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Vail EA, Chun RH, Tsai SD, Souter MJ, Lele AV. Anesthetic Management of Organ Recovery Procedures: Opportunities to Increase Clinician Engagement and Disseminate Evidence-based Practice. J Neurosurg Anesthesiol 2024; 36:174-176. [PMID: 37000806 DOI: 10.1097/ana.0000000000000915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/18/2023] [Indexed: 04/01/2023]
Affiliation(s)
| | - Rebekah H Chun
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Michael J Souter
- Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington, Seattle, WA
| | - Abhijit V Lele
- Departments of Anesthesiology and Pain Medicine and Neurological Surgery University of Washington, Seattle, WA
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Gosling AF, Wright MC, Cherry A, Milano CA, Patel CB, Schroder JN, DeVore A, McCartney S, Kerr D, Bryner B, Podgoreanu M, Nicoara A. The Role of Recipient Thyroid Hormone Supplementation in Primary Graft Dysfunction After Heart Transplantation: A Propensity-Adjusted Analysis. J Cardiothorac Vasc Anesth 2023; 37:2236-2243. [PMID: 37586950 DOI: 10.1053/j.jvca.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To investigate whether recipient administration of thyroid hormone (liothyronine [T3]) is associated with reduced rates of primary graft dysfunction (PGD) after orthotopic heart transplantation. DESIGN Retrospective cohort study. SETTING Single-center, university hospital. PARTICIPANTS Adult patients undergoing orthotopic heart transplantation. INTERVENTIONS A total of 609 adult heart transplant recipients were divided into 2 cohorts: patients who did not receive T3 (no T3 group, from 2009 to 2014), and patients who received T3 (T3 group, from 2015 to 2019). Propensity-adjusted logistic regression was performed to assess the association between T3 supplementation and PGD. MEASUREMENTS AND MAIN RESULTS After applying exclusion criteria and propensity-score analysis, the final cohort included 461 patients. The incidence of PGD was not significantly different between the groups (33.9% no T3 group v 40.8% T3 group; p = 0.32). Mortality at 30 days (3% no T3 group v 2% T3 group; p = 0.53) and 1 year (10% no T3 group v 12% T3 group; p = 0.26) were also not significantly different. When assessing the severity of PGD, there were no differences in the groups' rates of moderate PGD (not requiring mechanical circulatory support other than an intra-aortic balloon pump) or severe PGD (requiring mechanical circulatory support other than an intra-aortic balloon pump). However, segmented time regression analysis revealed that patients in the T3 group were less likely to develop severe PGD. CONCLUSIONS These findings indicated that recipient single-dose thyroid hormone administration may not protect against the development of PGD, but may attenuate the severity of PGD.
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Affiliation(s)
- Andre F Gosling
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC.
| | - Mary C Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Anne Cherry
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Adam DeVore
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sharon McCartney
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Daryl Kerr
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Benjamin Bryner
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Alina Nicoara
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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Brahmbhatt DH, Blitzer D, Billia F, Copeland H. Acute complication posttransplant: primary allograft dysfunction. Curr Opin Organ Transplant 2023; 28:376-383. [PMID: 37678172 DOI: 10.1097/mot.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
PURPOSE OF REVIEW Heart transplant is the gold standard treatment for patients with end-stage heart failure, improving both quality of life and survival. Despite advances in donor and recipient management, primary graft dysfunction (PGD) remains the most common cause of morbidity and mortality in the early posttransplant period. This review summarizes recent discoveries in the underlying pathophysiology, risk prediction and management of PGD. RECENT FINDINGS The incidence of PGD appears to be rising and it is not clear whether this is due to better recognition or secular changes in transplant practice. The utilization of donation after circulatory death organs for transplant is a further consideration for the development of PGD. Organ transport systems and preservation techniques may help to prevent PGD. As some of the risk factors for developing PGD remain modifiable, we summarize the current evidence for prevention and management of PGD. SUMMARY A better understanding will allow us to appropriately manage donors and recipients to reduce the complex interactions that lead to PGD. The development of an international consortium provides the opportunity for deep phenotyping and development of contemporary risk prediction models for PGD, which may reduce the incidence and consequent early mortality associated with heart transplantation.
