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Halpern NA, Tan KS, Bothwell LA, Boyce L, Dulu AO. Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020. Crit Care Med 2024; 52:223-236. [PMID: 38240506 PMCID: PMC11256975 DOI: 10.1097/ccm.0000000000005984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians. DESIGN Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test. SETTING U.S. adult ICUs and databases. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001). CONCLUSIONS There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.
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Affiliation(s)
- Neil A Halpern
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lilly A Bothwell
- Department of Strategy and Innovation, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lindsay Boyce
- MSK Library, Technology Division, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alina O Dulu
- Department of Anesthesiology and Critical Care Medicine, Critical Care Center, Memorial Sloan Kettering Cancer Center, New York, NY
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2
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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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Kopanczyk R, Lester J, Long MT, Kossbiel BJ, Hess AS, Rozycki A, Nunley DR, Habib A, Taylor A, Awad H, Bhatt AM. The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action. MEDICINA (KAUNAS, LITHUANIA) 2022; 59:47. [PMID: 36676669 PMCID: PMC9867461 DOI: 10.3390/medicina59010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.
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Affiliation(s)
- Rafal Kopanczyk
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jesse Lester
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Briana J. Kossbiel
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aaron S. Hess
- Department of Anesthesiology and Pathology & Laboratory Medicine, University of Wisconsin Hospitals & Clinics, Madison, WI 53792, USA
| | - Alan Rozycki
- Department of Pharmacology, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - David R. Nunley
- Department of Pulmonary, Critical Care & Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Alim Habib
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Ashley Taylor
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesia, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Amar M. Bhatt
- Department of Anesthesiology, Division of Critical Care, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Coppler PJ, Flickinger KL, Darby JM, Doshi A, Guyette FX, Faro J, Callaway CW, Elmer J. Early risk stratification for progression to death by neurological criteria following out-of-hospital cardiac arrest. Resuscitation 2022; 179:248-255. [PMID: 35914657 DOI: 10.1016/j.resuscitation.2022.07.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/27/2022] [Accepted: 07/22/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some patients resuscitated from out-of-hospital cardiac arrest (OHCA) progress to death by neurological criteria (DNC). We hypothesized that initial brain imaging, electroencephalography (EEG), and arrest characteristics predict progression to DNC. METHODS We identified comatose OHCA patients from January 2010 to February 2020 treated at a single quaternary care facility in Western Pennsylvania. We abstracted demographics and arrest characteristics; Pittsburgh Cardiac Arrest Category, initial motor exam and pupillary light reflex; initial brain computed tomography (CT) grey-to-white ratio (GWR), sulcal or basal cistern effacement; initial EEG background and suppression ratio. We used two modeling approaches: fast and frugal tree (FFT) analysis to create an interpretable clinical risk stratification tool and ridge regression for comparison. We used bootstrapping to randomly partition cases into 80% training and 20% test sets and evaluated test set sensitivity and specificity. RESULTS We included 1,569 patients, of whom 147 (9%) had diagnosed DNC. Across bootstrap samples, >99% of FFTs included three predictors: sulcal effacement, and in cases without sulcal effacement, the combination of EEG background suppression and GWR ≤ 1.23. This tree had mean sensitivity and specificity of 87% and 81%. Ridge regression with all available predictors had mean sensitivity 91 % and mean specificity 83%. Subjects falsely predicted as likely to progress to DNC generally died of rearrest or withdrawal of life sustaining therapies due to poor neurological prognosis. Two of these cases awakened from coma during the index hospitalization. CONCLUSIONS Sulcal effacement on presenting brain CT or EEG suppression with GWR ≤ 1.23 predict progression to DNC after OHCA.
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Affiliation(s)
- Patrick J Coppler
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ankur Doshi
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Faro
- Department of Family Medicine, Soin Medical Center - Kettering Health Network, Beavercreek, OH, USA
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
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5
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Marsolais P, Larouche G, Lagacé AM, Williams V, Serri K, Bernard F, Rico P, Frenette AJ, Williamson D, Albert M, Charbonney E. The Suitability of Potential Organ Donors Using Real Case-Scenarios; Do we Need to Create a "Donor Board" Process for Donors Perceived as Unlikely Suitable? Transpl Int 2022; 35:10107. [PMID: 35340845 PMCID: PMC8944411 DOI: 10.3389/ti.2022.10107] [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: 10/12/2021] [Accepted: 01/11/2022] [Indexed: 12/01/2022]
Abstract
Introduction: Despite availability of selection criteria, different interpretations can lead to variability in the appreciation of donor eligibility with possible viable organs missed. Our primary objective was to test the perception of feasibility of potential organ donors through the survey of a small sample of external evaluators. Methods: Clinical scenarios summarizing 66 potential donors managed in the first year of our Organ Recovery Center were sent to four critical care physicians to evaluate the feasibility of the potential donors and the probability of organ procurement. Results: Potential donors procuring at least one organ were identified in 55 of the 66 cases (83%). Unanimity was reached in 38 cases, encompassing 35 out of the 55 converted and 3 of the non-converted donors. The overall agreement was moderate (kappa = 0.60, 95% CI: 0.37–0.82). For the organs finally procured for transplantation, organ donation was predicted for the majority of the cases, but high discrepancy was present with the final outcome of organs not procured (particularly liver and kidney). Conclusion: The assessment of a potential donor is a complex dynamic process. In order to increase organ availability, standardized electronically clinical data, as well a “donor board” structure of decision might inform future systems.
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Affiliation(s)
- Pierre Marsolais
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | | | - Anne-Marie Lagacé
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada
| | - Virginie Williams
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada
| | - Karim Serri
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Francis Bernard
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Philippe Rico
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Anne Julie Frenette
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Facutly of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - David Williamson
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Facutly of Pharmacy, Université de Montréal, Montréal, QC, Canada
| | - Martin Albert
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Emmanuel Charbonney
- Hôpital du Sacré-Coeur de Montréal (CIUSSS-NIM), Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.,Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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6
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Zhao J, Liu D, Huang J, Jiang HC, Chen Y, Li HX, Li XS, Chen JY. The Low Utilization Rate of Donor Lungs in China: A Single-Center Experience. Ann Transplant 2021; 26:e931409. [PMID: 34373440 PMCID: PMC8364286 DOI: 10.12659/aot.931409] [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] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Despite the increasing number of organ donations, the utilization rate of donor lungs in China is much lower than that in many other countries. MATERIAL AND METHODS The donor lungs were evaluated before departure (stage 1), after on-site management (stage 2), and after harvesting (stage 3). Variables of donor lungs from medical institutions with lung transplant qualification (group A) and those without qualification (group B) were compared. The outcome measurements for lung recipients were early survival and primary graft dysfunction. RESULTS Among the 277 donor lungs, 140 (51%) were suitable for transplantation and 101 were sent to our institution for 62 single-lung transplantations and 50 double-lung transplantations. The acceptability rates at stage 1, stage 2, and stage 3 were 78%, 56%, and 51%, respectively. In addition, 69 (50.4%) donor lungs were abandoned for poor quality related to management, 24 (17.5%) for no adequate recipients, 15 (10.9%) for family refusal, 14 (10.2%) for organ procurement organization-related reasons, and 15 (10.9%) for other reasons. Donors in group A were ventilated longer and had longer ischemic time than those in group B. However, bronchoscopy, imaging, and oxygenation in group A achieved better results than in group B. No between-group difference in 30-day mortality or rate of grade 3 primary graft dysfunction was observed. CONCLUSIONS Problems at supply and demand ends contribute to the low utilization rate of donor lungs in China. The poor management of donor lungs and the short waiting list for lung transplantation are major reasons.
