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Tannous LA, Westphal GA, Ioshii SO, de Lima Alves GN, Pigatto RN, Pinto RL, de Carvalho KAT, Francisco JC, Guarita-Souza LC. Histological, Laboratorial, and Clinical Benefits of an Optimized Maintenance Strategy of a Potential Organ Donor-A Rabbit Experimental Model. Life (Basel) 2023; 13:1439. [PMID: 37511814 PMCID: PMC10381703 DOI: 10.3390/life13071439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Most transplanted organs are obtained from brain-dead donors. Inflammation results in a higher rate of rejection. Objectives: The objective of this animal model of brain death (BD) was to evaluate the effect of the progressive institution of volume expansion, norepinephrine, and combined hormone therapy on clinical, laboratory, and histological aspects. Methods: Twenty rabbits were divided: A (control), B (induction of BD + infusion of crystalloid), C (BD + infusion of crystalloid and noradrenaline (NA)), and D (BD + infusion of crystalloid + vasopressin + levothyroxine + methylprednisolone + NA). The animals were monitored for four hours with consecutives analysis of vital signs and blood samples. The organs were evaluated by a pathologist. Results: In Group D, we observed fewer number and lesser volume of infusions (p = 0.032/0.014) when compared with groups B and C. Mean arterial pressure levels were higher in group D when compared with group B (p = 0.008). Group D had better glycemic control when compared with group C (p = 0.016). Sodium values were elevated in group B in relation to groups C and D (p = 0.021). In Group D, the organ perfusion was better. Conclusion: The optimized strategy of management of BD animals is associated with better hemodynamic, glycemic, and natremia control, besides reducing early signs of ischemia.
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Affiliation(s)
- Luana Alves Tannous
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Sergio Ossamu Ioshii
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | - Raul Nishi Pigatto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | - Rafael Luiz Pinto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
| | | | | | - Luiz César Guarita-Souza
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba 80215-901, Paraná, Brazil
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2
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Polanco Pujol L, Velasco JC, González García J, Herranz Amo F, Lledó García E, Chomón GB, Castro JMD, Chamizo JA, Chacón GA, Gárate MM, Ríos DS, Diez Cordero J, Durán Merino R, Hernández Fernández C. Deceased donor kidney procurement: Systematic review of the surgical technique. ACTAS UROLÓGICAS ESPAÑOLAS (ENGLISH EDITION) 2022; 47:140-148. [PMID: 36462604 DOI: 10.1016/j.acuroe.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/28/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation. OBJECTIVES Review of the available literature on kidney procurement procedure. MATERIAL AND METHODS Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish. RESULTS Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time. CONCLUSIONS Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.
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Renaudier M, Binois Y, Dumas F, Lamhaut L, Beganton F, Jost D, Charpentier J, Lesieur O, Marijon E, Jouven X, Cariou A, Bougouin W. Organ donation after out-of-hospital cardiac arrest: a population-based study of data from the Paris Sudden Death Expertise Center. Ann Intensive Care 2022; 12:48. [PMID: 35666323 PMCID: PMC9170852 DOI: 10.1186/s13613-022-01023-7] [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: 02/21/2022] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Organ shortage is a major public health issue, and patients who die after out-of-hospital cardiac arrest (OHCA) could be a valuable source of organs. Here, our objective was to identify factors associated with organ donation after brain death complicating OHCA, in unselected patients entered into a comprehensive real-life registry covering a well-defined geographic area. METHODS We prospectively analyzed consecutive adults with OHCA who were successfully resuscitated, but died in intensive care units in the Paris region in 2011-2018. The primary outcome was organ donation after brain death. Independent risk factors were identified using logistic regression analysis. One-year graft survival was assessed using Cox and log-rank tests. RESULTS Of the 3061 included patients, 136 (4.4%) became organ donors after brain death, i.e., 28% of the patients with brain death. An interaction between admission pH and post-resuscitation shock was identified. By multivariate analysis, in patients with post-resuscitation shock, factors associated with organ donation were neurological cause of OHCA (odds ratio [OR], 14.5 [7.6-27.4], P < 0.001), higher pH (OR/0.1 increase, 1.3 [1.1-1.6], P < 0.001); older age was negatively associated with donation (OR/10-year increase, 0.7 [0.6-0.8], P < 0.001). In patients without post-resuscitation shock, the factor associated with donation was neurological cause of OHCA (OR, 6.9 [3.0-15.9], P < 0.001); higher pH (OR/0.1 increase, 0.8 [0.7-1.0], P = 0.04) and OHCA at home (OR, 0.4 [0.2-0.7], P = 0.006) were negatively associated with organ donation. One-year graft survival did not differ according to Utstein characteristics of the donor. CONCLUSIONS 4% of patients who died in ICU after OHCA led to organ donation. Patients with OHCA constitute a valuable source of donated organs, and special attention should be paid to young patients with OHCA of neurological cause.