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Affiliation(s)
- Darshan H Brahmbhatt
- Division of Cardiology, Department of Medicine, University of Toronto
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - David Blitzer
- Department of Surgery, Division of Cardiovascular Surgery, Columbia University, New York, New York
| | - Filio Billia
- Division of Cardiology, Department of Medicine, University of Toronto
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Hannah Copeland
- Lutheran Hospital
- Indiana University School of Medicine - Fort Wayne, Fort Wayne, Indiana, USA
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Brown MB, Abramowicz AE, Panzica PJ, Weber G. Anesthetic Considerations of Organ Procurement After Brain and Cardiac Death: A Narrative Review. Cureus 2023; 15:e40629. [PMID: 37476138 PMCID: PMC10355135 DOI: 10.7759/cureus.40629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/22/2023] Open
Abstract
Organ donation procedures have become more frequent in the US as the need for transplants is increasing. Defining the anesthesiologist's role in organ donations after brain and cardiac death is important, as is understanding its ethics and practical physiologic and perioperative implications. Despite this, there are few papers specifically addressing the anesthetic management of organ donors. This review summarizes the preoperative, intraoperative, and postmortem considerations for the anesthesiologist involved in organ donation after either brain or cardiac death. A search of the published literature was performed using PubMed, Excerpta Medica dataBASE (EMBASE), and Google Scholar in March of 2022 for articles addressing anesthetic considerations of organ procurement surgeries after brain and cardiac death. This review demonstrates that anesthesiologists play a significant role in the organ procurement process. Their role in the perioperative management of the donor may affect the outcomes of organ transplantation. The gap between the number of organs harvested and the number of patients awaiting organ transplantation remains high despite continued efforts to increase the number of available organs. Perioperative management of organ donors aims at counteracting the associated unique physiologic derangements and targets optimization of oxygenation of the organs intended for procurement. Optimizing care after death can help ensure the viability of organs and the best outcomes for recipients. As organ donation after cardiac death (DCD) becomes more frequent in the US, anesthesiologists should be aware of the DCD classifications of donors and emerging novel perfusion techniques.
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Affiliation(s)
| | - Apolonia E Abramowicz
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Peter J Panzica
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
| | - Garret Weber
- Department of Anesthesiology, Westchester Medical Center, Valhalla, USA
- School of Medicine, New York Medical College, Valhalla, USA
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Felder S, Fischer P, Böhler K, Angermair S, Treskatsch S, Witte W. [Anaesthesiological management of postmortem organ donors - What Evidence is Out There?]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:183-193. [PMID: 36958314 DOI: 10.1055/a-1839-5014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
The transplantation of organs from postmortem organ donors has been a lifesaving and quality-of-life-improving therapy for patients with irreversible organ failure for many years. In Germany, however, there has been an imbalance between the number of organs donated postmortem and the number of patients on the waiting list for years. The anesthesiological management of multiple organ harvesting (MOE) in postmortem organ donors is not an everyday challenge for various reasons: A lack of practical expertise due to the small number of MOE, even at university hospitals (usually < 20 per year), complex pathophysiological changes in the cardiovascular system and other organ functions of the postmortem organ donor and the lack of guidelines complicate anesthesiological management. This paper compiles the existing literature and reviews whether evidence-based recommendations can be derived for anesthesiologic management for MOE.
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Balogh J, Jonna S, Diaz G, Williams GW, Moguilevitch M, Pivalizza EG. The role of anesthesiologists in organ donation. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Yin S, Rong J, Chen Y, Cao L, Liu Y, Mo S, Li H, Jiang N, Shi H, Wang T, Shi Y, Zhu Y, Xiong W, Chen Y, Xu G, Chen X, Chen X, Yin M, Gong F, Huang W, Dong Y, Björn N, Stefan T, Guo Z, He X. Transplantation of a beating heart: A first in man. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 23:100449. [PMID: 35465045 PMCID: PMC9019404 DOI: 10.1016/j.lanwpc.2022.100449] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND In the current practice, graft ischaemia and reperfusion injury (IRI) is considered an inevitable component in organ transplantation, contributes to compromised organ quality, inferior graft survival and limitations in organ availability. Among all the donor organs, the heart is most vulnerable to IRI and the tolerated ischaemic time is the shortest. METHODS By combining adapted surgical techniques and normothermic machine perfusion (NMP), we performed the first case of ischaemia-free beating heart transplantation (IFBHT) in man. The donor heart was procured after an in situ NMP circuit was established, then underwent ex situ NMP and implanted under NMP support. The post-transplant graft function was monitored. FINDINGS The donor heart was procured, preserved, and implanted under a continuously perfused, normothermic, oxygenated, beating state. During ex situ NMP, the donor heart beat with sinus rhythm and adequate ventricular contraction, consumed oxygen and lactate, suggesting a good cardiac function. The dynamic electrocardiogram demonstrated an absence of ischaemic injury of the donor heart during the entire procedure. The echocardiogram showed an immediate graft function with a left ventricle ejection fraction (LVEF) of 70%. The patient was discharged on post-transplantation day 20 and was followed up for 8 months with normal cardiac function and life. INTERPRETATION This study shows the feasibility of IFBHT procedure, which might be able to completely avoid graft IRI, has thus the potential to improve transplant outcome while increasing organ utilization. FUNDING This study was funded by National Natural Science Foundation of China, Guangdong Provincial Key Laboratory Construction Projection on Organ Donation and Transplant Immunology, and Guangdong Provincial International Cooperation Base of Science and Technology.