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Affiliation(s)
- Jin Zhao
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Dong Liu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Jian Huang
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Hua-Chi Jiang
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Yuan Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Hui-Xing Li
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
| | - Xiao-Shan Li
- Chinese Lung Transplantation Registry and Data Management Center, Wuxi, Jiangsu, China (mainland)
| | - Jing-Yu Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated with Nanjing Medical University, Wuxi, Jiangsu, China (mainland)
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7
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Kazzaz YM, Da'ar OB. Assessing comfort level of organ donation competencies among pediatric intensivists in Saudi Arabia: a national survey. BMC MEDICAL EDUCATION 2020; 20:358. [PMID: 33046074 PMCID: PMC7552448 DOI: 10.1186/s12909-020-02262-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND As increasing the number of organ donations presents a global challenge, Saudi Arabia is no different. Intensivists can play a major role in maximizing the organ donation process and minimize the challenges. The purpose of this study was to investigate Saudi pediatric intensivists' comfort and importance levels of organ donation competencies. METHODS We conducted a cross-sectional survey whose sampling frame included 100 pediatric intensivists. The pediatrician intensivists were identified through an updated list provided by the Saudi Critical Care Society. We assessed 14 competencies categorized into four domains: the general donation, donation after brain death (DBD), neurological determination of death, and medicolegal, religious, and ethical domains. Then we investigated the association between these competencies and physicians' characteristics. RESULTS With a response rate of 76%, we found that 40-60% of the surveyed pediatric intensivists rated their comfort in 6 out of 14 competencies as high or very high. There was a statistically significant gap in the intensivists' rating of 10 competencies (i.e., high importance but low comfort levels). Ordinal regression showed that comfort levels with the general donation, neurological determination of death, and medicolegal, religious, and ethical domains were higher in intensivists who were frequently involved with DBD than those who had never been exposed. CONCLUSIONS Pediatric intensivists expressed low comfort levels to organ donation competencies that are essential for maximizing donation rates. Adapting mandatory comprehensive donation education programs and dedicated physician specialists may be beneficial in critical care units aiming to increase donation rates.
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Affiliation(s)
- Yasser M Kazzaz
- Department of Pediatrics, Ministry of National Guards - Health Affairs, Riyadh, Kingdom of Saudi Arabia.
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | - Omar B Da'ar
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Health Systems, College of Public Health and Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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8
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Manara AR, Thomas I. Current status of organ donation after brain death in the UK. Anaesthesia 2020; 75:1205-1214. [DOI: 10.1111/anae.15038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 01/07/2023]
Affiliation(s)
- A. R. Manara
- Department of Intensive Care Medicine and Anaesthesia Southmead Hospital Bristol UK
| | - I. Thomas
- Department of Intensive Care Medicine and Anaesthesia Southmead Hospital Bristol UK
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9
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Impact of the elderly donor on an abdominal organ transplantation program. Eur Surg 2020. [DOI: 10.1007/s10353-020-00637-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Miñambres E, Ruiz P, Ballesteros MA, Álvarez C, Cifrián JM, Atutxa L, Ventoso A, Castillo F, Gastaca M. Combined lung and liver procurement in controlled donation after circulatory death using normothermic abdominal perfusion. Initial experience in two Spanish centers. Am J Transplant 2020; 20:231-240. [PMID: 31265753 DOI: 10.1111/ajt.15520] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 06/01/2019] [Accepted: 06/21/2019] [Indexed: 01/25/2023]
Abstract
Combining simultaneously lung and liver procurement in controlled donation after circulatory death (cDCD) using normothermic abdominal perfusion (NRP) for abdominal grafts and cooling and rapid recovery technique (RR) for the lungs increases the complexity of the procurement procedure and might injure the grafts. A total of 19 cDCDs from two centers using this combined procedure were evaluated, and 16 liver and 21 lung transplantations were performed. As controls, 34 donors after brain death (DBDs) were included (29 liver and 41 lung transplantations were performed). Two cDCD liver recipients developed primary nonfunction (12.5%). No cases of ischemic cholangiopathy were observed among cDCD recipients. The 1-year and 2-year liver recipients survival was 87.5% and 87.5% for the cDCD group, and 96% and 84.5% for the DBD group, respectively (P = .496). The 1-year and 2-year lung recipients survival was 84% and 84% for the cDCD group and 90% and 90% for the DBD group, respectively (P = .577). This is the largest experience ever reported in cDCD with the use of NRP combined with RR of the lungs. This combined method offers an outstanding recovery rate and liver and lung recipients survival comparable with those transplanted with DBDs. Further studies are needed to confirm our findings.
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Affiliation(s)
- Eduardo Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, University of Cantabria, Santander, Spain
| | - Patricia Ruiz
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| | - Maria Angeles Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Álvarez
- Service of Thoracic Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Jose Manuel Cifrián
- Service of Neumology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Lander Atutxa
- Transplant Coordination Unit & Service of Intensive Care, Donostia University Hospital, San Sebastian, Spain
| | - Alberto Ventoso
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
| | - Federico Castillo
- Hepatobiliary Surgery and Liver Transplantation Unit, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Mikel Gastaca
- Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, Bilbao, Spain
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11
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Organ donation after resuscitation from cardiac arrest. Resuscitation 2019; 145:63-69. [PMID: 31654724 DOI: 10.1016/j.resuscitation.2019.10.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/27/2019] [Accepted: 10/14/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND We compared the characteristics and outcomes of post-arrest donors to those of other donors, described the proportion of post-arrest decedents who donated, and compared their characteristics to post-arrest decedents who did not donate. METHODS We performed a retrospective cohort study including patients who died at a single academic medical center from January 1, 2010 to February 28, 2019. We linked our registry of consecutive post-arrest patients to donation-related data from the Center for Organ Procurement and Recovery (CORE). We used data from CORE to identify donor eligibility, first person designation, family approaches to seek consent for donation, and approach outcomes. We determined number of organs procured and number transplanted, stratified by donor type (brain death donors (BDD) vs donors after circulatory determination of death (DCD)). RESULTS There were 12,130 decedents; 1525 (13%) were resuscitated from cardiac arrest. CORE staff approached families of 836 (260 (31%) post-arrest, 576 (69%) not post-arrest) to request donation. Post-arrest patients and families were more likely to authorize donation (172/260 (66%) vs 331/576 (57%), P = 0.02), and more likely to be DCDs (50/146 (34%) vs 55/289 (19%), P < 0.001). Overall, 4.1 ± 1.5 organs were procured and 2.9 ± 1.9 transplanted per BDD, which did not differ by post-arrest status, 3.2 ± 1.2 organs were procured and 1.8 ± 1.1 transplanted per DCD. Number of organs transplanted per DCD did not differ by post-arrest status. Unfavorable arrest characteristics were more common among post-arrest organ donors compared to non-donors. CONCLUSION Patients resuscitated from cardiac arrest with irrecoverable brain injury have excellent potential to become organ donors.
