1
|
Abstract
OBJECTIVE The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.
Collapse
|
2
|
Bery A, Ali A, Cypel M, Kreisel D. Centralized Organ Recovery and Reconditioning Centers. Thorac Surg Clin 2022; 32:167-174. [PMID: 35512935 DOI: 10.1016/j.thorsurg.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An increased focus on improving efficiency and decreasing costs has resulted in alternative models of donor management and organ recovery. The specialized donor care facility model provides highly efficient and cost-effective donor care at a free-standing facility, resulting in improved organ yield, shorter ischemic times, decreased travel, and fewer nighttime operations. Ex vivo lung perfusion (EVLP) improves utilization of extended criteria donor lungs, and centralized EVLP facilities have the potential to increase transplant volumes for smaller transplant programs in specified geographic regions. These alternative models are increasingly being used in the United States to improve waitlist mortality and combat the ongoing donor organ shortage.
Collapse
Affiliation(s)
- Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, St Louis, MO 63110, USA.
| | - Aadil Ali
- Toronto Lung Transplant Program, Division of Thoracic Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 9N969, Toronto, Ontario M5G 2C4, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Division of Thoracic Surgery, Department of Surgery, University Health Network, University of Toronto, Toronto General Hospital, 200 Elizabeth Street, 9N969, Toronto, Ontario M5G 2C4, Canada
| | - Daniel Kreisel
- Department of Surgery, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA; Department of Pathology & Immunology, Washington University School of Medicine, Campus Box 8234, 660 South Euclid Avenue, St Louis, MO 63110, USA
| |
Collapse
|
3
|
Bery A, Marklin G, Itoh A, Kreisel D, Takahashi T, Meyers BF, Nava R, Kozower BD, Shepherd H, Patterson GA, Puri V. Specialized Donor Care Facility Model and Advances in Management of Thoracic Organ Donors. Ann Thorac Surg 2021; 113:1778-1786. [PMID: 33421385 DOI: 10.1016/j.athoracsur.2020.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/13/2020] [Accepted: 12/15/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Donor hearts and lungs are more susceptible to the inflammatory physiologic changes that occur after brain death. Prior investigations have shown that protocolized management of potential organ donors can rehabilitate donor organs that are initially deemed unacceptable. In this review we discuss advances in donor management models with particular attention to the specialized donor care facility model. In addition we review specific strategies to optimize donor thoracic organs and improve organ yield in thoracic transplantation. METHODS We performed a literature review by searching the PubMed database for medical subject heading terms associated with organ donor management models. We also communicated with our local organ procurement organization to gather published and unpublished information first-hand. RESULTS The specialized donor care facility model has been shown to improve the efficiency of organ donor management and procurement while reducing costs and minimizing travel and its associated risks. Lung protective ventilation, recruitment of atelectatic lung, and hormone therapy (eg, glucocorticoids and triiodothyronine/thyroxine) are associated with improved lung utilization rates. Stroke volume-based resuscitation is associated with improved heart utilization rates, whereas studies evaluating hormone therapy (eg, glucocorticoids and triiodothyronine/thyroxine) have shown variable results. CONCLUSIONS Lack of high-quality prospective evidence results in conflicting practices across organ procurement organizations, and best practices remain controversial. Future studies should focus on prospective, randomized investigations to evaluate donor management strategies. The specialized donor care facility model fosters a collaborative environment that encourages academic inquiry and is an ideal setting for these investigations.
Collapse
Affiliation(s)
- Amit Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.
| | | | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Hailey Shepherd
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
4
|
Noreen SM, Rosendale J, Carrico RJ. Informed Clustering of Donation Service Areas for Improved Benchmarking. Prog Transplant 2020; 30:199-207. [PMID: 32588740 DOI: 10.1177/1526924820933818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The donation community continuously strives to collaborate and share effective practices to further the mission of saving and healing lives. Donation service areas in which the Organ Procurement Organizations (OPOs) work are multifaceted in their demographics, inciting the Organ Procurement and Transplantation Network to consider a more holistic and objective measure of similarity rather than the size of population alone or locational proximity alone. This would allow OPOs, as a part of their quality improvement efforts, to learn from and mentor other organizations that are dealing with similar challenges. By incorporating multiple informative characteristics together, we can distinguish those likenesses only revealed by taking into account multiple factors simultaneously. We used statistical approaches that take many characteristics of interest describing a donation service area and purposely excluded performance measures that an OPO may be able to influence by their own practices. Unsupervised learning methods combined the original characteristics into a smaller number of new variables, eliminating correlation and overlap in information from the original characteristics, and clustered donation service areas based on the general characteristics and population of the area. This analysis is a first step in providing a different perspective for OPOs to learn from other organizations that may face similar challenges, as well as to share best practices and open new lines of communication.