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Affiliation(s)
- M Renaudier
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - Y Binois
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - F Dumas
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Emergency Department, Cochin-Hotel-Dieu Hospital, AP-HP, Paris, France.,Université de Paris, Paris, France
| | - L Lamhaut
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Intensive Care Unit and SAMU 75, Necker Enfants-Malades Hospital, Paris, France
| | - F Beganton
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France
| | - D Jost
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Brigade Des Sapeurs-Pompiers de Paris (BSPP), Paris, France
| | - J Charpentier
- Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris Cedex 14, France
| | - O Lesieur
- Université de Paris, Paris, France.,Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - E Marijon
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - X Jouven
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Université de Paris, Paris, France.,Cardiology Department, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - A Cariou
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France. .,Paris Sudden Death Expertise Center, Paris, France. .,Université de Paris, Paris, France. .,Medical Intensive Care Unit, AP-HP, Cochin Hospital, Paris Cedex 14, France.
| | - W Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France.,Paris Sudden Death Expertise Center, Paris, France.,Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
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Polanco Pujol L, Velasco JC, González García J, Herranz Amo F, Lledó García E, Chomón GB, Castro JMD, Chamizo JA, Chacón GA, Gárate MM, Ríos DS, Diez Cordero J, Durán Merino R, Hernández Fernández C. Extracción renal en donante cadáver: revisión sistemática de la técnica quirúrgica. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Neuroprognostication after Cardiac Arrest: Who Recovers? Who Progresses to Brain Death? Semin Neurol 2021; 41:606-618. [PMID: 34619784 DOI: 10.1055/s-0041-1733789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Approximately 15% of deaths in developed nations are due to sudden cardiac arrest, making it the most common cause of death worldwide. Though high-quality cardiopulmonary resuscitation has improved overall survival rates, the majority of survivors remain comatose after return of spontaneous circulation secondary to hypoxic ischemic injury. Since the advent of targeted temperature management, neurologic recovery has improved substantially, but the majority of patients are left with neurologic deficits ranging from minor cognitive impairment to persistent coma. Of those who survive cardiac arrest, but die during their hospitalization, some progress to brain death and others die after withdrawal of life-sustaining treatment due to anticipated poor neurologic prognosis. Here, we discuss considerations neurologists must make when asked, "Given their recent cardiac arrest, how much neurologic improvement do we expect for this patient?"
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Yoshikawa MH, Rabelo NN, Welling LC, Telles JPM, Figueiredo EG. Brain death and management of the potential donor. Neurol Sci 2021; 42:3541-3552. [PMID: 34138388 PMCID: PMC8210518 DOI: 10.1007/s10072-021-05360-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 05/28/2021] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Marcia Harumy Yoshikawa
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil.
| | - Nícollas Nunes Rabelo
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil
| | | | - João Paulo Mota Telles
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil
| | - Eberval Gadelha Figueiredo
- Department of Neurological Surgery, University of Sao Paulo, Rua Eneas Aguiar, 255, São Paulo, 05403-010, Brazil
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Lugon Ferreira-Jr AC, Miguel GPS, Moscon I, Abreu IW, Aguiar JBDEOS, Vecci TRDS. Comparison of results on the use of extended criteria liver doners for transplants in Espírito Santo. Rev Col Bras Cir 2021; 48:e20202492. [PMID: 33978120 PMCID: PMC10683471 DOI: 10.1590/0100-6991e-20202492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/18/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION liver Transplantation is currently the treatment of choice for several terminal liver diseases. Despite the increase in performed transplants, the waiting lists continue to increase. In order to expand the supply of organs, transplantation teams have started to use previously rejected livers for transplants because of an increased risk of unfavorable outcomes. OBJECTIVE to evaluate the use of livers of expanded criterion donators. METHODS retrospective study of medical records. The livers were classified as normal or expanded criteria. The groups were divided in low and high MELD. A multivariate analysis was performed through logistic regression. RESULTS there was no statistical difference regarding early, late and global mortality between the groups. Decreased survival was observed in patients with high MELD (higher or equal to 20) when they received grafts from expanded criterion donators. The association between the occurrence of cardiorespiratory arrest and presence of elevated total bilirubin in donators was associated with higher mortality rates in expanded criterion livers. CONCLUSION the overall results are similar, but expanded criteria liver donators was associated with higher mortality in patients with high MELD.