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12
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Wilkey BJ, Abrams BA. Mitigation of Primary Graft Dysfunction in Lung Transplantation: Current Understanding and Hopes for the Future. Semin Cardiothorac Vasc Anesth 2019; 24:54-66. [DOI: 10.1177/1089253219881980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury that develops within the first 72 hours after lung transplantation. The overall incidence of PGD is estimated to be around 30%, and the 30-day mortality for grade 3 PGD around 36%. PGD is also associated with the development of bronchiolitis obliterans syndrome, a specific form of chronic lung allograft dysfunction. In this article, we will discuss perioperative strategies for PGD prevention as well as possible future avenues for prevention and treatment.
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Abstract
OBJECTIVES To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU. DATA SOURCES AND STUDY SELECTION A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord. DATA EXTRACTION AND DATA SYNTHESIS The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries. CONCLUSIONS The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
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Identification of Hemodynamic Risk Factors for Apnea Test Failure During Brain Death Determination. Transplant Proc 2019; 51:1655-1660. [PMID: 31255358 DOI: 10.1016/j.transproceed.2019.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 04/22/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE An apnea test is essential step for diagnosing brain death and is known to be relatively safe. However, various complications such as hypoxia, arrhythmias, and hypotension could occur. Herein, we identified risk factors of failed apnea test and determined their optimal cutoff values. METHODS We retrospectively analyzed 512 patients of apnea test to diagnose brain death and classified them into 2 groups according to success or failure of the test. Demographic characteristics, value of arterial blood gas analysis, and systolic blood pressure (SBP) were collected, and alveolar-arterial gradient (A-a gradient) and Pao2/fraction of inspired oxygen ratio were calculated to evaluate the respiratory status. RESULTS A total of 484 patients completed the apnea test, and the test was aborted in 28 patients because of hypotension or refractory hypoxemia. The SBP, pH, Pao2, and Pao2/fraction of inspired oxygen ratio were higher in success group, whereas A-a gradient was lower. In multivariate analysis, low SBP (odds ratio [OR], 0.976; 95% CI, 0.958-0.994; P = .01), low pH (OR, 0.004; 95% CI, 0.000-0.184; P = .005), and elevated A-a gradient (OR, 1.005; 95% CI, 1.003-1.008; P = .001) were associated with apnea test failure. The optimal cutoff values to predict the test failure were 105.0 mm Hg for pretesting SBP, 7.326 for pretesting pH, and 556.4 mm Hg for pretesting A-a gradient. CONCLUSION Early recognition and aggressive management for the risk factors are important to reduce failure rates of apnea test and consequently improve outcomes of organ procurement.
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Pan B, Huang C, Fang X, Huang X, Li T. Noninvasive and sensitive optical assessment of brain death. JOURNAL OF BIOPHOTONICS 2019; 12:e201800240. [PMID: 30379409 DOI: 10.1002/jbio.201800240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/22/2018] [Accepted: 10/30/2018] [Indexed: 05/18/2023]
Abstract
Brain death is an irreversible loss of all brain functions, and the assessment is crucial for organ supply for transplantation. The noninvasive, sensitive, universally available and timely ancillary method to assess brain death has not been established. Here, we attempted to explore a noninvasive way in brain death assessment. Eighteen brain-dead patients and 20 healthy subjects were measured by near-infrared spectroscopy (NIRS), with a multiple-phase protocol at varied fraction of inspired O2 (FIO2 ). We found that the concentration changes ratios of oxyhemoglobin to deoxyhemoglobin (Δ[HbO2 ]/Δ[Hb]) in the cerebral cortex of brain-dead patients were significantly higher than those of healthy subjects. And, the Δ[HbO2 ]/Δ[Hb] in low-to-high FIO2 phase was most sensitive to distinguish brain-dead patients from healthy subjects, with a recommended threshold ranged in 1.40~1.50. The innovative incorporation of NIRS and a varied FIO2 protocol was shown to be a noninvasive and reliable way in assessing brain death. This successful attempt of NIRS application is a help for fast and accurate evaluation of brain death, promptly offering quality-assured donor organs and indicate us a protocol-aided way to expand the use of NIRS.
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Affiliation(s)
- Boan Pan
- Biomedical Engineering Institute, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- State Key Lab Elect Thin Film & Integrated Device, University of Electronic Science and Technology of China, Chengdu, China
| | - Chong Huang
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky
| | - Xiang Fang
- Biomedical Engineering Institute, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
| | - Xiaobo Huang
- State Key Lab Elect Thin Film & Integrated Device, University of Electronic Science and Technology of China, Chengdu, China
| | - Ting Li
- Biomedical Engineering Institute, Chinese Academy of Medical Science and Peking Union Medical College, Tianjin, China
- State Key Lab Elect Thin Film & Integrated Device, University of Electronic Science and Technology of China, Chengdu, China
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17
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Weiss J, Elmer A, Béchir M, Brunner C, Eckert P, Endermann S, Lenherr R, Nebiker M, Tisljar K, Haberthür C, Immer FF. Deceased organ donation activity and efficiency in Switzerland between 2008 and 2017: achievements and future challenges. BMC Health Serv Res 2018; 18:876. [PMID: 30458762 PMCID: PMC6247533 DOI: 10.1186/s12913-018-3691-8] [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: 07/24/2018] [Accepted: 11/05/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Various actions have been taken during the last decade to increase the number of organs from deceased donors available for transplantation in Switzerland. This study provides an overview on key figures of the Swiss deceased organ donation and transplant activity between 2008 and 2017. In addition, it puts the evolution of the Swiss donation program's efficiency in relation to the situation in the neighboring countries. METHODS This study is an analysis of prospective registry data, covering the period from 1 January 2008 to 31 December 2017. It includes all actual deceased organ donors (ADD) in Switzerland. Donor data were extracted from the Swiss Organ Allocation System. The "donor conversion index" (DCI) methodology and data was used for the comparison of donation program efficiency in Switzerland, Germany, Austria, Italy and France. RESULTS During the study period there were 1116 ADD in Switzerland. The number of ADD per year increased from 91 in 2008 to 145 in 2017 (+ 59%). The reintroduction of the donation after cardiocirculatory death (DCD) program in 2011 resulted in the growth of annual percentages of DCD donors, reaching a maximum of 27% in 2017. The total number of organs transplanted from ADD was 3763 (3.4 ± 1.5 transplants per donor on average). Of these, 48% were kidneys (n = 1814), 24% livers (n = 903), 12% lungs (n = 445), 9% hearts (n = 352) and 7% pancreata or pancreatic islets (n = 249). The donation program efficiency assessment showed an increase of the Swiss DCI from 1.6% in 2008 to 2.7% in 2017 (+ 69%). The most prominent efficiency growth was observed between 2012 and 2017. Even though Swiss donation efficiency increased during the study period, it remained below the DCI of the French and Austrian donation programs. CONCLUSION Swiss donation activity and efficiency grew during the last decade. The increased donation efficiency suggests that measures implemented so far were effective. The lower efficiency of the Swiss donation program, compared to the French and Austrian programs, may likely be explained by the lower consent rate in Switzerland. This issue should be addressed in order to achieve the goal of more organs available for transplantation.