Collapse
Affiliation(s)
- Samantha M Noreen
- Research Department, 14646United Network for Organ Sharing, Richmond, VA, USA
| | - John Rosendale
- Research Department, 14646United Network for Organ Sharing, Richmond, VA, USA
| | - Robert J Carrico
- Research Department, 14646United Network for Organ Sharing, Richmond, VA, USA
| |
Collapse
|
5
|
Akabayashi A, Nakazawa E, Ozeki-Hayashi R, Tomiyama K, Mori K, Demme RA, Akabayashi A. Twenty Years After Enactment of the Organ Transplant Law in Japan: Why Are There Still So Few Deceased Donors? Transplant Proc 2018; 50:1209-1219. [PMID: 29880339 DOI: 10.1016/j.transproceed.2018.02.078] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/12/2018] [Accepted: 02/06/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Twenty years have passed since the 1997 enactment of the Organ Transplant Law in Japan, but the number of deceased donors remains extremely low. In this study we examine why deceased donation has continued to remain so infrequent. METHODS This investigation was a secondary analysis of published data from the Japan Organ Transplant Network, 2016 Fact Book of Organ Transplantation in Japan, and International Registry on Organ Donation and Transplantation. RESULTS In the past 20 years, donation intent declarations, knowledge, and respect for family member's wishes have increased, whereas resistance toward transplantation has decreased. Despite this, the traditional perspective on corpses of gotai manzoku (ie, the soul cannot be put to rest without being physically intact and without defect), the family-centricism, and reward-seeking altruism have not changed much. Living organ transplants have alleviated the organ deficiency somewhat, and the law requiring family consent seems to have contributed to the observed small increase in deceased donors. CONCLUSION The number of deceased donors is unlikely to increase suddenly. However, 8 strategies are proposed to increase the number of deceased donors, including: increasing the number of donor procurement coordinators and establishing a training system; increasing the number of organ procurement facilities; creating hub transplant centers and training transplant surgeons; implementing radical reform in public education; reducing workload and improving education of emergency physicians, neurosurgeons, and pediatricians; revisiting the stringent standards of brain-death determination; revisiting the registration process; and considering development of a Japanese version of organ procurement organizations as well as revisions to the Organ Transplant Law. The Japanese government and academic societies must work together to increase the number of deceased donors in Japan.
Collapse
Affiliation(s)
- A Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - E Nakazawa
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - R Ozeki-Hayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - K Tomiyama
- Division of Abdominal Transplant Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - K Mori
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan
| | - R A Demme
- Division of Medical Humanities and Bioethics, University of Rochester Medical Center, Rochester, New York
| | - A Akabayashi
- Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo, Tokyo, Japan.
| |
Collapse
|
6
|
Van Gelder F, Van Hees D, de Roey J, Monbaliu D, Aerts R, Coosemans W, Daenen W, Pirenne J. Implementation of an Intervention Plan Designed to Optimize Donor Referral in a Donor Hospital Network. Prog Transplant 2016; 16:46-51. [PMID: 16676674 DOI: 10.1177/152692480601600110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context The shortage of donor organs remains the most important factor of waiting list mortality in organ transplantation worldwide. Donor detection is influenced by the legal system, family refusal, and underreporting caused by erroneous knowledge of donation criteria and lack of familiarity with the procedure. Objective To identify possible key factors of donor referral patterns within an existing cooperation with donor hospitals and donor units across the Dutch-speaking part of Belgium, an area of approximately 3 million inhabitants. An intervention plan to optimize the cooperation and procedure quality and efficiency was designed. Design The intervention plan was based on 3 essential principles in donor referral by donor reporters, information on donor criteria, facilitation of the donor procedure, and communication between donor reporters and the transplant center. The interventions were structured to optimize all 3 of these principles. Two successive periods of 4 years were retrospectively compared. Participants Data were collected retrospectively on donor referral behavior from a total of 37 donor hospitals and donor units over an 8-year period. Main Outcome Measures The referrals were reviewed for potential donors, effective donors, percentage of effective donors, refusal rate of relatives, number of tissue donors, impact on local and national transplant programs, and national donor numbers. Results Data showed a significant positive impact on donor referrals and donor referral behavior (+27% potential donors, +30% effective donors, +172.7% tissue donors, −7% family refusals rates, +9.63% national donors). The results stress the importance of reduced workload and optimization of communication and information availability in an existing donor hospital network.