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Affiliation(s)
| | - Gustavo Peixoto Soares Miguel
- - Meridional Hospital, Transplant Center - Cariacica - ES - Brasil
- - Federal University of Espírito Santo, Surgycal Clinic - Vitória - ES - Brasil
| | - Iara Moscon
- - Federal University of Espírito Santo, Surgycal Clinic - Vitória - ES - Brasil
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8
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Organ donation in the US and Europe: The supply vs demand imbalance. Transplant Rev (Orlando) 2020; 35:100585. [PMID: 33071161 DOI: 10.1016/j.trre.2020.100585] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Abstract
Organ donation and transplantation remain the best and most cost-effective clinical solution for end-stage organ failure. Several agencies across the US and Europe provide legislative, regulatory, and humanitarian services to generate smoother applications in all transplantation processes and donor-recipient relationships. US and European statistics present nine types of grafts, with kidneys being the most transplanted organ worldwide. However, organ shortage, religion, underrepresented minority groups, difficulties in obtaining consent, lack of understanding, and general ethical concerns present challenging barriers to organ donation, reflecting the complexity of graft procurement and allocation. Breaking down these barriers to reduce the organ-supply imbalance requires an appropriate multifaceted approach. Some of the key areas include increasing the potential donor pool and consent rates, apt organ allocation, and improving organ health. Additionally, suitable policies and standardized guidelines for both donors and recipients, alongside educational initiatives, are needed to ensure patient safety and global awareness. Looking forward, novel and effective research plans and initiatives are needed if we are to avoid a colossal supply-demand gap.
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9
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Valdes E, Agarwal S, Carroll E, Kvernland A, Bondi S, Snyder T, Kwon P, Frontera J, Gurin L, Czeisler B, Lewis A. Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2. J Neurol Sci 2020; 417:117087. [PMID: 32798855 PMCID: PMC7414304 DOI: 10.1016/j.jns.2020.117087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/14/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined. METHODS We describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes. RESULTS Four males and two females with a median age of 58.5 (IQR 47-68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13-18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support. CONCLUSION It is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.
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Affiliation(s)
- Eduard Valdes
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America.
| | - Shashank Agarwal
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Elizabeth Carroll
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Alexandra Kvernland
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Steven Bondi
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Thomas Snyder
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Patrick Kwon
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Jennifer Frontera
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
| | - Lindsey Gurin
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Psychiatry, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Rehabilitation Medicine, New York, NY 10016, United States of America
| | - Barry Czeisler
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
| | - Ariane Lewis
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
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Alnajjar HA, Alzahrani M, Alzahrani M, Banweer M, Alsolami E, Alsulami A. Awareness of brain death, organ donation, and transplantation among medical students at single academic institute. Saudi J Anaesth 2020; 14:329-334. [PMID: 32934625 PMCID: PMC7458020 DOI: 10.4103/sja.sja_765_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/31/2020] [Accepted: 01/16/2020] [Indexed: 11/19/2022] Open
Abstract
Objective: To assess the knowledge of the concept of brain death, attitude, and level of awareness towards organ donation and transplantation, among medical students and interns at the University of Jeddah, Kingdom of Saudi Arabia. Methods: A cross-sectional study via electronic questionnaire over period of 3 weeks to 2nd through 6th year medical students and interns at university of Jeddah. Results: A response rate of 113 out of 151 (74.83%) was achieved. Among participants, 36% expressed uncertainty when questioned about the concept of brain death. 8.8% of the participants were against the idea of organ donation. 60% of those who refused to contemplate organ donation were unfamiliar with the brain death concept. No significant difference was seen regarding fears about cosmetic disfiguration between those familiar and unfamiliar with the concept of brain death. 60.2% of the study cohort would consider donating their organs to family members but only 29.2% of them had discussed the matter of organ donation and transplantation with them, while 44.2% had discussed the matter with their friends. Majority of medical students (71.7%) were interested in being organ donors. Conclusion: Knowledge of organ donation and transplantation were adequate. Matter accepting brain death and its implication still not clear for most of participants. We believe there is still room to improve. This could be achieved by integrating more education about different aspects of brain death and its implications through medical school years.
