associated with a decrease in vasopressor score of 24 (95% confidence interval, 6-43; p = .011).

CONCLUSIONS

T4 reduced vasopressor needs in children with cessation of neurologic function and hemodynamic instability. A prospective study of T4 in critically ill and hemodynamically unstable children appears warranted.

Cadaveric donors

The diagnosis of brain death describes the final catastrophic state of a person for whom, except for ventilators and pharmacology, death would surely have already intervened. Although we think of death as an ending, if the patient becomes an organ donor it is also a beginning. For, at the moment we lose one patient, we potentially gain others in the fortunate recipients of viable grafts.

Analysis of heart donation for cardiac transplantation at the National Taiwan University Hospital: Fifteen-year cases review

The demand for organ transplantation is disparate to the supply of organ donors. The organ shortage is a limitation for transplantation. This study analyzed the status of heart donors at the National Taiwan University Hospital (NTUH) from July 1987 through November 2001 using registry records. One hundred ninety-four total heart donors yielded about 25 donors per year in the late era (years of 1995-2001). The majority of heart donors were men (78.4%) of O blood type (46.9%) with a mean age of 29.8 (SD = 11.9) years. Though head injury was the main source of heart donors (78.4%), cerebrovascular accident patients have increased (15%) since 1995. However, the number of donors from head injury decreased in the year of 1997, when Taiwan passed a law to force motorcycle drivers to wear safety helmets. The average interval from brain death to donation was 75.4 (SD = 71.2) hours. One hundred fifty-six (80.4%) of the 194 donor hearts came from outside hospitals. However, the majority of heart transplantations (166 cases, 85.6%) were done at the NTUH. Implementing a program for a smooth donation and organ procurement processes should provide better donor management in cardiac transplantation.

Different impact of normo- and hypotensive brain death on renal macro- and microperfusion--an experimental evaluation in a porcine model

BACKGROUND

Despite the growing use of kidneys from living donors, organs harvested from brain dead donors are the dominant graft types used in renal transplantation. It is accepted that brain death (BD) has a damaging effect on the renal allograft, with a lower graft survival. Amongst various causes, changes in renal microperfusion could be responsible. Renocortical microperfusion was assessed during BD using thermal diffusion in a porcine model.

METHODS

Two types of BD were induced in two groups of pigs [hypotension (Hypo-BD): n = 11; normotension (Normo-BD): n = 10] and compared to controls (n = 5) over a period of 210 min. We analysed systemic parameters [heart rate (HR), mean arterial blood pressure (MAP)], aortic blood flow (ABF) and renal perfusion [renal artery blood flow (RABF) and renocortical blood flow (RCBF)].

RESULTS

Following the two distinct forms of BD induction, a stable normo- or hypotension was observed. Haemodynamic parameters were only slightly changed (control group: MAP, 62+/-2 mmHg; HR, 95+/-3/min; Normo-BD: MAP, 56+/-4 mmHg; HR, 104+/-8/min; Hypo-BD: MAP, 43+/-3 mmHg; HR, 112+/-7/min). Solely dependent on systemic haemodynamics, RABF and RCBF decreased in the Hypo-BD (RABF: 142+/-19 to 94+/-9 ml/100 g/min; RCBF: 80+/-4 to 52+/-2 ml/100 g/min), while in Normo-BD group RABF mildly changed (158+/-13 ml/100 g/min) and RCBF decreased slightly from 76+/-3 to 70+/-6 ml/100 g/min. As opposed to the Normo-BD group, animals with Hypo-BD showed a significant decrease in RABF (reduction of 34%) and RCBF (reduction of 35%) with a sharp drop of MAP (reduction of 25%), however ABF remained relatively constant.

CONCLUSIONS

In this model, a reduction of renocortical microperfusion in brain dead pigs was only found during haemodynamic instability (hypotension) and could not be attributed to BD as such. Our findings would support intensive cardiocirculatory stabilization for potential BD donors in order to minimize kidney preservation damage.

Cadaveric organ donor recruitment at Los Angeles County Hospital: improvement after formation of a structured clinical, educational and administrative service

BACKGROUND/AIMS

There remains a critical shortage of cadaveric organs. At a large inner city level one trauma centre, several strategies were devised and combined to (a). optimize the physiologic status of potential donors, (b). promote awareness of the donation process among health care professionals and (c). perform quality control on the organ donation system - all in an effort to improve organ donation rates. Resuscitative and maintenance protocols were devised and implemented through a multidisciplinary team approach for patients diagnosed with brain death. We report the effect this approach has had on organ donation in a single centre.