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Affiliation(s)
- Julius Weiss
- Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland
| | - Andreas Elmer
- Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland
| | - Markus Béchir
- Zentrum für Innere Medizin, Hirslanden Klinik Aarau, Aarau, Switzerland
| | - Christian Brunner
- Zentrum für Intensivmedizin, Luzerner Kantonsspital, Luzern, Switzerland
| | - Philippe Eckert
- Service de Médecine Intensive Adulte et Centre des Brûlés, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Susann Endermann
- Klinik für Anästhesiologie, Intensiv-, Rettungs- und Schmerzmedizin, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Renato Lenherr
- Chirurgische Intensivmedizin USZ, Universitätsspital Zürich, Zürich, Switzerland
| | - Mathias Nebiker
- Transplantationszentrum, Direktion Medizin und Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Bern, Switzerland
| | - Kai Tisljar
- Medizinische Intensivstation, Universitätsspital Basel, Basel, Switzerland
| | - Christoph Haberthür
- Klinik Hirslanden, Institut für Anästhesiologie und Intensivmedizin, Zürich, Switzerland
| | - Franz F Immer
- Swisstransplant, the Swiss National Foundation for Organ Donation and Transplantation, Bern, Switzerland.
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Park H, Park SJ, Kyong K, Cho HR. Kidney Donation From a Patient Who Underwent Endovascular Aneurysm Repair. EXP CLIN TRANSPLANT 2018; 17:561-563. [PMID: 29957157 DOI: 10.6002/ect.2018.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Organ shortage is the greatest challenge facing the field of organ transplantation in Korea. There are no reports of patients who have undergone endovascular aneurysm repair being considered as kidney donors. We successfully performed kidney transplant procedures in a 62-year-old man and a 57-year-old man using kidneys recovered from a 67-year-old female brain-dead donor who underwent endovascular aneurysm repair 6 months before organ retrieval. To the best of our knowledge, this is the first report of transplants performed with organs from a donor who previously underwent endovascular aneurysm repair.
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Affiliation(s)
- Hojong Park
- From the Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Hahnenkamp K, Böhler K, Wolters H, Wiebe K, Schneider D, Schmidt HHJ. Organ-Protective Intensive Care in Organ Donors. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:552-8. [PMID: 27598872 DOI: 10.3238/arztebl.2016.0552] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 05/02/2016] [Accepted: 05/02/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND The ascertainment of brain death (the irreversible, total loss of brain function) gives the physician the opportunity to limit or stop further treatment. Alternatively, if the brain-dead individual is an organ donor, the mode of treatment can be changed from patient-centered to donationcentered. Consensus-derived recommendations for the organ-protective treatment of brain-dead organ donors are not yet available in Germany. METHODS This review is based on pertinent publications retrieved by a selective search in PubMed, and on the authors' clinical experience. RESULTS Brain death causes major pathophysiological changes, including an increase in catecholamine levels and a sudden drop in the concentration of multiple hormones, among them antidiuretic hormone, cortisol, insulin, and triand tetraiodothyronine. These changes affect the function of all organ systems, as well as the hemodynamic state and the regulation of body temperature. The use of standardized donor management protocols might well increase the rate of transplanted organs per donor and improve the quality of the transplanted organs. In addition, the administration of methylprednisolone, desmopressin, and vasopressin could be a useful supplement to treatment in some cases. Randomized controlled trials have not yet demonstrated either improved organ function or prolonged survival of the transplant recipients. CONCLUSION The evidence base for organ-protective intensive care is weak; most of the available evidence is on the level of expert opinion. There is good reason to believe, however, that the continuation of intensive care, in the sense of early donor management, can make organ transplantation more successful both by increasing the number of transplantable organs and by improving organ quality.
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Affiliation(s)
- Klaus Hahnenkamp
- Department of Anesthesiology and Intensive Care Medicine, University Medicine Greifswald, German Organ Transplantation Foundation, North-East Donor Region, Berlin, Department of General and Visceral Surgery, University Hospital Münster, Department of Thoracic and Cardiovascular Surgery, University Hospital Münster, Department of Anaesthesiology and Intensive Care, University Hospital Leipzig, Department of Transplant Medicine, University Hospital Münster
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Dimarakis I, Banner NR, Rushton S, Wong HSE, Berman M, Howell N, Payne J, Dark J, Mehew J, Venkateswaran R. The interval between brainstem death and cardiac assessment influences the retrieval of hearts for transplantation. Eur J Cardiothorac Surg 2018; 53:1135-1143. [DOI: 10.1093/ejcts/ezx513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/18/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ioannis Dimarakis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, UK
| | - Nicholas R Banner
- Department of Cardiothoracic Transplantation, Harefield Hospital, Middlesex, UK
| | - Sally Rushton
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | | | - Marius Berman
- Department of Cardiothoracic Transplantation, Papworth Hospital, Cambridge, UK
| | - Neil Howell
- Department of Cardiothoracic Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - John Payne
- Department of Transplantation, Golden Jubilee National Hospital, Clydebank, UK
| | - John Dark
- Department of Cardiothoracic Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jenny Mehew
- Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, UK
| | - Rajamiyer Venkateswaran
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, UK
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Souter MJ, Eidbo E, Findlay JY, Lebovitz DJ, Moguilevitch M, Neidlinger NA, Wagener G, Paramesh AS, Niemann CU, Roberts PR, Pretto EA. Organ Donor Management: Part 1. Toward a Consensus to Guide Anesthesia Services During Donation After Brain Death. Semin Cardiothorac Vasc Anesth 2017; 22:211-222. [PMID: 29276852 DOI: 10.1177/1089253217749053] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Worldwide 715 482 patients have received a lifesaving organ transplant since 1988. During this time, there have been advances in donor management and in the perioperative care of the organ transplant recipient, resulting in marked improvements in long-term survival. Although the number of organs recovered has increased year after year, a greater demand has produced a critical organ shortage. The majority of organs are from deceased donors; however, some are not suitable for transplantation. Some of this loss is due to management of the donor. Improved donor care may increase the number of available organs and help close the existing gap in supply and demand. In order to address this concern, The Organ Donation and Transplantation Alliance, the Association of Organ Procurement Organizations, and the Transplant and Critical Care Committees of the American Society of Anesthesiologists have formulated evidence-based guidelines, which include a call for greater involvement and oversight by anesthesiologists and critical care specialists, as well as uniform reporting of data during organ procurement and recovery.
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Affiliation(s)
| | - E Eidbo
- 2 Association of Organ Procurement Organizations, Vienna, VA, USA
| | | | | | | | | | | | - Anil S Paramesh
- 8 Tulane University School of Medicine, New Orleans, LA, USA
| | - Claus U Niemann
- 9 University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Pamela R Roberts
- 10 University of Oklahoma Medical Center, Oklahoma City, OK, USA
| | - Ernesto A Pretto
- 11 University of Miami Miller School of Medicine, Miami, FL, USA
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Donor Indocyanine Green Clearance Test Predicts Graft Quality and Early Graft Prognosis After Liver Transplantation. Dig Dis Sci 2017; 62:3212-3220. [PMID: 28932926 DOI: 10.1007/s10620-017-4765-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 09/13/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Transplantation centers have given much attention to donor availability. However, no reliable quantitative methods have been employed to accurately assess graft quality before transplantation. Here, we report that the indocyanine green (ICG) clearance test is a valuable index for liver grafts. METHODS We performed the ICG clearance test on 90 brain-dead donors within 6 h before organ procurement between March 2015 and November 2016. We also analyzed the relationship between graft liver function and early graft survival after liver transplantation (LT). RESULTS Our results suggest that the ICG retention rate at 15 min (ICGR15) of donors before procurement was independently associated with 3-month graft survival after LT. The best donor ICGR15 cutoff value was 11.0%/min, and we observed a significant increase in 3-month graft failure among patients with a donor ICGR15 above this value. On the other hand, a donor ICGR15 value of ≤ 11.0%/min could be used as an early assessment index of graft quality because it provides additional information to the transplant surgeon or organ procurement organization members who must maintain or improve organ function to adapt the LT. CONCLUSION An ICG clearance test before liver procurement might be an effective quantitative method to predict graft availability and improve early graft prognosis after LT.