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Affiliation(s)
- Hani A Alnajjar
- Department of Anesthesia, University of Jeddah, Hamzah Ibn Al Qasim Street, Al Sharafeyah, Jeddah, Saudi Arabia
| | - Maan Alzahrani
- Medical Student, University of Jeddah, Hamzah Ibn Al Qasim Street, Al Sharafeyah, Jeddah, Saudi Arabia
| | - Muath Alzahrani
- Medical Student, University of Jeddah, Hamzah Ibn Al Qasim Street, Al Sharafeyah, Jeddah, Saudi Arabia
| | - Mazen Banweer
- Medical Student, University of Jeddah, Hamzah Ibn Al Qasim Street, Al Sharafeyah, Jeddah, Saudi Arabia
| | - Essam Alsolami
- Medical Student, University of Jeddah, Hamzah Ibn Al Qasim Street, Al Sharafeyah, Jeddah, Saudi Arabia
| | - Azzam Alsulami
- Medical Student, University of Jeddah, Hamzah Ibn Al Qasim Street, Al Sharafeyah, Jeddah, Saudi Arabia
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Marklin GF, Klinkenberg WD, Helmers B, Ahrens T. A stroke volume-based fluid resuscitation protocol decreases vasopressor support and may increase organ yield in brain-dead donors. Clin Transplant 2020; 34:e13784. [PMID: 31957104 DOI: 10.1111/ctr.13784] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 01/13/2020] [Indexed: 11/29/2022]
Abstract
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.
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Abstract
BACKGROUND Over the past 30 years, the demographics, clinical characteristics, and management of trauma patients have changed dramatically. During this same period, the organ donor population has also changed. The interactions between these two demographic shifts have not been examined in a systematic way. We hypothesize that trauma victims continue to be an important source of organs. We set out to systematically examine traumatic donors in an attempt to identify opportunities to increase organ recovery and quality. METHODS In this retrospective analysis, we compared trauma donors (TDs) and non-TDs (NTDs) in the Scientific Registry of Transplant Recipients standard analysis files, a clinical data set collected by the Organ Procurement Transplant Network on all solid organ transplant candidates, donors, and recipients in the United States since 1987. RESULTS Scientific Registry of Transplant Recipients contained data on 191,802 deceased donors. The percentage of TDs decreased from 55.3% in 1987 to 35.8% in 2016 (p < 0.001) primarily due to a steady increase in NTDs. Trauma donors are younger and have fewer comorbidities while the percentage of donors who were public health service high risk or who underwent donation after cardiac death were clinically similar. The TDs produce more organs/donor (3.5 vs. 2.4, p < 0.001), are more likely to yield an extrarenal organ, and exhibit lower (better) Kidney Donor Risk Index scores, a predictor of graft longevity. These better outcomes are maintained after stratifying by age. CONCLUSION Over the past 30 years, the number of NTDs has increased much more than the number of TDs. However, TDs remain a critically important organ donor source, yielding more organs per donor, better quality kidneys, and a higher likelihood of extrarenal organs. Potential causes, such as improved resuscitation protocols, should be examined in the future. LEVEL OF EVIDENCE Retrospective review, level III.
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Abstract
OBJECTIVES To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral. DATA SOURCES Medline and Embase databases from January 2006 to September 2017. STUDY SELECTION All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations. DATA EXTRACTION Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers. DATA SYNTHESIS One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported. CONCLUSIONS Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.
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Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality. Intensive Care Med 2019; 45:343-353. [PMID: 30741327 PMCID: PMC7095373 DOI: 10.1007/s00134-019-05551-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/28/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To provide a practical overview of the management of the potential organ donor in the intensive care unit. METHODS Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted. RESULTS AND CONCLUSIONS Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely.