METHOD

A death record review (DRR) by the local organ procurement agency (OPO) was used to identify the number of patients diagnosed with brain death at Los Angeles County Hospital each year from 1995 through 2001. Data were collected to determine the number of these potential donors that eventually underwent organ donation. Data were collected for two time intervals: Phase I (1995-98) and Phase II (1999-2001). During Phase I, there was no focused institutional programme for the approach to potential donors. During Phase II, an institutional programme including the following characteristics was implemented: 1). donor resuscitation protocol, 2). assignment of a dedicated OPO coordinator liaison to interact with families, hospital personnel and the coroner's office, 3). assignment of the primary role of stabilization and care of potential donors and the integration of all medical services to the trauma service, and 4). biweekly conferences to review policies, protocols, and outcomes of donor management strategies.

RESULTS

From 1995 to 2001 there was a large increase in patient referrals for donor evaluation from 86 (Phase I) to 124 (Phase II). There was a smaller increase in the number of suitable donors: Phase I (mean: 51/year) and Phase II (mean: 63/year). There was, however, an increase in the mean number of actual organ donors from 14.2/year to 25.7/year from Phase I to Phase II and an increase in organs donated from 29 to 49. Organ donor declines decreased from 53% (Phase I) to 39% (Phase II).

CONCLUSIONS

Strategies to increase the number of cadaveric organs available for organ transplantation are crucial. A strategy combining prompt identification of potential organ donors, institution of resuscitative protocols, a multidisciplinary team approach, educational activities and utilization of personnel expert in organ procurement led to a marked increase in the number of organ donors and the number of organs donated at a single institution. Wider application of this approach should prove successful in increasing organ donation in a similar fashion in other institutions.

Increasing the quantity of lungs for transplantation using high-frequency chest wall oscillation: a proposal

The use of chest physiotherapy in donor patient management occupies an established place in most lung procurement protocols. Although its merits remain controversial and uncorroborated by direct data, some studies support the efficacy of chest physiotherapy in a variety of pulmonary patient populations. Comparative studies have shown that an airway clearance technology utilizing high-frequency chest wall oscillation clears pulmonary secretions as well as or better than chest physiotherapy, but has few of its contraindications and disadvantages. The implementation of high-frequency chest wall oscillation as part of the donor lung procurement protocol may increase rates of successful lung recovery by providing effective clearance of obstructing pulmonary secretions containing destructive by-products of inflammation and entrapped pathogens. High-frequency chest wall oscillation may also improve arterial blood gas values, a critical factor in increasing lung procurement rates. Although speculative, the benefits of high-frequency chest wall oscillation on donor lungs might improve perfusion and oxygenation of other organs for possible transplantation.

Organ donation rates in a neurosurgical intensive care unit

OBJECT

The number of patients waiting for organ transplantation continues to grow, while organs are donated by very few of the thousands of potential donors who die every year. The authors' neurosurgical intensive care unit (NICU) has worked closely with coordinators from the local organ procurement organization (OPO) for many years. In this study, the authors analyze donation rates in the NICU and discuss factors that may be important in maximizing these rates.

METHODS

All referrals from the NICU to the OPO from 1996 to 1999 were analyzed. Of the 180 referrals, 98 patients were found to be medically suitable as potential donors. Another 15 patients died of hemodynamic collapse shortly after admission to the NICU. If one assumes that all 15 patients would have been suitable donors, the unsuccessful resuscitation rate becomes 15 (13.3%) of 113. Of the 98 eligible donors, consent was obtained and organs or tissue were recovered in 72, yielding a successful organ procurement rate of 73.5%.

CONCLUSIONS

Close working relationships among physicians, nurses, and OPO coordinators can result in higher donation rates than have been reported previously. Aggressive resuscitation and stabilization of all patients, early identification of potential organ donors, prompt declaration of brain death, and attempts by the OPO coordinator to build rapport with families are all important factors that may increase donation rates. Because most organ donors have sustained catastrophic intracranial events, neurosurgeons are uniquely positioned to influence organ donation policies at their hospitals and thus to salvage some benefit from tragic cases of overwhelming brain injury.