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Affiliation(s)
- Shengli Yin
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Jian Rong
- Department of Extracorporeal Circulation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yinghua Chen
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, NO.58 Zhongshan Er Road, Guangzhou 510080, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China
| | - Lu Cao
- Department of Extracorporeal Circulation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yunqi Liu
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Shaoyan Mo
- Department of Extracorporeal Circulation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Hanzhao Li
- Department of Cardiac Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Nan Jiang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Han Shi
- Department of Extracorporeal Circulation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Tielong Wang
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, NO.58 Zhongshan Er Road, Guangzhou 510080, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China
| | - Yongxu Shi
- Department of Extracorporeal Circulation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yanling Zhu
- Department of Extracorporeal Circulation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Wei Xiong
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yili Chen
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Guixing Xu
- Department of Neurosurgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaoxiang Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Xiaojun Chen
- Operating Room and Anesthesia Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Meixian Yin
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, NO.58 Zhongshan Er Road, Guangzhou 510080, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China
| | - Fengqiu Gong
- Operating Room and Anesthesia Centre, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Wenqi Huang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Nashan Björn
- Organ Transplantation Centre, The First Affiliated Hospital of the University of Science and Technology of China, Hefei 230001, China
| | - Tullius Stefan
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhiyong Guo
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, NO.58 Zhongshan Er Road, Guangzhou 510080, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China
| | - Xiaoshun He
- Organ Transplant Centre, The First Affiliated Hospital, Sun Yat-sen University, NO.58 Zhongshan Er Road, Guangzhou 510080, China
- Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), Guangzhou 510080, China
- Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, Guangzhou 510080, China
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Nazemian R, Matta M, Aldamouk A, Zhu L, Awad M, Pophal M, Palmer NR, Armes T, Hausladen A, Stamler JS, Reynolds JD. S-Nitrosylated hemoglobin predicts organ yield in neurologically-deceased human donors. Sci Rep 2022; 12:6639. [PMID: 35459243 PMCID: PMC9033847 DOI: 10.1038/s41598-022-09933-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 03/09/2022] [Indexed: 11/09/2022] Open
Abstract
Current human donor care protocols following death by neurologic criteria (DNC) can stabilize macro-hemodynamic parameters but have minimal ability to preserve systemic blood flow and microvascular oxygen delivery. S-nitrosylated hemoglobin (SNO-Hb) within red blood cells (RBCs) is the main regulator of tissue oxygenation (StO2). Based on various pre-clinical studies, we hypothesized that brain death (BD) would decrease post-mortem SNO-Hb levels to negatively-impact StO2 and reduce organ yields. We tracked SNO-Hb and tissue oxygen in 61 DNC donors. After BD, SNO-Hb levels were determined to be significantly decreased compared to healthy humans (p = 0·003) and remained reduced for the duration of the monitoring period. There was a positive correlation between SNO-Hb and StO2 (p < 0.001). Furthermore, SNO-Hb levels correlated with and were prognostic for the number of organs transplanted (p < 0.001). These clinical findings provide additional support for the concept that BD induces a systemic impairment of S-nitrosylation that negatively impacts StO2 and reduces organ yield from DNC human donors. Exogenous S-nitrosylating agents are in various stages of clinical development. The results presented here suggest including one or more of these agents in donor support regimens could increase the number and quality of organs available for transplant.