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Hoste P, Ferdinande P, Vogelaers D, Vanhaecht K, Hoste E, Rogiers X, Eeckloo K, Vandewoude K. Adherence to guidelines for the management of donors after brain death. J Crit Care 2018; 49:56-63. [PMID: 30388489 DOI: 10.1016/j.jcrc.2018.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/02/2018] [Accepted: 10/19/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Pieter Hoste
- Department of General Internal Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Intensive Care, General Hospital Sint-Lucas Ghent, Groenebriel 1, 9000 Ghent, Belgium.
| | - Patrick Ferdinande
- Surgical and Transplantation ICU, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Dirk Vogelaers
- Department of General Internal Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; European Pathway Association, Kapucijnenvoer 35, 3000 Leuven, Belgium.
| | - Eric Hoste
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Research Foundation - Flanders (FWO), Egmontstraat 5, 1000 Brussels, Belgium.
| | - Xavier Rogiers
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Transplant Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Kristof Eeckloo
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium.
| | - Koenraad Vandewoude
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 3K3, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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16
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Hoste P, Hoste E, Ferdinande P, Vandewoude K, Vogelaers D, Van Hecke A, Rogiers X, Eeckloo K, Vanhaecht K. Development of key interventions and quality indicators for the management of an adult potential donor after brain death: a RAND modified Delphi approach. BMC Health Serv Res 2018; 18:580. [PMID: 30041683 PMCID: PMC6056930 DOI: 10.1186/s12913-018-3386-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 06/12/2018] [Accepted: 07/12/2018] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Pieter Hoste
- Department of General Internal Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Department of Intensive Care, General Hospital Sint-Lucas, Groenebriel 1, 9000, Ghent, Belgium.
| | - Eric Hoste
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Research Foundation - Flanders (FWO), Egmontstraat 5, 1000, Brussels, Belgium
| | - Patrick Ferdinande
- Surgical and Transplantation ICU, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Koenraad Vandewoude
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Dirk Vogelaers
- Department of General Internal Medicine, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Ann Van Hecke
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,University Centre for Nursing and Midwifery, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of Public Health, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Nursing Department, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Xavier Rogiers
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,Department of Transplant Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Kristof Eeckloo
- Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35, 3000, Leuven, Belgium.,Department of Quality Management, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,European Pathway Association, Kapucijnenvoer 35, 3000, Leuven, Belgium
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Nakamura MT, Rodio GE, Tchaicka C, Padilha EF, Jorge AC, Duarte PAD. Predictors of Organ Donation Among Patients With Brain Death in the Intensive Care Unit. Transplant Proc 2018; 50:1220-1226. [PMID: 29731163 DOI: 10.1016/j.transproceed.2018.02.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- M T Nakamura
- Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | - G E Rodio
- Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | - C Tchaicka
- General ICU, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil.
| | - E F Padilha
- Transplantation and Organ Donation Committee, Hospital Universitário do Oeste do Paraná, Cascavel/PR, Brazil
| | - A C Jorge
- General ICU, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | - P A D Duarte
- General ICU, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
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18
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Ríos A, López-Navas A, López-López A, Gómez FJ, Iriarte J, Herruzo R, Blanco G, Llorca FJ, Asunsolo A, Sánchez P, Gutiérrez PR, Fernández A, de Jesús MT, Alarcón LM, del Olivo M, Fuentes L, Hernández JR, Virseda J, Yelamos J, Bondía JA, Hernández AM, Ayala MA, Ramírez P, Parrilla P. Do Spanish Medical Students Understand the Concept of Brain Death? Prog Transplant 2018; 28:77-82. [DOI: 10.1177/1526924817746687] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To analyze the level of understanding of the brain death concept among medical students in universities in Spain. Methods: This cross-sectional sociological, interdisciplinary, and multicenter study was performed on 9598 medical students in Spain. The sample was stratified by geographical area and academic year. A previously validated self-reported measure of brain death knowledge (questionnaire Proyecto Colaborativo Internacional Donante sobre la Donación y Transplante de Organos) was completed anonymously by students. Results: Respondents completed 9275 surveys for a completion rate of 95.7%. Of those, 67% (n = 6190) of the respondents understood the brain death concept. Of the rest, 28% (n = 2652) did not know what it meant, and the remaining 5% (n = 433) believed that it did not mean that the patient was dead. The variables related to a correct understanding of the concept were: (1) being older ( P < .001), (2) studying at a public university ( P < .001), (3) year of medical school ( P < .001), (4) studying at one of the universities in the south of Spain ( P = .003), (5) having discussed donation and transplantation with the family ( P < .001), (6) having spoken to friends about the matter ( P < .001), (7) a partner’s favorable attitude toward donation and transplantation ( P < .001), and (8) religious beliefs ( P < .001). Conclusions: Sixty-seven percent of medical students know the concept of brain death, and knowledge improved as they advanced in their degree.
