Patterns of organ donation among resuscitated patients at a regional cardiac arrest center

Temporal trends in organ donation among cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation

AIMS

This study explores the evolution of organ donation from patients treated with extracorporeal-cardiopulmonary-resuscitation (ECPR) for refractory out-of-hospital-cardiac-arrest (OHCA) and evaluates the public health benefits of a mature ECPR program.

METHODS

This retrospective, single-center study included OHCA patients (2016-2023) who had mostly initial shockable rhythms and were treated with ECPR. Organ donation rates from non-survivors through these years were analyzed. The public health benefit of ECPR was determined by the ratio of the sum of survivors with Cerebral Performance Category 1-2 and non-survivors who donated at least 1 solid organ, to the total ECPR patients. Temporal trends were analyzed yearly using linear regression.

RESULTS

Out of 419 ECPR patients presenting with refractory OHCA over the study period, 116 survived neurologically intact (27.7%). Among non-survivors (n = 303), families of 41 (13.5%) consented to organ donation (median age 51 years, 75.6% male) and organs from 38 patients were harvested, leading to 74 organ transplants to 73 recipients. The transplanted organs included 43 kidneys (58.1%), 27 livers (36.5%), 3 lungs (4%), and 1 heart (1.4%), averaging 2.4 ± 0.9 accepted organs/donor. The number of organ donors and successful transplants correlated positively with the years since the ECPR program's initiation (ptrend = 0.009, ptrend = 0.01). Overall, 189 patients (116 survivors, 73 organ recipients) benefited from ECPR, achieving organ-failure-free survival. The cumulative public health benefit of ECPR, considering the 116 survivors and 38 donors was 36.8%.

CONCLUSION

The public health benefits of an established ECPR program extend beyond individual ECPR patient survival, forming a new, previously under-recognized source of transplant donors.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center

BACKGROUND

Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area.

METHODS

We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests.

RESULTS

Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor.

CONCLUSIONS

4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.

Organ donation after resuscitation from cardiac arrest

BACKGROUND

We compared the characteristics and outcomes of post-arrest donors to those of other donors, described the proportion of post-arrest decedents who donated, and compared their characteristics to post-arrest decedents who did not donate.

METHODS

We performed a retrospective cohort study including patients who died at a single academic medical center from January 1, 2010 to February 28, 2019. We linked our registry of consecutive post-arrest patients to donation-related data from the Center for Organ Procurement and Recovery (CORE). We used data from CORE to identify donor eligibility, first person designation, family approaches to seek consent for donation, and approach outcomes. We determined number of organs procured and number transplanted, stratified by donor type (brain death donors (BDD) vs donors after circulatory determination of death (DCD)).

RESULTS

There were 12,130 decedents; 1525 (13%) were resuscitated from cardiac arrest. CORE staff approached families of 836 (260 (31%) post-arrest, 576 (69%) not post-arrest) to request donation. Post-arrest patients and families were more likely to authorize donation (172/260 (66%) vs 331/576 (57%), P = 0.02), and more likely to be DCDs (50/146 (34%) vs 55/289 (19%), P < 0.001). Overall, 4.1 ± 1.5 organs were procured and 2.9 ± 1.9 transplanted per BDD, which did not differ by post-arrest status, 3.2 ± 1.2 organs were procured and 1.8 ± 1.1 transplanted per DCD. Number of organs transplanted per DCD did not differ by post-arrest status. Unfavorable arrest characteristics were more common among post-arrest organ donors compared to non-donors.

CONCLUSION

Patients resuscitated from cardiac arrest with irrecoverable brain injury have excellent potential to become organ donors.

Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association

Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.

Management of Comatose Survivors of Cardiac Arrest

PURPOSE OF REVIEW

Because the whole-body ischemia-reperfusion insult associated with cardiac arrest often results in brain injury, neurologists perform an important role in postresuscitation cardiac arrest care. This article provides guidance for the assessment and management of brain injury following cardiac arrest.

RECENT FINDINGS

Neurologists have many roles in postresuscitation cardiac arrest care: (1) early assessment of brain injury severity to help inform triage for invasive circulatory support or revascularization; (2) advocacy for the maintenance of a neuroprotective thermal, hemodynamic, biochemical, and metabolic milieu; (3) detection and management of seizures; (4) development of an accurate, multimodal, and conservative approach to prognostication; (5) application of shared decision-making paradigms around the likely outcomes of therapy and the goals of care; and (6) facilitation of the neurocognitive assessment of survivors. Therefore, optimal management requires early neurologist involvement in patient care, a detailed knowledge of postresuscitation syndrome and its complex interactions with prognosis, expertise in bringing difficult cases to their optimal conclusions, and a support system for survivors with cognitive deficits.

SUMMARY

Neurologists have a critical role in postresuscitation cardiac arrest care and are key participants in the treatment team from the time of first restoration of a perfusing heart rhythm through the establishment of rehabilitation services for survivors.

