Guidelines for maintenance of adult patients with brain death and potential for multiple organ donations: the Task Force of the Brazilian Association of Intensive Medicine the Brazilian Association of Organs Transplantation, and the Transplantation Center of Santa Catarina

[Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence]

Hintergrund

Die Anzahl postmortal gespendeter Organe ist in Deutschland weit geringer als der Bedarf. Dies unterstreicht die Wichtigkeit einer optimalen Versorgung während des gesamten Prozesses der Organspende.

Fragestellung

Es existieren internationale Leitlinien und nationale Empfehlungen zu intensivmedizinischen organprotektiven Maßnahmen beim Organspender. Für das anästhesiologische Management fehlen evidenzbasierte Empfehlungen. Ziel dieser Übersichtsarbeit ist es, anhand der vorhandenen Evidenz die pathophysiologischen Veränderungen des irreversiblen Hirnfunktionsausfalls zu rekapitulieren und sich kritisch mit den empfohlenen Behandlungsstrategien und therapeutischen Zielgrößen auseinanderzusetzen. Auch auf ethische Aspekte der Betreuung des postmortalen Organspenders wird eingegangen.

Methode

Diese Übersichtsarbeit basiert auf einer selektiven Literaturrecherche in PubMed (Suchwörter: „brain dead donor“, „organ procurement“, „organ protective therapy“, „donor preconditioning“, „perioperative donor management“, „ethical considerations of brain dead donor“). Internationale Leitlinien und nationale Empfehlungen wurden besonders berücksichtigt.

Ergebnisse

Insgesamt ist die Evidenz für optimale intensivmedizinische und perioperative organprotektive Maßnahmen beim postmortalen Organspender sehr gering. Nationale und internationale Empfehlungen zu Zielwerten und medikamentösen Behandlungsstrategien unterscheiden sich teilweise erheblich: kontrollierte randomisierte Studien fehlen. Der Stellenwert einer Narkose zur Explantation bleibt sowohl unter pathophysiologischen Gesichtspunkten als auch aus ethischer Sicht ungeklärt.

Schlussfolgerungen

Die Kenntnisse über die pathophysiologischen Prozesse im Rahmen des irreversiblen Hirnfunktionsausfalls und die organprotektiven Maßnahmen sind ebenso Grundvoraussetzung wie die ethische Auseinandersetzung mit dem Thema postmortale Organspende. Nur dann kann das Behandlungsteam in dieser herausfordernden Situation sowohl dem Organempfänger als auch dem Organspender und seinen Angehörigen gerecht werden.

Strategies for hemodynamic maintenance of potential brain-dead donor: integrative review

OBJECTIVE

To learn about the scientific production on strategies adopted for hemodynamic maintenance of brain-dead patients.

METHODS

Integrative review with articles published between 2007 and 2019, in Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), PubMed® and ScienceDirect. The descriptors " Hemodinâmica AND Morte Encefálica " and "Hemodynamics AND Brain Death" were used. Exclusion criteria were non-human research and gray literature.

RESULTS

A total of 21 articles were listed. As strategies, the use of drugs - noradrenaline (n=8), vasopressin (n=7), dobutamine (n=6), hydrocortisone (n=4) and methylprednisolone (n=4); invasive (n=10) and noninvasive (n=13) cardiac monitoring; control of ventilatory parameters (n=12); and correction of fluid and electrolyte disturbances (n=17) were highlighted.

CONCLUSION

The main strategies found in this integrative review were regulation of blood pressure and temperature, use of catecholamines and corticosteroids, in addition to the need for an early diagnosis of brain death. However, the lack of clearer protocols on the subject is notorious, making management with the potential donor difficult.

Brain death and management of the potential donor

One of the first attempts to define brain death (BD) dates from 1963, and since then, the diagnosis criteria of that entity have evolved. In spite of the publication of practice parameters and evidence-based guidelines, BD is still causing concern and controversies in the society. The difficulties in determining brain death and making it understood by family members not only endorse futile therapies and increase health care costs, but also hinder the organ transplantation process. This review aims to give an overview about the definition of BD, causes, physiopathology, diagnosis criteria, and management of the potential brain-dead donor. It is important to note that the BD determination criteria detailed here follow the AAN’s recommendations, but the standard practice for BD diagnosis varies from one country to another.