Collapse
|
7
|
Doyle M, Subramanian V, Vachharajani N, Collins K, Wellen JR, Stahlschmidt E, Brockmeier D, Coleman J, Kappel D, Chapman WC. Organ Donor Recovery Performed at an Organ Procurement Organization-Based Facility Is an Effective Way to Minimize Organ Recovery Costs and Increase Organ Yield. J Am Coll Surg 2016; 222:591-600. [DOI: 10.1016/j.jamcollsurg.2015.12.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 11/24/2022]
|
8
|
Blau JE, Abegg MR, Flegel WA, Zhao X, Harlan DM, Rother KI. Long-term immunosuppression after solitary islet transplantation is associated with preserved C-peptide secretion for more than a decade. Am J Transplant 2015; 15:2995-3001. [PMID: 26184712 PMCID: PMC5158099 DOI: 10.1111/ajt.13383] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 05/12/2015] [Accepted: 05/13/2015] [Indexed: 01/25/2023]
Abstract
We report on two patients with type 1 diabetes (T1D) after solitary islet transplantation in 2001. They received steroid-sparing immunosuppression (daclizumab, sirolimus, and tacrolimus according to the Edmonton protocol). Both patients became insulin independent for 2 years: Patient A, a 42-year-old female with a 12-year history of T1D, received two islet infusions; patient B, a 53-year-old female with a 40-year T1D history, received one islet infusion. Pretransplant, both had undetectable C-peptide concentrations and frequent and severe hypoglycemia. Pretransplant, hemoglobin A1c (HbA1c) was 7.8% and 8.8% and insulin requirements were 0.47 and 0.33 units/kg/day, respectively. Posttransplant, C-peptide levels remained detectable while immunosuppression was continued, but decreased over time. Insulin was re-started 2 years posttransplant in both patients. Since patient A's glycemia and insulin requirements trended toward pretransplant levels, immunosuppression was discontinued after 13 years. This resulted in a sudden cessation of C-peptide secretion. Patient B continues on immunosuppression, has better HbA1c, and half the insulin requirement compared to pretransplant. Both patients no longer experience severe hypoglycemia. Herein, we document blood glucose concentrations over time (>30 000 measurements per patient) and β cell function based on C-peptide secretion. Despite renewed insulin dependence, both patients express satisfaction with having undergone the procedure.
Collapse
Affiliation(s)
- J. E. Blau
- Diabetes, Endocrinology, and Obesity Branch, NIDDK National Institutes of Health, Bethesda, MD
| | - M. R. Abegg
- Diabetes, Endocrinology, and Obesity Branch, NIDDK National Institutes of Health, Bethesda, MD
| | - W. A. Flegel
- Department of Transfusion Medicine, NIH Clinical Center National Institutes of Health, Bethesda, MD
| | - X. Zhao
- Diabetes, Endocrinology, and Obesity Branch, NIDDK National Institutes of Health, Bethesda, MD
| | - D. M. Harlan
- Division of Diabetes, Endocrinology, and Nutrition Diabetes Center of Excellence, Department of Internal Medicine, University of Massachusetts Medical School, North Worcester, MA
| | - K. I. Rother
- Diabetes, Endocrinology, and Obesity Branch, NIDDK National Institutes of Health, Bethesda, MD,Corresponding author: Kristina I. Rother,
| |
Collapse
|
9
|
Breakdown in the organ donation process and its effect on organ availability. J Transplant 2015; 2015:831501. [PMID: 25949819 PMCID: PMC4407530 DOI: 10.1155/2015/831501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/13/2015] [Indexed: 11/18/2022] Open
Abstract
Background. This study examines the effect of breakdown in the organ donation process on the availability of transplantable organs. A process breakdown is defined as a deviation from the organ donation protocol that may jeopardize organ recovery. Methods. A retrospective analysis of donation-eligible decedents was conducted using data from an independent organ procurement organization. Adjusted effect of process breakdown on organs transplanted from an eligible decedent was examined using multivariable zero-inflated Poisson regression. Results. An eligible decedent is four times more likely to become an organ donor when there is no process breakdown (adjusted OR: 4.01; 95% CI: 1.6838, 9.6414; P < 0.01) even after controlling for the decedent's age, gender, race, and whether or not a decedent had joined the state donor registry. However once the eligible decedent becomes a donor, whether or not there was a process breakdown does not affect the number of transplantable organs yielded. Overall, for every process breakdown occurring in the care of an eligible decedent, one less organ is available for transplant. Decedent's age is a strong predictor of likelihood of donation and the number of organs transplanted from a donor. Conclusion. Eliminating breakdowns in the donation process can potentially increase the number of organs available for transplant but some organs will still be lost.