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Affiliation(s)
- Antonio Ríos
- International Collaborative Donor Project (“Proyecto Colaborativo Internacional Donante”), Murcia, Spain
- Department of Surgery, Paediatrics, Obstetrics and Gynaecology, University of Murcia, Murcia, Spain
- Transplant Unit, Surgery Service, IMIB—Virgen de la Arrixaca University Hospital, Murcia, Spain
- Regional Transplant Centre, Consejería de Sanidad y Consumo, Murcia, Spain
| | - A. López-Navas
- International Collaborative Donor Project (“Proyecto Colaborativo Internacional Donante”), Murcia, Spain
- Department of Psychology, Universidad Católica San Antonio (UCAM), Murcia, Spain
| | - A. López-López
- San Juan University Hospital of Alicante, Alicante, Spain
| | | | | | - R. Herruzo
- Universidad Autónoma de Madrid, Madrid, Spain
| | - G. Blanco
- Liver Transplant Unit, Hospital Infanta Cristina, Badajoz, Spain
| | | | - A. Asunsolo
- Department of Surgery, Universidad de Alcalá de Henares, Madrid, Spain
| | - P. Sánchez
- Facultad de Medicina, Universidad de Málaga, Málaga, Spain
| | - P. R. Gutiérrez
- Department of Surgery, Universidad de La Laguna, Tenerife, Spain
| | - A. Fernández
- Departamento de Ciencias Biomédicas Básicas, Universidad Europea de Madrid, Madrid, Spain
| | | | - L. Martínez Alarcón
- International Collaborative Donor Project (“Proyecto Colaborativo Internacional Donante”), Murcia, Spain
- Transplant Unit, Surgery Service, IMIB—Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - M. del Olivo
- Medicine Faculty, Universidad de Oviedo, Oviedo, Spain
| | - L. Fuentes
- Department of Pharmacology and Physiology, Universidad de Zaragoza, Huesca, Spain
| | - J. R. Hernández
- Universidad de las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Islas Canarias, Spain
| | - J. Virseda
- Universidad de Castilla La Mancha, Albacete, Spain
| | - J. Yelamos
- Department of Immunology, Hospital del Mar, Barcelona, Spain
| | - J. A. Bondía
- Facultad de Medicina, Universidad de Málaga, Málaga, Spain
| | - A. M. Hernández
- Endocrinology and Nutrition Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - M. A. Ayala
- Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, Mexico
- HGSZ No. 10 del Instituto Mexicano del Seguro Social Delegación Guanajuato, Guanajuato, Mexico
| | - P. Ramírez
- International Collaborative Donor Project (“Proyecto Colaborativo Internacional Donante”), Murcia, Spain
- Department of Surgery, Paediatrics, Obstetrics and Gynaecology, University of Murcia, Murcia, Spain
- Transplant Unit, Surgery Service, IMIB—Virgen de la Arrixaca University Hospital, Murcia, Spain
- Regional Transplant Centre, Consejería de Sanidad y Consumo, Murcia, Spain
| | - P. Parrilla
- Department of Surgery, Paediatrics, Obstetrics and Gynaecology, University of Murcia, Murcia, Spain
- Transplant Unit, Surgery Service, IMIB—Virgen de la Arrixaca University Hospital, Murcia, Spain
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Zens TJ, Danobeitia JS, Chlebeck PJ, Zitur LJ, Odorico S, Brunner K, Coonen J, Capuano S, D’Alessandro AM, Matkowskyj K, Zhong W, Torrealba J, Fernandez L. Guidelines for the management of a brain death donor in the rhesus macaque: A translational transplant model. PLoS One 2017; 12:e0182552. [PMID: 28926566 PMCID: PMC5604963 DOI: 10.1371/journal.pone.0182552] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 07/20/2017] [Indexed: 01/08/2023] Open
Abstract
Introduction The development of a translatable brain death animal model has significant potential to advance not only transplant research, but also the understanding of the pathophysiologic changes that occur in brain death and severe traumatic brain injury. The aim of this paper is to describe a rhesus macaque model of brain death designed to simulate the average time and medical management described in the human literature. Methods Following approval by the Institutional Animal Care and Use Committee, a brain death model was developed. Non-human primates were monitored and maintained for 20 hours after brain death induction. Vasoactive agents and fluid boluses were administered to maintain hemodynamic stability. Endocrine derangements, particularly diabetes insipidus, were aggressively managed. Results A total of 9 rhesus macaque animals were included in the study. The expected hemodynamic instability of brain death in a rostral to caudal fashion was documented in terms of blood pressure and heart rate changes. During the maintenance phase of brain death, the animal’s temperature and hemodynamics were maintained with goals of mean arterial pressure greater than 60mmHg and heart rate within 20 beats per minute of baseline. Resuscitation protocols are described so that future investigators may reproduce this model. Conclusion We have developed a reproducible large animal primate model of brain death which simulates clinical scenarios and treatment. Our model offers the opportunity for researchers to have translational model to test the efficacy of therapeutic strategies prior to human clinical trials.