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Affiliation(s)
- Ryan Nazemian
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Anesthesiology and Perioperative Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Maroun Matta
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Pulmonology and Sleep Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Amer Aldamouk
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Anesthesiology and Perioperative Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Lin Zhu
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Anesthesiology and Perioperative Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Mohamed Awad
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Anesthesiology and Perioperative Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Megan Pophal
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Nicole R Palmer
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Anesthesiology and Perioperative Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Tonya Armes
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Alfred Hausladen
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA
| | - Jonathan S Stamler
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Department of Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA.,Harrington Discovery Institute, University Hospitals-Cleveland Medical Center, 4-128 Wolstein Research Building, 2103 Cornell Road, Cleveland, OH, 44106, USA
| | - James D Reynolds
- Institute for Transformative Molecular Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA. .,Department of Anesthesiology and Perioperative Medicine, School of Medicine Case Western Reserve University, Cleveland, OH, USA. .,Harrington Discovery Institute, University Hospitals-Cleveland Medical Center, 4-128 Wolstein Research Building, 2103 Cornell Road, Cleveland, OH, 44106, USA.
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Lele AV, Nair BG, Fong C, Walters AM, Souter MJ. Anesthetic Management of Brain-dead Adult and Pediatric Organ Donors: The Harborview Medical Center Experience. J Neurosurg Anesthesiol 2022; 34:e34-e39. [PMID: 32149890 DOI: 10.1097/ana.0000000000000683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 02/10/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The exposure of anesthesiologists to organ recovery procedures and the anesthetic technique used during organ recovery has not been systematically studied in the United States. METHODS A retrospective cohort study was conducted on all adult and pediatric patients who were declared brain dead between January 1, 2008, and June 30, 2019, and who progressed to organ donation at Harborview Medical Center. We describe the frequency of directing anesthetic care by attending anesthesiologists, anesthetic technique, and donor management targets during organ recovery. RESULTS In a cohort of 327 patients (286 adults and 41 children), the most common cause of brain death was traumatic brain injury (51.1%). Kidneys (94.4%) and liver (87.4%) were the most common organs recovered. On average, each year, an attending anesthesiologist cared for 1 (range: 1 to 7) brain-dead donor during organ retrieval. The average anesthetic time was 127±53.5 (mean±SD) minutes. Overall, 90% of patients received a neuromuscular blocker, 63.3% an inhaled anesthetic, and 33.9% an opioid. Donor management targets were achieved as follows: mean arterial pressure ≥70 mm Hg (93%), normothermia (96%), normoglycemia (84%), urine output >1 to 3 mL/kg/h (61%), and lung-protective ventilation (58%). CONCLUSIONS During organ recovery from brain-dead organ donors, anesthesiologists commonly administer neuromuscular blockers, inhaled anesthetics, and opioids, and strive to achieve donor management targets. While infrequently being exposed to these cases, it is expected that all anesthesiologists be cognizant of the physiological perturbations in brain-dead donors and achieve physiological targets to preserve end-organ function. These findings warrant further examination in a larger multi-institutional cohort.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
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Englbrecht JS, Lanckohr C, Ertmer C, Zarbock A. [Perioperative management of the brain-dead organ donor : Anesthesia between ethics and evidence]. Anaesthesist 2021; 71:384-391. [PMID: 34748026 PMCID: PMC9068648 DOI: 10.1007/s00101-021-01065-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jan Sönke Englbrecht
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Christian Lanckohr
- Antibiotic Stewardship (ABS)-Team, Institut für Hygiene, Universitätsklinikum Münster, Münster, Deutschland
| | - Christian Ertmer
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
| | - Alexander Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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Zheng D, Liu G, Chen L, Xie W, Sun J, Wang S, Tai Q. Effects of Terlipressin on Management of Hypotensive Brain-Dead Patients Who are Potential Organ Donors: A Retrospective Study. Front Pharmacol 2021; 12:716759. [PMID: 34658857 PMCID: PMC8517172 DOI: 10.3389/fphar.2021.716759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 09/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Administration of terlipressin can reverse hypotension in potential organ donors with norepinephrine-resistance. The aim of this study was to determine the effects of terlipressin on the hemodynamics, liver function, and renal function of hypotensive brain-dead patients who were potential organ donors. Methods: A retrospective study was conducted by using the ICU database of one hospital. 18 patients in a total of 294 brain-dead cases were enrolled and administered terlipressin intravenously. All physiological parameters of recruited patients were obtained at baseline, 24 and 72 h after administration, and immediately before organ procurement. Results: Terlipressin induced significant increases in mean arterial pressure (MAP) from 69.56 ± 10.68 mm Hg (baseline) to 101.82 ± 19.27 mm Hg (immediately before organ procurement) and systolic blood pressure (SBP) from 89.78 ± 8.53 mm Hg (baseline) to 133.42 ± 26.11 mm Hg (immediately before organ procurement) in all patients. The increases in MAP were accompanied by significant decreases in heart rate (HR) from 113.56 ± 28.43 bpm (baseline) to 83.89 ± 11.70 bpm (immediately before organ procurement), which resulted in the decrease of norepinephrine dose over time from 0.8 ± 0.2 μg/kg/min (baseline) to 0.09 ± 0.02 μg/kg/min (immediately before organ procurement). There were no changes in central venous pressure, liver function including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin. Renal function, assessed by serum creatinine (SCr), urine output (UOP), creatinine clearance rate (CCr), and estimated glomerular filtration rate (eGFR), improved significantly. Conclusion: Our analysis of brain-dead patients with hypotension indicates that administration of terlipressin can significantly increases MAP, SBP, UOP, CCr, and eGFR, while decreases HR and Scr. Terlipressin appears to help maintain hemodynamic stability, reduce vasoactive support, and improve renal function.