A stroke volume-based fluid resuscitation protocol decreases vasopressor support and may increase organ yield in brain-dead donors

Brain-dead donors are frequently hypovolemic and hypotensive requiring vasopressor support. We studied a stroke volume-based fluid resuscitation and vasopressor weaning protocol prospectively on 64 hypotensive donors, with a recent control cohort of 30 hypotensive donors treated without a protocol. Stroke volume was measured every 30 minutes for 4 hours by pulse contour analysis or esophageal Doppler. A 500 mL saline fluid bolus was infused over 30 minutes and repeated if the stroke volume increased by 10%. No fluid was infused if the stroke volume did not increase by 10%. Vasopressors were weaned every 10 minutes if the mean arterial pressure was greater than 65 mm Hg. The protocol group received 1937 ± 906 mL fluid compared to 1323 ± 919 mL in the control group (P = .003). Mean time on vasopressors was decreased from 957.6 ± 586.2 to 176.3 ± 82.2 minutes (P<.001). Donors in the protocol group were more likely to donate four or more organs than donors in the control group (OR = 4.114, 95% Confidence Interval (CI) = 1.003-16.876). While more organs were transplanted per donor in the protocol group (3.39 ± 1.52) than in the control group (2.93 ± 1.44) (P = .268), the difference did not reach statistical significance. A goal-directed fluid resuscitation protocol decreased organ ischemia and may increase organs transplanted.

DONORS (Donation Network to Optimise Organ Recovery Study): Study protocol to evaluate the implementation of an evidence-based checklist for brain-dead potential organ donor management in intensive care units, a cluster randomised trial

INTRODUCTION

There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest.

METHODS AND ANALYSIS

The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor.

ETHICS AND DISSEMINATION

The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT03179020; Pre-results.

A Canadian survey of critical care physicians' hemodynamic management of deceased organ donors

PURPOSE

We sought to characterize Canadian physicians' perspectives and stated practices regarding their hemodynamic care of deceased organ donors.

METHODS

We designed a 24-item electronic survey that was independently pretested for relevance, clarity, and intra-rater reliability by ten critical care clinicians. With the help of provincial organ donation organizations (ODO), we identified intensive care units (ICUs) with a high volume of adult deceased donors (defined by the management of five or more donors per year for two consecutive years). Medical directors of these high-volume ICUs helped identify ICU physicians to whom our survey was emailed.

RESULTS

Of the 448 ICU physicians from 37 centres in nine provinces that were emailed, 184/448 (41.1%) responded to one or more survey questions. Respondents identified specialist nurses from ODOs as their primary source of guidance in donor care (107/165; 60%). They typically diagnosed an autonomic storm according to a rise in blood pressure (159/165; 96.4%) and/or heart rate (135/165; 81.8%); nevertheless, their stated management varied substantially. After termination of the autonomic storm, preferred first-line vasopressors were norepinephrine (93/164; 56.7%) and vasopressin (68/164; 41.5%). Twenty-one respondents (21/162; 13.0%) reported that they never administer inotropes to donors. Corticosteroid and thyroid hormone prescriptions for all donors was reported by 62/161 (37.6%) and 50/161 (31.1%) respondents, respectively. Respondents perceived an influence from ODO nurses or transplant physicians when prescribing corticosteroids (77/161; 47.8%) and/or thyroid hormones (33/161; 20.5%) CONCLUSION: We observed important variability in self-perceived practices of ICU physicians in the hemodynamic management of deceased donors, particularly in the treatment of the autonomic storm, in the prescription of hormone therapy, and in the administration of inotropes.

Impact of Educational and Organizational Initiatives in Organ Donation in a Southern Brazilian State in the Last Decade

BACKGROUND

The unbalance between the demand and supply of organs for transplant is a universal phenomenon. This study shows Santa Catarina's experience with educational and organizational initiatives in the state's transplant system to describe the result of such actions in increasing donation rates.

METHODS

This is a before and after study. Medical data on potential organ donors, listed in the Santa Catarina Transplant Registry between January 2004 and December 2017, were analyzed. This 13-year period was divided into 3 phases. Phase 1, from 2005 to 2007, corresponds to the organization of the program without specific measures. Phase 2, from 2008 to 2011, is associated with theoretical/practical training on family interviews. Phase 3, from 2012 to 2017, is related to the implementation of a protocol for the management of potential deceased donors.

RESULTS

Referrals grew from 35.1 per million population (pmp) (phase 1) to 49.4 pmp (phase 1) and 74.0 pmp (phase 3), translating into a 110.8% (P < .001) increase. Lack of family consent dropped from 39.8% to 27.8% in phase 3, a global reduction of 30.1% (P < .001). Loss of donors to cardiac arrest were reduced from 51.9% to 23.3% to 12.2%. Effective donors, which varied from 12.0 pmp to 20.0 pmp and 32.7 pmp, increased by 172.5% (P < .001).

CONCLUSIONS

This study demonstrates the positive association between articulated educational initiatives and improvements in potential donors' identification, which, associated with cardiac arrest loss control and increased family consent, brought about significantly better results in organ donation.