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Affiliation(s)
- Tiffany J. Zens
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Juan S. Danobeitia
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Peter J. Chlebeck
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Laura J. Zitur
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Scott Odorico
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Kevin Brunner
- Wisconsin Primate Research Center, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Jennifer Coonen
- Wisconsin Primate Research Center, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Saverio Capuano
- Wisconsin Primate Research Center, University of Wisconsin, Madison, Wisconsin, United States of America
| | - Anthony M. D’Alessandro
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Kristina Matkowskyj
- University of Wisconsin Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Weixiong Zhong
- University of Wisconsin Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Jose Torrealba
- University of Texas Southwestern Medical Center Department of Pathology, Dallas, Texas, United States of America
| | - Luis Fernandez
- University of Wisconsin Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- * E-mail:
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Hernández-Tejedor A, Peñuelas O, Sirgo Rodríguez G, Llompart-Pou J, Palencia Herrejón E, Estella A, Fuset Cabanes M, Alcalá-Llorente M, Ramírez Galleymore P, Obón Azuara B, Lorente Balanza J, Vaquerizo Alonso C, Ballesteros Sanz M, García García M, Caballero López J, Socias Mir A, Serrano Lázaro A, Pérez Villares J, Herrera-Gutiérrez M. Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.medine.2017.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. Med Intensiva 2017; 41:285-305. [PMID: 28476212 DOI: 10.1016/j.medin.2017.03.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/25/2017] [Accepted: 03/11/2017] [Indexed: 12/14/2022]
Abstract
The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.
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22
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Organ donor management: Eight common recommendations and actions that deserve reflection. Med Intensiva 2017; 41:559-568. [PMID: 28318674 DOI: 10.1016/j.medin.2017.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 01/18/2023]
Abstract
Despite major advances in our understanding of the physiopathology of brain death (BD), there are important controversies as to which protocol is the most appropriate for organ donor management. Many recent reviews on this subject offer recommendations that are sometimes contradictory and in some cases are not applied to other critically ill patients. This article offers a review of the publications (many of them recent) with an impact upon these controversial measures and which can help to confirm, refute or open new areas of research into the most appropriate measures for the management of organ donors in BD, and which should contribute to discard certain established recommendations based on preconceived ideas, that lead to actions lacking a physiopathological basis. Aspects such as catecholamine storm management, use of vasoactive drugs, hemodynamic objectives and monitoring, assessment of the heart for donation, and general care of the donor in BD are reviewed.
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Connor JP, Cunningham AM, Raife T, Rose WN, Medow JE. Standardization of transfusion practice in organ donors using the Digital Intern, an electronic decision support algorithm. Transfusion 2017; 57:1369-1375. [DOI: 10.1111/trf.14066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Joseph P. Connor
- Department of Pathology and Laboratory Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - Ashley M. Cunningham
- Department of Pathology and Laboratory Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - Thomas Raife
- Department of Pathology and Laboratory Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - William N. Rose
- Department of Pathology and Laboratory Medicine; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
| | - Joshua E. Medow
- Department of Neurological Surgery; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin
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Abstract
Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.