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Affiliation(s)
- Donghua Zheng
- Intensive Care Unit, The East Division of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Genglong Liu
- Department of Pathology, The Affiliated Cancer Hospital, Guangzhou Medical University, Guangzhou, China
| | - Li Chen
- Intensive Care Unit, The East Division of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenfeng Xie
- Intensive Care Unit, The East Division of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiaqi Sun
- Intensive Care Unit, The East Division of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Siqi Wang
- Intensive Care Unit, The East Division of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiang Tai
- Intensive Care Unit, The East Division of the First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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12
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Al-Adhami A, Avtaar Singh SS, De SD, Singh R, Panjrath G, Shah A, Dalzell JR, Schroder J, Al-Attar N. Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma. Curr Probl Cardiol 2021; 47:100941. [PMID: 34404551 DOI: 10.1016/j.cpcardiol.2021.100941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow.
| | - Sudeep Das De
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, Virginia
| | - Gurusher Panjrath
- Heart Failure and Mechanical Circulatory Support Program, George Washington University Hospital, Washington, DC
| | - Amit Shah
- Advanced Heart Failure and Cardiac Transplant Unit, Fiona Stanley Hospital, Perth, Australia
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Jacob Schroder
- Heart Transplantation Program, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow
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13
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Perioperative management of the organ donor after diagnosis of death using neurological criteria. BJA Educ 2021; 21:194-200. [PMID: 33927892 DOI: 10.1016/j.bjae.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 01/03/2021] [Indexed: 11/19/2022] Open
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14
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Neuberger J, Callaghan C. Organ utilization - the next hurdle in transplantation? Transpl Int 2020; 33:1597-1609. [PMID: 32935386 DOI: 10.1111/tri.13744] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/26/2020] [Accepted: 09/08/2020] [Indexed: 12/14/2022]
Abstract
Nonutilization of organs from consented deceased donors remains a significant factor in limiting patient access to transplantation. Critical to reducing waste is a clear understanding of why organs are not used: accurate metrics are essential to identify the extent and causes of waste but use of these measures as targets or comparators between units/jurisdictions must be done with caution as focus on any one measure may result in unintended adverse consequences. Comparison between centres or countries may be misleading because of variation in definitions, patient or graft characteristics. Two of the most challenging areas to improve appropriate deceased donor organ utilization are appetite for risk and lack of validated tools to help identify an organ that will function appropriately. Currently, the implanting surgeon is widely considered to be accountable for the use of a donated organ so guidelines must be clear to allow and support sensible decisions and recognition that graft failure or inadvertent disease transmission are not necessarily attributable to poor decision-making. Accepting an organ involves balancing risk and benefit for the potential recipient. Novel technologies such as machine perfusion may allow for more robust guidance as to the functioning of the organ.
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Affiliation(s)
| | - Chris Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, Guy's Hospital and the Evelina London Children's Hospital, London, UK
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15
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Hwang HP, Kim JM, Shin S, Ahn HJ, Lee S, Joo DJ, Han SY, Haam SJ, Hwang JK, Yu HC. Organ procurement in a deceased donor. KOREAN JOURNAL OF TRANSPLANTATION 2020; 34:134-150. [PMID: 35769061 PMCID: PMC9186815 DOI: 10.4285/kjt.2020.34.3.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/11/2022] Open
Abstract
With the increasing demand for organ transplantation, organ procurement from a deceased donor is an essential step for deceased donor organ transplantation. A proper surgical technique for the procurement of an organ graft from a deceased donor must be carried out to avoid any damage to it. Moreover, how to manage deceased donors until they enter the operating room in a stable condition is a critical point to be considered. The establishment of a surgical technique and preoperative management for organ procurement is encouraged to achieve a nationwide standard and consistency for organ graft sharing among the transplant units.