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Report of the ISHLT Working Group on primary lung graft dysfunction Part IV: Prevention and treatment: A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1121-1136. [DOI: 10.1016/j.healun.2017.07.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/16/2017] [Indexed: 12/14/2022] Open
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Understanding the effect of corticosteroid pretreatment in brain-dead organ donors: new mechanistic insights for improvement of organ quality in liver transplantation. Clin Sci (Lond) 2017; 131:2377-2379. [PMID: 28870982 DOI: 10.1042/cs20170178] [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: 04/18/2017] [Revised: 06/05/2017] [Accepted: 08/02/2017] [Indexed: 11/17/2022]
Abstract
Transplant surgeons are currently faced with the challenge to accept marginal liver transplants due to steatosis or old age. Improving organ quality by implementing a selective organ protective donor management could be the first step towards a graft of enhanced quality. However, the molecular mechanisms of such treatments are still poorly understood. Glucocorticoid medication in donor medicine has been carried out and discussed for a long time. In a recent study published in Clinical Science, Jiménez-Castro et al. [Clin. Sci. (2017) 131, 733-746] demonstrate how liver histology and transplant liver function can be improved by administration of glucocorticoids to brain-dead donor rats with steatotic livers. This work illustrates the need for further trials in order to selectively improve the quality of steatotic livers with a potential for liver transplantation.
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Abstract
End-organ failure is associated with high mortality and morbidity, in addition to increased health care costs. Organ transplantation is the only definitive treatment that can improve survival and quality of life in such patients; however, due to the persistent mismatch between organ supply and demand, waiting lists continue to grow across the world. Careful intensive care management of the potential organ donor with goal-directed therapy has the potential to optimize organ function and improve donation yield.
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Miñambres E, Suberviola B, Dominguez-Gil B, Rodrigo E, Ruiz-San Millan JC, Rodríguez-San Juan JC, Ballesteros MA. Improving the Outcomes of Organs Obtained From Controlled Donation After Circulatory Death Donors Using Abdominal Normothermic Regional Perfusion. Am J Transplant 2017; 17:2165-2172. [PMID: 28141909 DOI: 10.1111/ajt.14214] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/04/2017] [Accepted: 01/21/2017] [Indexed: 02/06/2023]
Abstract
The use of donation after circulatory death (DCD) has increased significantly during the past decade. However, warm ischemia results in a greater risk for transplantation. Indeed, controlled DCD (cDCD) was associated with inferior outcomes compared with donation after brain death. The use of abdominal normothermic regional perfusion (nRP) to restore blood flow before organ recovery in cDCD has been proposed as better than rapid recovery to reverse the effect of ischemia and improve recipients' outcome. Here, the first Spanish series using abdominal nRP as an in situ conditioning method is reported. A specific methodology to avoid restoring circulation to the brain after death determination is described. Twenty-seven cDCD donors underwent abdominal nRP during at least 60 min. Thirty-seven kidneys, 11 livers, six bilateral lungs, and one pancreas were transplanted. The 1-year death-censored kidney survival was 91%, and delayed graft function rate was 27%. The 1-year liver survival rate was 90.1% with no cases of ischemic cholangiopathy. Transplanted lungs and pancreas exhibited primary function. The use of nRP may represent an advance to increase the number and quality of grafts in cDCD. Poor results in cDCD livers could be reversed with nRP. Concerns about restoring brain circulation after death are easily solved.
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Affiliation(s)
- E Miñambres
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - B Suberviola
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | - E Rodrigo
- Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - J C Ruiz-San Millan
- Service of Nephrology, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - J C Rodríguez-San Juan
- Service of General Surgery, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - M A Ballesteros
- Transplant Coordination Unit & Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
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Giwa S, Lewis JK, Alvarez L, Langer R, Roth AE, Church GM, Markmann JF, Sachs DH, Chandraker A, Wertheim JA, Rothblatt M, Boyden ES, Eidbo E, Lee WPA, Pomahac B, Brandacher G, Weinstock DM, Elliott G, Nelson D, Acker JP, Uygun K, Schmalz B, Weegman BP, Tocchio A, Fahy GM, Storey KB, Rubinsky B, Bischof J, Elliott JAW, Woodruff TK, Morris GJ, Demirci U, Brockbank KGM, Woods EJ, Ben RN, Baust JG, Gao D, Fuller B, Rabin Y, Kravitz DC, Taylor MJ, Toner M. The promise of organ and tissue preservation to transform medicine. Nat Biotechnol 2017; 35:530-542. [PMID: 28591112 PMCID: PMC5724041 DOI: 10.1038/nbt.3889] [Citation(s) in RCA: 312] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/28/2017] [Indexed: 02/06/2023]
Abstract
The ability to replace organs and tissues on demand could save or improve millions of lives each year globally and create public health benefits on par with curing cancer. Unmet needs for organ and tissue preservation place enormous logistical limitations on transplantation, regenerative medicine, drug discovery, and a variety of rapidly advancing areas spanning biomedicine. A growing coalition of researchers, clinicians, advocacy organizations, academic institutions, and other stakeholders has assembled to address the unmet need for preservation advances, outlining remaining challenges and identifying areas of underinvestment and untapped opportunities. Meanwhile, recent discoveries provide proofs of principle for breakthroughs in a family of research areas surrounding biopreservation. These developments indicate that a new paradigm, integrating multiple existing preservation approaches and new technologies that have flourished in the past 10 years, could transform preservation research. Capitalizing on these opportunities will require engagement across many research areas and stakeholder groups. A coordinated effort is needed to expedite preservation advances that can transform several areas of medicine and medical science.