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Affiliation(s)
- C B Maciel
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - D Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - D M Greer
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
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Hu XJ, Dong NG, Liu JP, Li F, Sun YF, Wang Y. Status on Heart Transplantation in China. Chin Med J (Engl) 2016; 128:3238-42. [PMID: 26612301 PMCID: PMC4794876 DOI: 10.4103/0366-6999.170238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Nian-Guo Dong
- Department of Cardiovascular Surgery; Organ Transplantation Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
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Hoste P, Ferdinande P, Hoste E, Vanhaecht K, Rogiers X, Eeckloo K, Van Deynse D, Ledoux D, Vandewoude K, Vogelaers D. Recommendations for further improvement of the deceased organ donation process in Belgium. Acta Clin Belg 2016; 71:303-12. [PMID: 27594299 DOI: 10.1080/17843286.2016.1216259] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Belgium has achieved high deceased organ donation rates but according to the medical record data in the Donor Action database, deceased potential donors are still missed along the pathway. Between 2010 and 2014, 12.9 ± 3.3% of the potential donors after brain death (DBD) and 24.6 ± 1.8% of the potential donors after circulatory (DCD) death were not identified. Conversion rates of 41.7 ± 2.1% for DBD and 7.9 ± 0.9% for DCD indicate room for further improvement. We identify and discuss different issues in the monitoring of donation activities, practices and outcomes; donor pool; legislation on deceased organ donation; registration; financial reimbursement; educational and training programs; donor detection and practice clinical guidance. The overall aim of this position paper, elaborated by a Belgian expert panel, is to provide recommendations for further improvement of the deceased organ donation process up to organ procurement in Belgium.
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Organ donation in adults: a critical care perspective. Intensive Care Med 2016; 42:305-315. [DOI: 10.1007/s00134-015-4191-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 12/13/2015] [Indexed: 10/22/2022]
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Redelmeier DA, Scales DC. Missing the Diagnosis of Brain Death as a Self-Erasing Error. Am J Respir Crit Care Med 2015; 192:280-2. [PMID: 26230234 DOI: 10.1164/rccm.201503-0499oe] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Donald A Redelmeier
- 1 Department of Medicine and.,2 Clinical Epidemiology Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences in Ontario, Toronto, Ontario, Canada.,4 Division of General Internal Medicine and.,5 Center for Leading Injury Prevention Practice Education and Research, Toronto, Ontario, Canada
| | - Damon C Scales
- 1 Department of Medicine and.,7 Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.,2 Clinical Epidemiology Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,3 Institute for Clinical Evaluative Sciences in Ontario, Toronto, Ontario, Canada.,6 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; and
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Coberly EA, Booth GS. Ten-year retrospective review of transfusion practices in beating-heart organ donors. Transfusion 2015; 56:339-43. [PMID: 26443559 DOI: 10.1111/trf.13340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/12/2015] [Accepted: 08/12/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent studies suggest that restrictive transfusion strategies are equivocal or noninferior to liberal strategies in various patient populations; however, evidence for the optimal transfusion threshold or current transfusion practice in beating-heart organ donors is lacking. A 10-year retrospective analysis of blood product utilization in beating-heart organ donors was performed to determine current transfusion practice. STUDY DESIGN AND METHODS An institutional review board-approved retrospective review of 439 beating-heart organ donors from January 1, 2004, to October 1, 2014, was performed. For each donor, hemoglobin (Hb), platelet (PLT), prothrombin time/international normalized ratio (PT/INR), and fibrinogen levels as well as all transfusion reaction reports were recorded from the time of declaration of brain death to organ procurement. RESULTS Red blood cell transfusion occurred in 304 donors (69.2%), with a trough Hb level of more than 8 g/dL in 63.2% and more than 10 g/dL in 15.8%; final Hb was more than 10 g/dL in 44.1% of transfused donors. PLT transfusion occurred in 165 donors (37.6%), with a trough PLT count of more than 50 × 10(9) /L in 113 (68.5%) and more than 100 × 10(9) /L in 15 (9.1%). Plasma transfusion occurred in 217 donors (49.4%), with a peak INR of less than 1.5 in 75 donors (34.6%) and a peak INR of 1.6 to 2.0 in 112 donors (51.6%). Only 17.4% of donors who received cryoprecipitate had fibrinogen levels measured, and results were all more than 200 mg/dL. Transfusion reactions were underreported (p = 0.0001). CONCLUSIONS This study suggests potential suboptimal use of limited biologic resources in beating-heart organ donors, as well as significant underreporting of suspected transfusion reactions. Additional studies are indicated to determine optimal transfusion thresholds in this population.
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Affiliation(s)
- Emily A Coberly
- Department of Pathology and Anatomical Sciences, University of Missouri Health System, Columbia, Missouri.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Garrett S Booth
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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