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Affiliation(s)
- Hong Pil Hwang
- Department of Surgery, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Shin
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyung Joon Ahn
- Division of Transplantation and Vascular Surgery, Department of Surgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Sik Lee
- Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yeup Han
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Seok Jin Haam
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jeong Kye Hwang
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee Chul Yu
- Department of Surgery, Research Institute of Clinical Medicine, Biomedical Research Institute, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
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16
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Abstract
Primary graft dysfunction (PGD) remains the leading cause of early mortality post-heart transplantation. Despite improvements in mechanical circulatory support and critical care measures, the rate of PGD remains significant. A recent consensus statement by the International Society of Heart and Lung Transplantation (ISHLT) has formulated a definition for PGD. Five years on, we look at current concepts and future directions of PGD in the current era of transplantation.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, Scotland.
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland.
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland.
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, Scotland
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, Scotland
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland
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17
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Champigneulle B, Neuschwander A, Bronchard R, Favé G, Josserand J, Lebas B, Bastien O, Pirracchio R. Intraoperative management of brain-dead organ donors by anesthesiologists during an organ procurement procedure: results from a French survey. BMC Anesthesiol 2019; 19:108. [PMID: 31202272 PMCID: PMC6570868 DOI: 10.1186/s12871-019-0766-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed at describing usual anesthetic practices for brain-dead donors (BDD) during an organ procurement (OP) procedure and to assess the knowledge and self-confidence of French anesthesiologists with this practice. METHODS An electronic and anonymous survey with closed-questions about anesthetic management of BDD was distributed to French anesthesiologists via the mailing list of the French Society of Anesthesiology and Intensive Care Medicine. RESULTS Four hundred fifty-eight responses were analyzed. Respondents were mainly attending physicians with more than 10 years of clinical experience. 78% of them declared being cognizant of guidelines regarding management of BDD. Advanced hemodynamic monitoring and endocrine substitution were rarely considered by respondents (31 and 35% of respondents, respectively). 98% of the respondents used crystalloids for fluid resuscitation. During the procedure, use of neuromuscular blockers, opioids and sedative agents were considered by respectively 84, 61 and 27% of the respondents. A very high level of agreement (10 [8-10], on a ten-points Likert-style scale) was reported concerning the expected impact of intraoperative anesthetic management on the primary function of grafts. CONCLUSIONS Declared anesthetic practice appeared in accordance with guidelines concerning organ donor management in the ICU. Further studies are needed to evaluate the specific impact of intraoperative management during this procedure and thus the need for specific anesthetic guidelines.
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Affiliation(s)
- Benoit Champigneulle
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France.,West francilian network for organ and tissue procurement, Paris, France
| | - Arthur Neuschwander
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France
| | - Régis Bronchard
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France
| | - Gersende Favé
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France.,Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Julien Josserand
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France
| | - Benjamin Lebas
- Anesthesiology and Intensive Care Department, Hautepierre Hospital, Strasbourg, France
| | - Olivier Bastien
- Agence de la Biomédecine, Direction Prélèvement Greffe Organes-Tissus, Saint-Denis La Plaine, France
| | - Romain Pirracchio
- Anesthesiology and Intensive Care Department, European Hospital Georges-Pompidou, Assistance Publique - Hôpitaux de Paris (AP-HP), 20 rue Leblanc, 75015, Paris, France. .,Paris Descartes University, Sorbonne Paris Cité, Paris, France. .,Département de biostatistiques et d'informatique médicale, INSERM U-1153, Équipe ECSTRA, Université Paris Diderot; Hôpital Saint-Louis, AP-HP, Paris, France.
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18
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Zerillo J, Ramsay M, Mandell MS, Sakai T. An Update in Abdominal Organ Transplantation Anesthesia in 2018: Society for the Advancement of Transplant Anesthesia (SATA). Semin Cardiothorac Vasc Anesth 2018; 22:109-110. [PMID: 29701539 DOI: 10.1177/1089253218768558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - M Susan Mandell
- 3 University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tetsuro Sakai
- 4 University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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