Care of the potential pediatric organ donor

Survey of U.S. Organ Procurement Organizations Regarding Pediatric Organ Donor Management

OBJECTIVE

To describe the current practice of pediatric organ donor management in the United States for donors declared dead based upon neurologic criteria. The study directs particular attention to how pediatric donors are defined, the use of donor management guidelines, the use of donor management goals, and the involvement of pediatric critical care or transplantation expertise.

DESIGN

Cross-sectional observational study using a web-based survey and follow-up telephone interview with respondents from U.S. organ procurement organizations. The study also incorporated organ procurement organization-specific data on organ yield for the 4-year period (2010-2013) preceding the study.

SETTING

The 58 U.S. organ procurement organizations.

SUBJECTS

Respondents chosen by each organ procurement organization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All 58 U.S. organ procurement organizations participated in the study. Fifty-two respondents (90%) indicated that their organ procurement organization distinguished pediatric from adult donors resulting in 28 unique pediatric definitions. Thirty-nine organ procurement organizations utilized some form of written pediatric management guidelines, and 27 (47%) maintained pediatric donor management goals; compliance was infrequently monitored for both guidelines (28%) and goals (33%). A pediatric intensivist was always or usually involved in pediatric donor management at 47 organ procurement organizations (81%); transplant/organ recovery surgeons were always or usually involved at 12 organ procurement organizations (21%). There was an increase in the number of organs transplanted per donor among donors 11-17 years old for organ procurement organizations that used donor management goals for the duration of the period studied (p < 0.01). There was also an increase in the ratio of observed/expected organs transplanted among donors of 0-10 years old for organ procurement organizations that always or usually consulted a transplant/organ recovery surgeon (p = 0.02) although this did not reach our threshold for statistical significance..

CONCLUSIONS

There is little consensus among organ procurement organizations regarding the definition of "pediatric" during organ donor management. Most organ procurement organizations employ written pediatric guidelines and use pediatric intensive care physicians for assistance in managing these donors. There is a positive association between the use of donor management goals and organ yield among pediatric donors in the 11- to 17-year age group.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

Changing pattern of donor selection criteria in deceased donor liver transplant: a review of literature

During the last couple of decades, with standardization and progress in surgical techniques, immunosuppression and post liver transplantation patient care, the outcome of liver transplantation has been optimized. However, the principal limitation of transplantation remains access to an allograft. The number of patients who could derive benefit from liver transplantation markedly exceeds the number of available deceased donors. The large gap between the growing list of patients waiting for liver transplantation and the scarcity of donor organs has fueled efforts to maximize existing donor pool and identify new avenues. This article reviews the changing pattern of donor for liver transplantation using grafts from extended criteria donors (elderly donors, steatotic donors, donors with malignancies, donors with viral hepatitis), donation after cardiac death, use of partial grafts (split liver grafts) and other suboptimal donors (hypernatremia, infections, hypotension and inotropic support).

The pancreas allograft donor: current status, controversies, and challenges for the future

The pancreas allograft is a scarce resource that is currently underutilized. The selection of appropriate deceased donors for pancreas procurement is of paramount importance for minimizing technical failure and optimizing long-term outcomes in pancreas transplantation. Despite the increasing demand for pancreas transplantation, increases in overall organ donation rates and the evolution of criteria that constitute an "acceptable" pancreas donor, the number of deceased donor pancreas transplants being performed in the United States has actually declined in recent years. Although there are many factors that must be considered during evaluation of the potential pancreas allograft donor to minimize morbidity and graft loss, it is evident that there are transplantable organs that are not used. In this review, deceased donor pancreas identification, management, selection, allocation, assessment, preservation, and the problem of pancreas underutilization will be discussed.

Circulatory arrest in a brain-dead organ donor: is the use of cardiac compression permissible?

Care of the brain-dead patient is common in intensive care practice. Aggressive donor management is advocated to increase supply of viable organs. Significant controversy exists over cardiac resuscitation in patients determined dead by cardiac criteria. The issue, till now, has not been addressed in brain dead patients. We discuss a case of cardiac resuscitation of a brain-dead donor to ensure organ donation. This case allows us to examine the use of brain death criteria to declare death, the controversy regarding cardiac resuscitation in organ donor patients, and the standards for use of cardiac resuscitation in the organ donor declared dead by brain death criteria. The consent process for organ donation in brain dead patients should address the possibility of subsequent cardiac arrest.

Report of the Paris consensus meeting on expanded criteria donors in liver transplantation

Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. Consensus recommendations are needed. This article reports the conclusions of a consensus meeting held in Paris in March 2007 with the contribution of experts from Europe, the United States, and Asia. Definitions of expanded criteria donors with respect to donor variables (including age, liver function tests, steatosis, infections, malignancies, and heart-beating versus non-heart-beating, among others) are proposed. It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.

Signs of life and signs of death: brain death and other mixed messages at the end of life

Brain death is a medical, legal and cultural category constructed to fill an important need created by evolving medical technologies and practices. However, managing life and death via organ transplants and brain death criteria is not without controversy; there remains much confusion and ambivalence in both lay and medical populations regarding both organ donation and the diagnostic category of brain death. By way of a case study of cranial trauma taken from a larger study of bereaved parents, this article discusses how, from a parent's perspective, brain death and organ donation are neither morally nor medically straightforward concepts. The case study presented in this article demonstrates the necessity for more research and clinical training in communication issues regarding brain death and end-of-life care with families in critical care situations.

