Haemodynamic correction in multiorgan donation

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.

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.

Improved outcome with organs from carbon monoxide poisoned donors for intrathoracic transplantation

BACKGROUND

The success of intrathoracic organ transplantation has lead to a growing imbalance between the demand and supply of donor organs. Accordingly, there has been an expansion in the use of organs from nonconventional donors such as those who died from carbon monoxide poisoning. We describe our experience with 7 patients who were transplanted using organs after fatal carbon monoxide poisoning.

METHODS

A retrospective study of the 1,312 intrathoracic organ transplants between January 1979 and February 2000 was completed. Seven of these transplants (0.5%) were fulfilled with organs retrieved from donors after fatal carbon monoxide poisoning. There were six heart transplants and one single lung transplant. The history of carbon monoxide inhalation was obtained in all of these donors.

RESULTS

Five of 6 patients with heart transplant are alive and well with survival ranging from 68 to 1,879 days (mean, 969 +/- 823 days). One patient (a 29-year-old male) died 12 hours posttransplant caused by donor organ failure. The patient who had a right single lung transplant did well initially after the transplant, but died after 8 months caused by Pneumocystis carinii pneumonia. All those recipients who were transplanted from carbon monoxide poisoned donors and ventilated for more than 36 hours, survived for more than 30 days. Moreover, these donors were assessed and optimized by the Papworth donor management protocol.

CONCLUSIONS

Carbon monoxide poisoned organs can be considered for intrathoracic transplantation. In view of the significant risk of donor organ failure, a cautious approach is still warranted. Ideally, the donor should be hemodynamically stable for at least 36 hours from the time of poisoning and on minimal support. A formal approach of invasive monitoring and active management further improves the chances of successful outcome.

Brain death

The development and evolution of the concept of brain death has been necessary due to our technologic advances in medical care and organ transplantation. The current operational definition of brain death is based on coma, absent brain stem reflexes, and apnea, with use of confirmatory testing only as necessary. This definition has demonstrated functional utility and may be further refined over time. Medical providers and the public continue to become increasingly comfortable with the concept of brain death.

Triiodothyronine: spectrum of use in heart transplantation

Triiodothyronine (T3) deficiency, present in 85% of donors, in recipients with end-stage cardiomyopathy, and in patients after cardiopulmonary bypass (CPB), may contribute to donor heart dysfunction after heart transplantation (HT). Three separate studies were performed to investigate the various potential applications of T3 in HT. In the first study, donor hearts with statistically higher filling pressures, lower EF on echocardiograms, and higher inotrope requirements were resuscitated with T3 (0.6 microgram/kg bolus) and compared to normal donors not receiving T3. All patients survived the immediate postoperative period, and at 1 week and 6 months there were no significant differences in SBP, DBP, HR, cardiac index, CVP, PCWP, or LVEF on echocardiography. The next study involved giving T3 (0.6 microgram/kg bolus) versus placebo to normal donors in a blinded randomized fashion. Although there was a trend toward less inotrope use in the T3 group, there were no other differences. In the third study, placebo (group A) or T3 (group B; 0.2 microgram/kg bolus, 0.4 microgram/kg infusion over 6 hours) was given immediately before donor heart reperfusion. The recipient groups were similar with regard to age, donor/recipient weight ratio, ischemic time, thyroid hormone levels, and pretransplant hemodynamics. Lactate from coronary sinus effluent after 10 minutes of reperfusion was higher in group A, and more group A patients required higher than baseline inotropic support. In conclusion, T3 can be used effectively to resuscitate selective donor hearts with poor function and in recipients to improve myocardial aerobic metabolism; and T3 decreases both the amount and duration of inotropic support.

An approach to the retrieval of thoracic organs for transplantation

A critical, worldwide shortage of thoracic organs exists. The donor management program at Papworth Hospital, National Health Service Trust, Cambridge, United Kingdom, allows satisfactory transplantation of thoracic organs that initially appear unsuitable. The perioperative organ retrieval team members assess the cardiovascular status of all potential donors and manage suboptimal hemodynamics with hormonal replacement therapy consisting of triiodothyronine, antidiuretic hormone, epinephrine, and insulin. These donors' cardiovascular and pulmonary functions must be within acceptable limits at the time of organ excision. Our standardized approach facilitates objective decision making regarding the appropriate use of donor organs and has increased the number of available donor organs at Papworth Hospital by 30%. Morbidity and mortality rates in thoracic organ recipients have not increased since the authors developed the standardized approach, and more patients have benefited from thoracic organ transplantation.