Adherence to guidelines for the management of donors after brain death

PURPOSE

Guideline adherence for the management of a donor after brain death (DBD) is largely unknown. This study aimed to perform an importance-performance analysis of prioritized key interventions (KIs) by linking guideline adherence rates to expert consensus ratings for the management of a DBD.

MATERIALS AND METHODS

This observational, cross-sectional multicenter study was performed in 21 Belgian ICUs. A retrospective review of patient records of adult utilized DBDs between 2013 and 2016 used 67 KIs to describe adherence to guidelines.

RESULTS

A total of 296 patients were included. Thirty-five of 67 KIs had a high level of adherence congruent to a high expert panel rating of importance. Nineteen of 67 KIs had a low level of adherence in spite of a high level of importance according to expert consensus. However, inadequate documentation proved an important issue, hampering true guideline adherence assessment. Adherence ranged between 3 and 100% for single KI items and on average, patients received 72% of the integrated expert panel recommended care set.

CONCLUSIONS

Guideline adherence to an expert panel predefined care set in DBD donor management proved moderate leaving substantial room for improvement. An importance-performance analysis can be used to improve implementation and documentation of guidelines.

Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach

Background

A substantial degree of variability in practices exists amongst donor hospitals regarding the donor detection, determination of brain death, application of donor management techniques or achievement of donor management goals. A possible strategy to standardize the donation process and to optimize outcomes could lie in the implementation of a care pathway. The aim of the study was to identify and select a set of relevant key interventions and quality indicators in order to develop a specific care pathway for donation after brain death and to rigorously evaluate its impact.

Methods

A RAND modified three-round Delphi approach was used to build consensus within a single country about potential key interventions and quality indicators identified in existing guidelines, review articles, process flow diagrams and the results of the Organ Donation European Quality System (ODEQUS) project. Comments and additional key interventions and quality indicators, identified in the first round, were evaluated in the following rounds and a subsequent physical meeting. The study was conducted over a 4-month time period in 2016.

Results

A multidisciplinary panel of 18 Belgian experts with different relevant backgrounds completed the three Delphi rounds. Out of a total of 80 key interventions assessed throughout the Delphi process, 65 were considered to contribute to the quality of care for the management of a potential donor after brain death; 11 out of 12 quality indicators were validated for relevance and feasibility. Detection of all potential donors after brain death in the intensive care unit and documentation of cause of no donation were rated as the most important quality indicators.

Conclusions

Using a RAND modified Delphi approach, consensus was reached for a set of 65 key interventions and 11 quality indicators for the management of a potential donor after brain death. This set is considered to be applicable in quality improvement programs for the care of potential donors after brain death, while taking into account each country’s legislation and regulations regarding organ donation and transplantation.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3386-1) contains supplementary material, which is available to authorized users.

Predictors of Organ Donation Among Patients With Brain Death in the Intensive Care Unit

INTRODUCTION

Despite the improved care of potential organ donors with probable brain death (BD) in the intensive care unit (ICU), few epidemiologic and clinical data are available in developing countries.

OBJECTIVES

To evaluate ICU patients with suspected BD aiming to identify factors possibly related to success (organ donation) or failure (nondonation).

METHODS

Retrospective cohort study, from the patient records of an adult ICU of a Brazilian teaching hospital for 12 months. Data were tabulated, and descriptive statistics and univariate and multivariate analyses were performed.

RESULTS

During the study period, 85 patients with acute neurologic diseases and suspected BD were admitted to the ICU and included for analysis. Of these, there were 9 organ donors (7 liver and 9 kidney donors); 77.7% were men, with a mean age of 39.6 years and admission Acute Physiology and Chronic Health Evaluation II of 25.5. Two-thirds of the patients were victims of trauma. The mean time between acute neurologic event and organ withdrawal was 269 hours. The main prognostic factors related to the success of organ donation were the maximum serum lactate and creatinine levels during ICU admission.

CONCLUSIONS

The main clinical factors correlated with nonevolution for organ donation among ICU patients with clinical suspicion of BD were related to patient severity and organic dysfunction: serum lactate and creatinine level. Clinical care and monitoring are emphasized to improve the efficiency of the donation process.

Engineering a microcirculation for perfusion control of ex vivo-assembled organ systems: Challenges and opportunities

Donor organ shortage remains a clear problem for many end-stage organ patients around the world. The number of available donor organs pales in comparison with the number of patients in need of these organs. The field of tissue engineering proposes a plausible solution. Using stem cells, a patient's autologous cells, or allografted cells to seed-engineered scaffolds, tissue-engineered constructs can effectively supplement the donor pool and bypass other problems that arise when using donor organs, such as who receives the organ first and whether donor organ rejection may occur. However, current research methods and technologies have been unable to successfully engineer and vascularize large volume tissue constructs. This review examines the current perfusion methods for ex vivo organ systems, defines the different types of vascularization in organs, explores various strategies to vascularize ex vivo organ systems, and discusses challenges and opportunities for the field of tissue engineering.