Collapse
|
10
|
Implementation intentions as a strategy to increase the notification rate of potential ocular tissue donors by nurses: a clustered randomized trial in hospital settings. Nurs Res Pract 2014; 2014:921263. [PMID: 25132990 PMCID: PMC4124222 DOI: 10.1155/2014/921263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/09/2014] [Accepted: 06/18/2014] [Indexed: 11/18/2022] Open
Abstract
Aim. The purpose of this study is to evaluate the impact, among nurses in hospital settings, of a questionnaire-based implementation intentions intervention on notification of potential ocular tissue donors to donation stakeholders. Methods. This randomized intervention was clustered at the level of hospital departments with two study arms: questionnaire-based implementation intentions intervention and control. In the intervention group, nurses were asked to plan specific actions if faced with a number of barriers when reporting potential ocular donors. The primary outcome was the potential ocular tissue donors' notification rate before and after the intervention. Analysis was based on a generalized linear model with an identity link and a binomial distribution. Results. We compared outcomes in 26 departments from 5 hospitals, 13 departments per condition. The implementation intentions intervention did not significantly increase the notification rate of ocular tissue donors (intervention: 23.1% versus control: 21.1%; χ (2) = 1.14, 2; P = 0.56). Conclusion. A single and brief implementation intentions intervention among nurses did not modify the notification rate of potential ocular tissue donors to donation stakeholders. Low exposure to the intervention was a major challenge in this study. Further studies should carefully consider a multicomponent intervention to increase exposure to this type of intervention.
Collapse
|
11
|
Doyle MBM, Vachharajani N, Wellen JR, Lowell JA, Shenoy S, Ridolfi G, Jendrisak MD, Coleman J, Maher M, Brockmeier D, Kappel D, Chapman WC. A novel organ donor facility: a decade of experience with liver donors. Am J Transplant 2014; 14:615-20. [PMID: 24612713 DOI: 10.1111/ajt.12607] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 10/28/2013] [Accepted: 11/20/2013] [Indexed: 01/25/2023]
Abstract
Transplant surgeons have historically traveled to donor hospitals, performing complex, time-sensitive procedures with unfamiliar personnel. This often involves air travel, significant delays, and frequently occurs overnight.In 2001, we established the nation's first organ recovery center. The goal was to increase efficiency,reduce costs and reduce surgeon travel. Liver donors and recipients, donor costs, surgeon hours and travel time, from April 1,2001 through December 31,2011 were analyzed. Nine hundred and fifteen liver transplants performed at our center were analyzed based on procurement location (living donors and donation after cardiac death donors were excluded). In year 1, 36% (9/25) of donor procurements occurred at the organ procurement organization (OPO) facility, rising to 93%(56/60) in the last year of analysis. Travel time was reduced from 8 to 2.7 h (p<0.0001), with a reduction of surgeon fly outs by 93% (14/15) in 2011. Liver organ donor charges generated by the donor were reduced by37% overall for donors recovered at the OPO facility versus acute care hospital. Organs recovered in this novel facility resulted in significantly reduced surgeon hours, air travel and cost. This practice has major implications for cost containment and OPO national policy and could become the standard of care.
Collapse
|
12
|
|
13
|
Affiliation(s)
- Kathy J. Kalkbrenner
- Center for Bioethics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - George E. Hardart
- Center for Bioethics, Columbia University College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
14
|
Moazami N, Javadi OH, Kappel DF, Wagner J, Jendrisak MD. The feasibility of organ procurement at a hospital-independent facility: A working model of efficiency. J Thorac Cardiovasc Surg 2007; 133:1389-90. [PMID: 17467474 DOI: 10.1016/j.jtcvs.2006.12.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2006] [Revised: 12/06/2006] [Accepted: 12/12/2006] [Indexed: 10/23/2022]
Affiliation(s)
- Nader Moazami
- Section of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, MO, USA.
| | | | | | | | | |
Collapse
|
15
|
Conte JV, Baumgartner WA. Commentary on Cadaveric-donor organ recovery at a hospital-independent facility. Transplantation 2002; 74:931-2. [PMID: 12408165 DOI: 10.1097/00007890-200210150-00005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J V Conte
- Johns Hopkins Hospital, Baltimore, Maryland, USA
| | | |
Collapse
|