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Affiliation(s)
- Sebastian Giwa
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
- Ossium Health, San Francisco, California, USA
| | - Jedediah K Lewis
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
| | - Luis Alvarez
- Regenerative Biology Research Group, Cancer and Developmental Biology Laboratory, National Cancer Institute, Bethesda, Maryland, USA
- Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA
| | - Robert Langer
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Alvin E Roth
- Department of Economics, Stanford University, Stanford, California, USA
| | - George M Church
- Department of Genetics, Harvard Medical School, Boston, Massachusetts, USA
| | - James F Markmann
- Division of Transplant Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David H Sachs
- Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York, USA
| | - Anil Chandraker
- American Society of Transplantation, Mt. Laurel, New Jersey, USA
- Transplantation Research Center, Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jason A Wertheim
- American Society of Transplant Surgeons, Arlington Virginia, USA
- Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Edward S Boyden
- MIT Media Lab and McGovern Institute, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Elling Eidbo
- Association of Organ Procurement Organizations, Vienna, Virginia, USA
| | - W P Andrew Lee
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David M Weinstock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Gloria Elliott
- Department of Mechanical Engineering and Engineering Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
| | - David Nelson
- Department of Transplant Medicine, Nazih Zuhdi Transplant Institute, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Jason P Acker
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Society for Cryobiology, Baltimore, Maryland, USA
| | - Korkut Uygun
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Boris Schmalz
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Max Planck Institute of Psychiatry, Munich, Germany
| | - Brad P Weegman
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
| | - Alessandro Tocchio
- Organ Preservation Alliance, NASA Research Park, Moffett Field, California, USA
- Department of Radiology, Stanford School of Medicine, Stanford, California, USA
| | - Greg M Fahy
- 21st Century Medicine, Fontana, California, USA
| | - Kenneth B Storey
- Institute of Biochemistry, Carleton University, Ottawa, Ontario, Canada
| | - Boris Rubinsky
- Department of Mechanical Engineering, University of California Berkeley, Berkeley, California, USA
| | - John Bischof
- Department of Mechanical Engineering, University of Minnesota, Minneapolis, Minnesota, USA
| | - Janet A W Elliott
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Department of Chemical and Materials Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Teresa K Woodruff
- Division of Obstetrics and Gynecology-Reproductive Science in Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Utkan Demirci
- Department of Radiology, Stanford School of Medicine, Stanford, California, USA
- Department of Electrical Engineering (by courtesy), Stanford, California, USA
| | | | - Erik J Woods
- Ossium Health, San Francisco, California, USA
- Society for Cryobiology, Baltimore, Maryland, USA
- Department of Microbiology and Immunology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert N Ben
- Department of Chemistry and Biomolecular Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - John G Baust
- Department of Biological Sciences, Binghamton University, State University of New York, Binghamton, New York, USA
| | - Dayong Gao
- Society for Cryobiology, Baltimore, Maryland, USA
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Barry Fuller
- Division of Surgery &Interventional Science, University College Medical School, Royal Free Hospital Campus, London, UK
| | - Yoed Rabin
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | | | - Michael J Taylor
- Sylvatica Biotech, Inc., Charleston, South Carolina, USA
- Department of Mechanical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Mehmet Toner
- Department of Surgery, Center for Engineering in Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Marsolais P, Durand P, Charbonney E, Serri K, Lagacé AM, Bernard F, Albert M. The First 2 Years of Activity of a Specialized Organ Procurement Center: Report of an Innovative Approach to Improve Organ Donation. Am J Transplant 2017; 17:1613-1619. [PMID: 27873446 DOI: 10.1111/ajt.14139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 11/13/2016] [Accepted: 11/15/2016] [Indexed: 01/25/2023]
Abstract
The number of patients requiring organ transplants continues to outgrow the number of organs donated each year. In an attempt to improve the organ donation process and increase the number of organs available, we created a specialized multidisciplinary team within a specialized organ procurement center (OPC) with dedicated intensive care unit (ICU) beds and operating rooms. The OPC was staffed with ICU nurses, operating room nurses, organ donor management ICU physicians, and multidisciplinary staff. All organ donors within a designated geographic area were transferred to and managed within the OPC. During the first 2 years of operation, 126 patients were referred to the OPC. The OPC was in use for a total of 3527 h and involved 253 health workers. We retrieved 173 kidneys, 95 lungs, 68 livers, 37 hearts, and 13 pancreases for a total of 386 organs offered for transplantation. This translates to a total of 124.6 persons transplanted per million population, which compares most favorably to recently published numbers in developed countries. The OPC clearly demonstrates potential to increase the number of deceased donor organs available for transplant. Further studies are warranted to better understand the exact influence of the different components of the OPC on organ procurement.
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Affiliation(s)
- P Marsolais
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - P Durand
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - E Charbonney
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.,Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.,CSSSTR-CHAUR, Service de soins intensifs et médecine interne, Département de Médecine, Université de Montréal, Trois-Rivières, Canada
| | - K Serri
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.,Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - A-M Lagacé
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.,Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - F Bernard
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.,Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
| | - M Albert
- Service de Soins Intensifs, Département de Médecine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada.,Centre de recherche de l'Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Canada
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Spatenkova V, Bradac O, Suchomel P. Potential brain dead organ donation in neurocritical care mortality. J Neurosurg Sci 2017; 64:247-252. [PMID: 28497668 DOI: 10.23736/s0390-5616.17.04010-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mortality is a marker of quality in neurocritical care, but it also provides potential for donors after brain death (DBD) following irreversible acute brain damage. The aim of this study was to analyze the neurointensive care unit (NICU) mortality rate and recovery of potential DBD. METHODS We performed a 10-year prospective observational cohort computer database analysis of 6138 acute neurological and neurosurgical patients (pts, 58.2% male, mean: age 55.9±14.7 years, body weight 78.3±15.6 kg, body mass index 26.9±4.7, NICU stay 3.8±5.3 days): 3462 (56.4%) pts with brain disease (mostly stroke 43.2%, tumor 31.1%, trauma 13.6%); 10.3% pts with internal carotid artery (ICA) stenosis; 32.6% pts with spine diseases, and others. Mean Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission was 10.63±5.2 and Glasgow Coma Scale on admission was 13.79±2.51. RESULTS There were 159 (2.6%) cases of mortality with a significantly higher mortality rate in pts with brain diseases (95.6% of deceased pts, P<0.001) than in ICA stenosis (0.6%), spine (1.9%) and from others (1.9%). There were 23 (14.5%) pts with clinical signs of brain death, of whom 13 (56.5%) became donors. The main reasons for non-recovery of potential donors were hemodynamic instability (16.7%) and family reluctance (12.5%). CONCLUSIONS The study showed that our NICU mortality was 2.6%. There were relatively few clinical signs of brain death and not all potential donors were recovered.
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Affiliation(s)
- Vera Spatenkova
- Neurocenter, Unit of Neurointensive Care, Regional Hospital, Liberec, Czech Republic -
| | - Ondrej Bradac
- Department of Neurosurgery, Central Military Hospital, Charles University, Prague, Czech Republic
| | - Petr Suchomel
- Department of Neurosurgery, Neurocenter, Regional Hospital, Liberec, Czech Republic
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Spatenkova V, Pokorna E, Suchomel P. Five-Year Follow-Up on Transplanted Organs From Donors After Brain Death After Acute Stroke. EXP CLIN TRANSPLANT 2017; 15:445-447. [PMID: 28447929 DOI: 10.6002/ect.2016.0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Efficient intensive care donor management can help alleviate the shortage of organs for transplant. The aim of this study was to investigate the efficiency of management of donors after brain death from our neurointensive care unit. MATERIALS AND METHODS We conducted a prospective observational 5-year follow-up on 29 transplanted organs from 14 brain-dead donors after acute stroke (7 subarachnoid and 4 intracerebral hemorrhages, 3 ischemic strokes). Mean age of donors was 56.2 ± 8.70 years, and mean number of days of artificial ventilation was 5.0 ± 3.84. We transplanted 27 kidneys and 2 livers to 29 patients with mean age of 55.3 ± 9.76 years. No hearts or lungs were transplanted from these donors. RESULTS Of the 27 patients who underwent kidney transplant, 21 patients (78%) lived 5 years; of those, 17 patients (63%) had functional grafts. One patient (4%) had a primary afunctional graft, and 3 patients (11%) had graft rejection (at 3, 15, and 41 mo). Six patients (22%) died after kidney transplant, with 1 patient in this group having a functional graft, 1 patient having a primary afunctional graft, and 4 patients (15%) having graft rejection (at 1, 12, 44, and 56 mo). The 2 patients with liver transplants lived 5 years with functional grafts. CONCLUSIONS The 5-year follow-up showed that organs from 14 brain-dead donors improved and saved 19 lives, with 17 patients receiving kidney transplants and 2 patients receiving liver transplants. Another 7 patients had only partially improved quality of life.