Early declaration of death by neurologic criteria results in greater organ donor potential

BACKGROUND

Aggressive management of patients prior to and after determination of death by neurologic criteria (DNC) is necessary to optimize organ recovery, transplantation, and increase the number of organs transplanted per donor (OTPD). The effects of time management are understudied but potentially pivotal component. The objective of this study was to analyze specific time points (time to DNC, time to procurement) and the time intervals between them to better characterize the optimal timeline of organ donation.

METHODS

Using data over a 5-year time period (2011-2015) from the largest US OPO, all patients with catastrophic brain injury and donated transplantable organs were retrospectively reviewed. Active smokers were excluded. Maximum donor potential was seven organs (heart, lungs [2], kidneys [2], liver, and pancreas). Time from admission to declaration of DNC and donation was calculated. Mean time points stratified by specific organ procurement rates and overall OTPD were compared using unpaired t-test.

RESULTS

Of 1719 Declaration of Death by Neurologic Criteria organ donors, 381 were secondary to head trauma. Smokers and organs recovered but not transplanted were excluded leaving 297 patients. Males comprised 78.8%, the mean age was 36.0 (±16.8) years, and 87.6% were treated at a trauma center. Higher donor potential (>4 OTPD) was associated with shorter average times from admission to brain death; 66.6 versus 82.2 hours, P = 0.04. Lung donors were also associated with shorter average times from admission to brain death; 61.6 versus 83.6 hours, P = 0.004. The time interval from DNC to donation varied minimally among groups and did not affect donation rates.

CONCLUSIONS

A shorter time interval between admission and declaration of DNC was associated with increased OTPD, especially lungs. Further research to identify what role timing plays in the management of the potential organ donor and how that relates to donor management goals is needed.

Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance

Background

The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. Reducing the loss of transplantable organs from deceased potential donors as a function of cardiac arrest (CA) may contribute to an increase in organ donations. Our purpose was to test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential brain-dead donors (PBDDs) due to CA.

Methods

The quality improvement project included 27 hospitals that reported deceased donors prospectively to the Transplant Center of the State of Santa Catarina, Brazil. All deceased donors reported prospectively between May 2012 and April 2014 were analyzed. Hospitals were encouraged to use the VIP approach checklist during the management of PBDDs. The checklist was composed of the following goals: protocol duration 12–24 hours, temperature > 35 °C, mean arterial pressure ≥ 65 mmHg, diuresis 1–4 ml/kg/h, corticosteroids, vasopressin, tidal volume 6–8 ml/kg, positive end-expiratory pressure 8–10 cmH₂O, sodium < 150 mEq/L, and glycemia < 180 mg/dl. A logistic regression model was used to identify predictors of CA.

Results

There were 726 PBDD notifications, of which 324 (44.6) were actual donors, 141 (19.4 %) CAs, 226 (31.1 %) family refusals, and 35 (4.8 %) contraindications. Factors associated with CA reduction included use of the checklist (odds ratio (OR) 0.43, p < 0.001), maintenance performed inside the ICU (OR 0.49, p = 0.013), and vasopressin administration (OR 0.56, p = 0.04). More than three interventions had association with less CAs (OR 0.19, p < 0.001). After 24 months, CAs decreased from 27.3 % to 14.6 % (p = 0.002), reaching 12.1 % in the following two 4-month periods (p < 0.001). Simultaneous increases in organ recovered per donor and in actual donors were observed.

Conclusions

A quality improvement program based on education and the use of a goal checklist for the management of potential donors inside the ICU is strongly associated with a decrease in donor losses and an increase in organs recovered per donor.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1484-1) contains supplementary material, which is available to authorized users.

Heart transplantation: review

Heart transplantation is currently the definitive gold standard surgical approach in the treatment of refractory heart failure. However, the shortage of donors limits the achievement of a greater number of heart transplants, in which the use of mechanical circulatory support devices is increasing. With well-established indications and contraindications, as well as diagnosis and treatment of rejection through defined protocols of immunosuppression, the outcomes of heart transplantation are very favorable. Among early complications that can impact survival are primary graft failure, right ventricular dysfunction, rejection, and infections, whereas late complications include cardiac allograft vasculopathy and neoplasms. Despite the difficulties for heart transplantation, in particular, the shortage of donors and high mortality while on the waiting list, in Brazil, there is a great potential for both increasing effective donors and using circulatory assist devices, which can positively impact the number and outcomes of heart transplants.