Barriers toward organ donation in a Danish University Hospital

BACKGROUND

In Denmark, organ donation-rates are below the average in the western countries. We investigated the donor potential and identified barriers toward organ donation in a Danish university hospital.

METHODS

All patients who died in Aalborg University Hospital in 2012 were retrospectively identified. Patients with a CT- or MRI-proven deadly brain-lesion were eligible for inclusion.

RESULTS

Eighty-five patients with deadly brain-lesions were included, and of these 47 patients died in the intensive care unit (ICU). Older age and diagnosis of brain-hemorrhage and infarction were associated with admission to general ward (GW). In 62.4% of the patients the potential of becoming a donor was not identified. No donations occurred from patients dying from intracerebral hemorrhage or brain-infarction although they represented 44.7% of the potential donors.

DISCUSSION

This study reveals a huge, unrecognized donation potential at our hospital. About 30% was lost because they were never admitted to the ICU. After primary admission to the ICU, 15.3% of the potential donors were lost because they were transferred to the GW. In patients who died in the ICU 17.6% of the patients were not evaluated as potential donors. The relatives refused donation in 17.6% of cases.

CONCLUSION

It would be possible to raise the donation rate considerably if patients with donation potential are intubated and admitted to the ICU. When active treatment is considered withdrawn, possibility of organ donation should be evaluated, and the next of kin be approached by experienced staff.

Increasing survival after admission to UK critical care units following cardiopulmonary resuscitation

Background

In recent years there have been many developments in post-resuscitation care. We have investigated trends in patient characteristics and outcome following admission to UK critical care units following cardiopulmonary resuscitation (CPR) for the period 2004–2014. Our hypothesis is that there has been a reduction in risk-adjusted mortality during this period.

Methods

We undertook a prospectively defined, retrospective analysis of the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database (CMPD) for the period 1 January 2004 to 31 December 2014. Admissions, mechanically ventilated in the first 24 hours in the critical care unit and admitted following CPR, defined as the delivery of chest compressions in the 24 hours before admission, were identified. Case mix, withdrawal, outcome and activity were described annually for all admissions identified as post-cardiac arrest admissions, and separately for out-of-hospital cardiac arrest and in-hospital cardiac arrest. To assess whether in-hospital mortality had improved over time, hierarchical multivariate logistic regression models were constructed, with in-hospital mortality as the dependent variable, year of admission as the main exposure variable and intensive care unit (ICU) as a random effect. All analyses were repeated using only the data from those ICUs contributing data throughout the study period.

Results

During the period 2004–2014 survivors of cardiac arrest accounted for an increasing proportion of mechanically ventilated admissions to ICUs in the ICNARC CMPD (9.0 % in 2004 increasing to 12.2 % in 2014). Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during this period (OR 0.96 per year). Over this time, the ICU length of stay and time to treatment withdrawal has increased significantly. Re-analysis including only those 116 ICUs contributing data throughout the study period confirmed all the results of the primary analysis.

Conclusions

Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during the period 2004–2014. Over the same period the ICU length of stay and time to treatment withdrawal has increased significantly.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1390-6) contains supplementary material, which is available to authorized users.

Rates of organ donation in a UK tertiary cardiac arrest centre following out-of-hospital cardiac arrest

AIM

To ascertain the rate of successful organ donation (OD) within patients who sustained an out of hospital cardiac arrest (OHCA) with initial return of spontaneous circulation (ROSC) and survival to hospital admission, but whom subsequently do not survive to hospital discharge.

METHODS

A retrospective audit of ambulance service and hospital databases from January 2010 to January 2015 was undertaken in a United Kingdom tertiary-referral regional cardiac arrest centre. Crude denominator data for cardiac arrests was obtained from the regional ambulance service; the ICU database was interrogated for OHCA patient admissions and outcomes. Patients who died were cross-referenced against the local Organ Donation service database.

RESULTS

Five hundred and fourteen {514} patients were admitted to ICU following OHCA over this five year period. Two hundred and forty-one {241} patients (47%) survived to hospital discharge and 273 (53%) died of whom 106 (39%) were referred to a Specialist Nurse for Organ Donation (SNOD). The conversion rate after the family was approached was 64%. Twenty-eight {28} patients proceeded to donation and 25 patients (24%) successfully donated at least one organ. On average, a patient proceeding to donation provided 1.9 organs.

CONCLUSIONS

A proactive, systematic approach to OD in OHCA patients can provide a good conversion rate and substantial number of donors. Most donations occur after death from circulatory criteria. There is a positive socio-economic benefit with nearly £4m in savings to the health service within the next 5 years potentially being realised during this period by liberating patients from dialysis.

Postcardiac Arrest Management

Cardiac arrest afflicts more than 300,000 persons annually in North America alone. Advances in systematic, regimented postresuscitation care have lowered mortality and improved neurologic outcomes in select cohorts of patients over the last decade. Postcardiac arrest care now comprises its own link in the chain of survival. For most patients, high-quality postcardiac arrest care begins in the Emergency Department. This article reviews the evidence and offers treatment strategies for the key components of postcardiac arrest care.