Intensive Care Society of Ireland - Guidelines for management of the potential organ donor (2018-2nd edition)

Epidemiological Characteristics and Management of Multi-organ Donors in an Intensive Care Unit: An Eight-Year Retrospective Study

INTRODUCTION

Patients with brain death are the primary source of organs for transplantation worldwide. Recognizing patients with this diagnosis, providing proper care, and effectively managing them in an intensive care unit (ICU) has been shown to increase donation rates in leading countries. The increasing demand for organs compared to the available number for transplantation heightens the responsibility of caring for potential donors.

METHODS

An observational, cross-sectional, descriptive, and retrospective study was undertaken through the analysis of cases involving multiorgan donors diagnosed with brain death. This data was obtained from the coordination of donation and procurement at the Regional General Hospital 1 of the Mexican Institute of Social Security in Querétaro. The study encompassed the duration from January 1, 2016 to December 31, 2023.

STATISTICAL ANALYSIS

A database was created in the Excel program and subsequently, the analysis of the variables identified was carried out in the IBM SPSS Statics 25 software (IBM Corp., Armonk, NY). Qualitative variables were analyzed using contingency tables, frequency tables, and statistical correlation tables. For quantitative variables, the analysis included averages, percentages, means, medians, modes, variances, and standard deviations.

RESULTS

A total of 83 patients diagnosed with brain death were identified, of whom 56 became multiorgan donors. Thirty patients were excluded from donation, with the majority (19) due to family refusal. The primary age group was 10-20 years, accounting for 23.21% of cases. The mean age was 34.86 years. 71.43% of donors were male and 28.57% were female. The most frequent admission diagnosis was severe traumatic brain injury (46.43%). 56.6% of patients were admitted to the hospital with a Glasgow Coma Scale (GCS) score of 3 points. Brain death diagnosis was confirmed via angiography in 80.4% of cases. The average length of stay was 3.95 days. The average weight was 71.19 kg. The average height was 166 cm, and the mean BMI was 25.30. Forty patients had blood type O positive, accounting for 71.4%. A total of 255 organs and tissues were procured from 2016 to 2023: 103 kidneys, 97 corneas, 41 livers, six hearts, four skin and bone tissue derivatives, three pairs of lungs, and one heart valve. Hormone replacement therapy was not used in 55.4% of cases. Combined thyroid hormone and steroid regimen was used in nine patients (16.1%), and desmopressin was used in 12 patients (21.4%). During ICU stay, 69.6% of patients required norepinephrine to achieve perfusion goals.

CONCLUSIONS

The epidemiological profile characterizing the multiorgan donor at Regional Hospital 1 in Querétaro was typically male, with a mean age of 34.86 years, no comorbidities, presenting with severe traumatic brain injury upon arrival at the emergency department with a GCS score of 3 points. Norepinephrine was the most commonly used vasopressor, and the majority of patients did not meet hemodynamic criteria for initiating hormone replacement therapy.

Better liver transplant outcomes by donor interventions?

PURPOSE OF REVIEW

Donor risk factors and events surrounding donation impact the quantity and quality of grafts generated to meet liver transplant waitlist demands. Donor interventions represent an opportunity to mitigate injury and risk factors within donors themselves. The purpose of this review is to describe issues to address among donation after brain death, donation after circulatory determination of death, and living donors directly, for the sake of optimizing relevant outcomes among donors and recipients.

RECENT FINDINGS

Studies on donor management practices and high-level evidence supporting specific interventions are scarce. Nonetheless, for donation after brain death (DBD), critical care principles are employed to correct cardiocirculatory compromise, impaired tissue oxygenation and perfusion, and neurohormonal deficits. As well, certain treatments as well as marginally prolonging duration of brain death among otherwise stable donors may help improve posttransplant outcomes. In donation after circulatory determination of death (DCD), interventions are performed to limit warm ischemia and reverse its adverse effects. Finally, dietary and exercise programs have improved donation outcomes for both standard as well as overweight living donor (LD) candidates, while minimally invasive surgical techniques may offer improved outcomes among LD themselves.

SUMMARY

Donor interventions represent means to improve liver transplant yield and outcomes of liver donors and grafts.

Worldwide management of donors after neurological death: a systematic review and narrative synthesis of guidelines

OBJECTIVE

The objectives of this study were to systematically identify and describe guidelines for the care of neurologically deceased donors and to evaluate their methodological quality, with the aim of informing and supporting the new Canadian guidelines for the management of organ donors.

METHODOLOGY

Following a systematic search, we included any document endorsed by an organ donation organization, a professional society, or a government, that aims to direct the medical management of adult, neurologically deceased, multi-organ donors. We extracted recommendations pertaining to six domains: the autonomic storm, hemodynamic instability, hormone supplementation, ventilation, blood product transfusions, and general intensive care unit (ICU) care. Methodological quality of the guidelines was assessed by the validated AGREE-II tool.

MAIN FINDINGS

This review includes 27 clinical practice guidelines representing 26 countries published between 1993 and 2019. Using the AGREE-II validated tool for the evaluation of guidelines' quality, documents generally scored well on their scope and clarity of presentation. Nevertheless, quality was limited in terms of the scientific rigor of guideline development. Recommendations varied substantially across the domains of managing the autonomic storm, subsequent management of hemodynamic instability, hormone therapy, mechanical ventilation, blood product transfusion, and general ICU care. We found consistent recommendations for low tidal volume ventilation subsequent to the publication of a landmark clinical trial.

CONCLUSION

Highly inconsistent recommendations for deceased donor care summarized in this review likely reflect the relatively slow emergence of high-quality clinical research in this field, as well as a late uptake of recent validated guideline methodology. Even in this context of few randomized-controlled trials, our group supported the need for new Canadian guidelines for the management of organ donors that follow rigorous recognized methodology and grading of the evidence.

TRIAL REGISTRATION

PROSPERO (CRD42018084012); registered 25 February 2016.