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Affiliation(s)
- Vera Spatenkova
- From the the Neurocenter, Neurointensive Care Unit, Regional Hospital, Liberec, Czech Republic
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Wojda TR, Stawicki SP, Yandle KP, Bleil M, Axelband J, Wilde-Onia R, Thomas PG, Cipolla J, Hoff WS, Shultz J. Keys to successful organ procurement: An experience-based review of clinical practices at a high-performing health-care organization. Int J Crit Illn Inj Sci 2017; 7:91-100. [PMID: 28660162 PMCID: PMC5479082 DOI: 10.4103/ijciis.ijciis_30_17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Organ procurement (OP) from donors after brain death and circulatory death represents the primary source of transplanted organs. Despite favorable laws and regulations, OP continues to face challenges for a number of reasons, including institutional, personal, and societal barriers. This focused review presents some of the key components of a successful OP program at a large, high-performing regional health network. This review focuses on effective team approaches, aggressive resuscitative strategies, optimal communication, family support, and community outreach efforts.
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Affiliation(s)
- Thomas R. Wojda
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | - Stanislaw P. Stawicki
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | | | - Maria Bleil
- Gift of Life Donor Program, Philadelphia, PA 19123, USA
| | - Jennifer Axelband
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | - Rebecca Wilde-Onia
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | - Peter G. Thomas
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | - James Cipolla
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | - William S. Hoff
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
| | - Jill Shultz
- Department of Surgery, Level I Resource Trauma Center, St. Luke's University Health Network, Bethlehem, PA 19123, USA
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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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Influence of specific thoracic donor therapy on kidney donation and long-term kidney graft survival. J Nephrol 2016; 30:869-875. [PMID: 27830458 DOI: 10.1007/s40620-016-0355-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To analyze the impact of a specific thoracic donor-treatment protocol (including restrictive fluid balance) on kidney donation and on kidney graft survival. METHODS A cohort study. Lung Donors and kidney recipients from 2003 to 2008 were the pre-protocol cohort, and those from 2009 to 2013 were the protocol cohort. The main outcome variables were graft survival and rate of kidney donation. RESULTS Kidney donation rates were similar in both periods (86.2 vs. 86.2 %; p > 0.05). Both donors and kidney recipients were older and with more comorbidities in the protocol group and this is the reason there were more cases of delayed graft function (differences not statistically significant) and with higher sequential creatinine levels of kidney recipients during the protocol period. However, graft survival was similar in both groups. The probability of graft survival 5 years after transplantation was 0.75 (95 % confidence interval 0.65-0.85) in the pre-protocol cohort and 0.81 (0.70-0.92) in the protocol cohort. CONCLUSIONS Specific treatment for multi-organ donors including restrictive fluid balance does not affect kidney donation or kidney graft loss, and has no impact on long-term viability. Hemodynamics must be closely monitored by medical personnel with specific training.
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Serri K, Marsolais P. End-of-Life Issues in Cardiac Critical Care: The Option of Organ Donation. Can J Cardiol 2016; 33:128-134. [PMID: 28024551 DOI: 10.1016/j.cjca.2016.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/17/2016] [Accepted: 10/19/2016] [Indexed: 12/13/2022] Open
Abstract
Despite important advances in the care of postcardiac arrest patients, severe brain injury remains one of the major causes of death in the cardiac intensive care unit. Neurological prognostication after cardiac arrest has evolved significantly since the introduction of therapeutic hypothermia. It now relies on a multimodal approach and a minimal observation period of 72 hours is usually advocated. However, when brain injury is severe and the prognosis considered dismal, patients become eligible for organ donation. Patients with severe anoxic encephalopathy might evolve toward brain death and be candidates for donation after brain death. In the presence of severe brain injury without brain death criteria, when withdrawal of life-sustaining therapy is considered, patients might be eligible for donation after cardiocirculatory death. The diagnosis of brain death, the differences between donation after brain death and donation after cardiocirculatory death, family approach, and donor management in the intensive care unit are discussed. Because these are increasingly encountered situations in the cardiac intensive care unit, it is essential that physicians involved in cardiac critical care be familiar with these concepts.
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Affiliation(s)
- Karim Serri
- Hôpital du Sacré-Coeur de Montréal, Service de soins intensifs, Département de médecine, and Centre de recherche Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Pierre Marsolais
- Hôpital du Sacré-Coeur de Montréal, Service de soins intensifs, Département de médecine, and Centre de recherche Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
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Abstract
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.
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Alolod GP, Traino HM, Siminoff LA. Utility and Usability of the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD) as a Tool for OPO Hospital Development Staff. Prog Transplant 2016; 26:241-8. [PMID: 27323955 DOI: 10.1177/1526924816655960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CONTEXT Few systematic assessment tools are available to organ procurement organizations (OPOs) for evaluating donation climates of hospitals in their donation service areas (DSAs). The Rapid Assessment of hospital Procurement barriers in Donation (RAPiD) was developed for OPO hospital development staff to assess the organ donation climate of hospitals. OBJECTIVE To implement a national test of the RAPiD to examine its efficacy and usability by OPO hospital development staff. DESIGN Two-arm randomized design, comparing implementation of RAPiD protocol between qualitatively trained researchers (n = 7) and OPO hospital development staff (n = 24); all evaluators received the same training assessments of high-yield hospitals. SETTING A total of 77 hospitals in DSAs of 8 OPOs. PARTICIPANTS A total of 2552 health-care providers (HCPs) in high organ donor potential units. MAIN OUTCOME MEASURES Twenty-four donation-related attitudes, knowledge, and behaviors. RESULTS More HCPs interviewed in the autonomous condition were positive toward the concept of organ donation. However, HCPs in the assisted condition were more candid about and critical of the OPO. As for knowledge, fewer HCPs in the autonomous condition reported familiarity with the donation process, need for donors, and generally accepted timely referral criteria. With respect to behaviors, more respondents in the autonomous condition reported frequent or occasional contact with the OPO and routine or occasional referral criteria use. Due to issues of bias, inadequate research experience, conflicts of interest, and ongoing OPO hospital development initiatives, the RAPiD's usability by OPO-based hospital development staff is questionable and not recommended in its current form. A next generation of the RAPiD is described for future consideration.