Complications of brain death: frequency and impact on organ retrieval

Brain death is associated with complex hemodynamic, endocrine, and metabolic dysfunction that can lead to major complications with the potential donor. Untreated, this can progress to cardiovascular collapse with loss of valuable organs for transplantation. We hypothesized that brain death-related complications would have no effect on the number of organs donated if an aggressive donor management protocol was in place. We identified all successful organ donations between January 2000 and December 2003 and evaluated them for brain death-associated complications (defined as vasopressor requirement, coagulopathy, diabetes insipidus, cardiac ischemia, lactic acidosis, renal failure, and acute respiratory distress syndrome) and donated organs per donor. Sixty-nine organ donors were identified. Complications identified were as follows: intravenous vasopressor requirement in 97.1 per cent, coagulopathy in 55.1 per cent, thrombocytopenia in 53.6 per cent, diabetes insipidus in 46.4 per cent, cardiac ischemia in 30.4 per cent, lactic acidosis in 24.6 per cent, renal failure in 20.3 per cent, and acute respiratory distress syndrome in 13 per cent. There was no significant effect of complications on the average number of organs harvested, with the exception of an increase in organs harvested in the presence of diabetes insipidus. With the implementation of an aggressive organ donor management protocol, these complications can be effectively managed with no impact on the number of organs harvested for transplant.

Clinical Management of the Organ Donor

There is a critical mismatch between available organs for transplant and acutely or critically ill patients with end-stage organ disease. Patients who may benefit from organ transplantation far outnumber available organs. The causes for this imbalance are multiple. One cause is family refusal to donate. A second cause is nonrecognition or delay in determination of brain death. A third cause is donor loss due to profound cardiopulmonary and metabolic instability consequent to brain-stem herniation and brain death. Family refusal may be addressed by education, public awareness, as well as close attention to social, cultural and ethical issues, and optimal communication with donor families. Brain death may be consequent to traumatic brain injury, ischemic versus hemorrhagic stroke, as well as massive cerebral anoxia/ischemic following cardiac arrest. Nonrecognition or delay in brain death determination may be addressed by clinician education and frequent clinical assessment to detect early stages of brain-stem herniation refractory to aggressive measures for control of intracranial pressure. Donor loss due to profound cardiopulmonary and metabolic instability may be addressed by aggressive, mechanism-based treatment for clinical instability based on affected body system, as well as measures to support metabolic activity at the cellular and tissue level in the brain-dead organ donor. This article explores cerebral physiology related to impending brain death and catastrophic intracranial pressure elevations. In addition, physiologic consequences of brain death are correlated with affected body systems and mechanism-based therapies to support organ function pending transplantation. Ethical/legal issues are explored as related to patient autonomy and optimal family outcomes. Effective family communication, astute clinical assessment, and optimal clinical management of the organ donor are illustrated using a case study approach, highlighting the role of the advanced practice nurse in donor management.

Evaluation of coma and brain death

Coma is a nonspecific sign of widespread central nervous system impairment resulting from various metabolic and structural etiologies. The rapid recognition of this neurologic emergency and results from the history, physical examination, and early investigative studies are key to the identification and treatment of its underlying cause. The prognosis for recovery depends greatly on the underlying etiology as well as on its optimal treatment, which seeks to preserve neurologic function and maximize the potential for recovery by reversing the primary cause of brain injury, if known, and preventing secondary brain injury from anoxia, ischemia, hypoglycemia, cerebral edema, seizures, infections, and electrolyte and temperature disturbances. Brain death must be diagnosed with similar care and precision, and families approached compassionately about the diagnosis and their decisions regarding organ donation.

Muerte encefálica y donación en población infantil

BACKGROUND

Brain death is the irreversible cessation of intracranial neurologic function and is considered as the person's death. The objective of this study was to describe the characteristics of pediatric donors in the Hospital Central de Asturias from October 1995 to October 2002.

METHODS

We performed a retrospective and descriptive study of the dead children who were potential donors in the pediatric intensive care unit (PICU).

RESULTS

Of 43 dead children, 15 (34.9 %) were diagnosed with brain death. In four patients (family refusal in one, sepsis in two and brain tumor in one) there was no donation. In all patients, the diagnosis of brain death was based on clinical examination and electroencephalogram. Doppler ultrasonography and technetium-99m hexamethylpropyleneamineoxamine (Tc-99-HMPAO) scanning was also performed in three and nine patients respectively. The mean age of the donors was 8.1 years (range: 13 months-15 years). The male/female ratio was 3/1. The cause of death was multiple trauma in six children, brain hemorrhage in three, cardiac arrhythmias in three, lightning strike in one, diabetic ketoacidosis in one, septic shock in one and hypovolemic shock in one. The median interval between admission and brain death was 1.4 days (range: 3 hours-12 days). The time of organ support between brain death and donation was 8.4 hours (range: 6-13 hours). The most frequent complications after brain death were central diabetes insipidus in 90.9 % of the patients, hyperglycemia in 54.5 % and hypokalemia in 45.4 %. During support 72.7 % of the patients required inotropic aid.

CONCLUSIONS

In our PICU more than one-third of the dead children suffered brain death, and most became donors. The most frequent cause of brain death was multiple trauma. Coordination with the transplant team and the training of medical staff are important to achieve a high percentage of donations.