Presentation and outcomes for organ donation in patients with cerebral gunshot wounds

This study was undertaken to examine the presentation and outcomes relative to solid organ donation in patients with fatal cerebral gunshot wounds at a level I trauma center over a 7-year period. A retrospective chart review of patients with such wounds over the years 1993-99 was completed. Eighty (80) patients were considered potential solid organ donors. Of these, 28 (35%) became organ donors, yielding 97 transplantable organs. Ninety-six percent presented with a GCS of less than 6. Mean SBP on presentation was 130, ranging from 48 to 225. Median time from presentation to death was 18 hours. Intravenous fluids given over the first 6 hours averaged 4.3 liters. Pressors were required in 68% of cases, blood products in 34%. Consent rate for donation was 32% when requested by a physician and 59% when requested by an organ procurement organization (OPO) co-ordinator. No request was made in 15 cases. Patients with fatal cerebral gunshot wounds, but with solid organ donor potential, have a characteristic presentation. Those with hemodynamic stability and those whose hypotension responds promptly to treatment can be expected to have a donor potential despite their devastating brain injury. Minimal time and resources are required to support such patients. Additional organs may have been obtained if the request for donation was consistently separated from the families' notification of brain death, and if the request was initiated by an OPO coordinator rather than a physician. Further, all patients admitted with cerebral gunshot wounds and poor neurologic function should have local OPO referral, potential survival notwithstanding.

Organ donation and family decision-making within the Spanish donation system

This study analyses the variables associated with the decisions made by families of potential organ donors to give or deny consent for the extraction of organs. Different indicators were recorded in 68 cases of family interview for petition of consent carried out in 13 Spanish hospitals. Those variables showing the strongest relation with family decision (donation/refusal of consent) are knowledge shown by the family about the deceased's wishes with regard to donation (p<0.001), family relationship climate (p<0.01), expression of family's satisfaction level with medical attention received (p<0.01) and number of relatives present at the consent request interview (p<0.01). Logistic regression on family decision with considered variables correctly predicted relatives' final choice in 98.4% of cases. In turn, multivariate exploratory analysis highlights a potential association between the expression of the deceased's wishes and several concurrent variables in the process (satisfaction with personal treatment and medical attention received, emotional reactions in the interviews of notification of death and consent request). It also shows that patterns of reaction and family participation in this process may vary according to the sex of the deceased relative. Results suggest that both educational efforts devoted to promoting a positive attitude toward donation in the general population and the training of health professionals involved in the generation of organs may be key factors in reducing organ shortage.

Care of the potential pediatric organ donor

Although all of this information may create the impression that caring for a potential organ donor is an exceedingly complex task, in the authors' experience, this often is not true, and much energy can--and should--be devoted to the care of the bereaved family. Of crucial importance are the early recognition of brain death and the consequent radical switch of the treatment goal from preservation of the patient's brain and life to preservation of organs for the lives of others. Care for the donor is the natural extension of care for a critically ill or injured patient. During the foregoing discussion, the authors had to stress the absence of sound evidence on many points. Because many reports originate from transplant centers dedicated to a specific organ, gaining a comprehensive view on management options in the ICU further is hampered. Thus, this situation leaves another field in which investigations originating from pediatric intensivists could provide evidence urgently needed to make optimal choices. The next decade should see the thyroid hormone controversy solved by at least one controlled prospective study and the differential applicability of inotropic, vasoactive, or fluid-centered strategies. It seems self-evident that only graft survival and related parameters can form adequate endpoints for future studies.

Attitudes and behavior of young European adults towards the donation of organs--a call for better information

Public perception of organ donation critically affects the availability of organ transplantation in the Western world. To assess the attitude of young adults towards the donation of organs and to investigate potential factors influencing their knowledge and actual behavior regarding organ transplantation, we evaluated a handout questionnaire survey of all Swiss-Italian recruits during six of the years 1989-98 (n = 7272). The attitude of recruits towards organ donation did not change significantly within the 10-year survey period: 61% of young men would personally donate their organs in the case of brain death, 13% would refuse, and 26% had not made up their mind. If they had to decide for close relatives, 50% would consent; 60% of recruits neither knew their next of kin's attitude nor had informed them about their own opinion; 80% felt they were insufficiently informed about organ transplantation. A significantly more positive attitude towards organ donation was found among men who felt they were sufficiently informed, who had close next of kin who were aware of their personal attitude (p < 0.0001), who had contacts with transplanted persons (p < 0.015), or who believed in an existence after death (p < 0.001; chi2-test). Our results suggest that there is potentially large support towards organ donation in this population. To minimize the high rate of indecisiveness, young adults need more appropriate information on the subject and they ask for it.