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Affiliation(s)
- Gerard P Alolod
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Heather M Traino
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
| | - Laura A Siminoff
- Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, USA
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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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Gracious N. Maximizing organ yield from deceased Lead donors. J Anaesthesiol Clin Pharmacol 2016; 32:143. [PMID: 27275038 PMCID: PMC4874063 DOI: 10.4103/0970-9185.182083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Nathan SD, King CS. Organ Donors: Making the Most of What Is Offered. Chest 2015; 148:303-305. [PMID: 26238828 DOI: 10.1378/chest.15-1269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Steven D Nathan
- Advanced Lung Disease and Lung Transplant Clinic, Inova Fairfax Hospital Falls Church, VA.
| | - Christopher S King
- Advanced Lung Disease and Lung Transplant Clinic, Inova Fairfax Hospital Falls Church, VA
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Affiliation(s)
- Eunmi Gil
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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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. Crit Care Med 2015; 43:1291-325. [PMID: 25978154 DOI: 10.1097/ccm.0000000000000958] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Miñambres E, Pérez-Villares JM, Chico-Fernández M, Zabalegui A, Dueñas-Jurado JM, Misis M, Mosteiro F, Rodriguez-Caravaca G, Coll E. Lung donor treatment protocol in brain dead-donors: A multicenter study. J Heart Lung Transplant 2015; 34:773-80. [DOI: 10.1016/j.healun.2014.09.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/05/2014] [Accepted: 09/19/2014] [Indexed: 11/25/2022] Open
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When Operating on Dead People Saves Lives: Benefits of Surgical Organ Donor Intensivists. Case Rep Surg 2015; 2015:608673. [PMID: 26078909 PMCID: PMC4442278 DOI: 10.1155/2015/608673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 04/20/2015] [Indexed: 11/17/2022] Open
Abstract
Solid organ transplantation has emerged as a life-saving treatment for many patients suffering from end-stage organ failure. Organs have been successfully recovered after a variety of aggressive interventions. We propose that decompressive laparotomy, when clinically indicated, should be considered in the aggressive resuscitation of potential organ donors. A thorough literature review examining aggressive interventions on potential organ donors was conducted after experience with a unique case at this institution. Articles were reviewed for the types of interventions performed as well as the time frame in relation to organ donation. In our case, several ethical issues were raised when considering decompressive laparotomy in a patient pronounced dead by neurologic criteria. We propose that having a surgical intensivist involved in the management of potential donors will further increase the salvage rate, as more invasive resuscitation options are possible.
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Abstract
PURPOSE OF REVIEW Current pressures of organ supply and demand require maximization of potential for organ donation. The donor population is older and has more significant comorbidity than in the past.Optimal management of the donor after brain death (DBD) is essential to ensure that the greatest number of organs can be transplanted per donor. Defining evidence-based drugs and techniques to assist this has never been more important. RECENT FINDINGS Care of patients with catastrophic brain injury incorporating supportive therapy targeted at specific goals and delivered by experienced specialists provides the best donation outcomes. Such pathways represent best practice critical care applied to this population. In this context, the value of some previously recommended therapies appears questionable and warrants reassessment. Prolonged (>24 h) incorporeal organ conditioning may have significant benefits.Extracorporeal support in the resuscitation arena is emerging and, in patients who fail to respond, may yield a new source of donors. SUMMARY Early identification of potential DBD, best practice critical care, and achieving defined treatment goals are associated with more transplantable organs. Study of a complex intervention like donor management presents significant problems of organization, ethics and consent. This situation is recognized internationally and progress is being made.
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Shemie SD, MacDonald S. Improving the process of deceased organ and tissue donation: a role for donation physicians as specialists. CMAJ 2013; 186:95-6. [PMID: 24344147 DOI: 10.1503/cmaj.130050] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hwang DY, Gilmore EJ, Greer DM. Assessment of Brain Death in the Neurocritical Care Unit. Neurosurg Clin N Am 2013; 24:469-82. [DOI: 10.1016/j.nec.2013.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Masnou N, Rello J. The impact of lung transplantation on ICU personnel. Med Intensiva 2013; 37:206-8. [PMID: 23398845 DOI: 10.1016/j.medin.2012.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 12/18/2012] [Accepted: 12/19/2012] [Indexed: 11/19/2022]
Affiliation(s)
- N Masnou
- Transplant Coordination Department, Vall d'Hebron University Hospital, Barcelona, Spain.
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Traino HM, Alolod GP, Shafer T, Siminoff LA. Interim results of a national test of the rapid assessment of hospital procurement barriers in donation (RAPiD). Am J Transplant 2012; 12:3094-103. [PMID: 22900761 PMCID: PMC3532942 DOI: 10.1111/j.1600-6143.2012.04220.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Organ donation remains a major public health challenge with over 114 000 people on the waitlist in the United States. Among other factors, extant research highlights the need to improve the identification and timely referral of potential donors by hospital healthcare providers (HCPs) to organ procurement organizations (OPOs). We implemented a national test of the Rapid Assessment of hospital Procurement barriers in Donation (RAPiD) to identify assets and barriers to the organ donation and patient referral processes; assess hospital-OPO relationships and offer tailored recommendations for improving these processes. Having partnered with seven OPOs, data were collected at 70 hospitals with high donor potential in the form of direct observations and interviews with 2358 HCPs. We found that donation attitudes and knowledge among HCPs were high, but use of standard referral criteria was lacking. Significant differences were found in the donation-related attitudes, knowledge and behaviors of physicians and emergency department staff as compared to other staff in intensive care units with high organ donor potential. Also, while OPO staff were generally viewed positively, they were often perceived as outsiders rather than members of healthcare teams. Recommendations for improving the referral and donation processes are discussed.
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Affiliation(s)
- H M Traino
- Department of Social and Behavioral Health, Virginia Commonwealth University, Richmond, VA, USA.
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Billeter AT, Sklare S, Franklin GA, Wright J, Morgan G, O'Flynn PE, Polk HC. Sequential improvements in organ procurement increase the organ donation rate. Injury 2012; 43:1805-10. [PMID: 22920088 DOI: 10.1016/j.injury.2012.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 07/31/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Organ demand exceeds availability of transplantable organs. Organ procurement continues to suffer from failures to identify potential donors, inability to obtain consent for donation, as well as failures to retrieve certain organs as donor demographics change. The purpose of this article is to propose how sequentially introduced measures can increase organ donation rates as well as improve organ procurement. METHODS We analysed the effect of stepwise improvements in the organ procurement process patients in a university-based surgical intensive care unit over a 20-year period. We related newly introduced measures in the organ retrieval process with changes in donation rates. We specifically targeted these three main steps in the donation process: donor identification, conversion of potential donors to actual donors, and organ protection during the procurement process. Finally, we assessed the effect of the same measures on organ procurement after introduction in other hospitals of the same organ procurement region. RESULTS Introduction of quality improvement steps increased all of the observed parameters. The number of organ donors was stabilised due to a better identification of potential donors, a major increase in conversion from potential to actual donors, and an increase in extended criteria donor. Improvements in organ protection led to higher rates of organs transplanted per donor and increased recovery of lungs and hearts despite increasing donor age. The same measures were introduced successfully in other hospitals in our organ procurement region. CONCLUSION Sequential improvements in organ procurement can increase the yield of retrieved organs. The same measures can be applied to other hospitals and lead to comparable improvements in organ donation.
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Affiliation(s)
- Adrian T Billeter
- Department of Surgery, Price Institute of Surgical Research, School of Medicine, University of Louisville, 511 South Floyd Street, Louisville, KY 40202, United States.
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