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Dame C, von der Hude K, Kliemann M, Rösner B, Bührer C, Garten L. [... because We Should not Forget! Neonatal Organ Donation]. Z Geburtshilfe Neonatol 2021; 225:366-370. [PMID: 34384134 DOI: 10.1055/a-1509-3688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Obwohl sich fast 40% aller Todesfälle im Kindes- und Jugendalter während der Neugeborenenperiode ereignen, kommt es in der Neonatologie nur selten zur Organspende. Wir berichten über ein Neugeborenes, bei dem nach perinataler Asphyxie der endgültige, nicht behebbare Ausfall der Gesamtfunktion des Großhirns, des Kleinhirns und des Hirnstamms ("Hirntod") gemäß Transplantationsgesetz diagnostiziert wurde. Das Herz wurde nach der sogenannten zweiten richtliniengemäßen "Hirntoddiagnostik" zur Organspende entnommen und erfolgreich transplantiert. Besondere juristische Herausforderungen ergaben sich aus dem Umstand der anonymen Geburt, den notwendigen Regelungen der Vormundschaft sowie der Zuordnung des Totenfürsorgerechts. Medizinisch standen die speziellen Regelungen der Diagnostik des irreversiblen Hirnfunktionsausfalls bei Neugeborenen und der optimale Erhalt der Organfunktion vor Entnahme im Vordergrund. Für die Pflegenden stellte sich der Ablauf grundlegend anders dar als bei einer Therapiezieländerung mit anschließender palliativen Versorgung in Anwesenheit der Eltern. Angesichts der großen emotionalen Herausforderungen erwiesen sich die Einbindung aller Beteiligten in die Entscheidungsabläufe und die Übernahme der besonderen Verantwortung als hilfreich.Although almost 40% of all deaths prior to 18 years of age occur within the neonatal period, organ donation is rare in neonatology. Herein we report about a newborn infant with perinatal asphyxia and permanent, irreversible loss of brain function (cerebrum, cerebellum and brain stem), managed according to the criteria and instructions defined by the German law of donor organ transplantation. After confirmation of irreversible loss of brain function, the heart was successfully transplanted. Specific legal challenges resulted from the instance of an anonymous birth, the guardianship required, and the specific regulations of welfare of the deceased individual. The most prominent medical challenges consisted in the specific regulatory purposes for the diagnosis of the irreversible loss of brain function in neonates and the optimal maintenance of organ functions prior to donation. From the nursing point of view, the proceeding differed entirely compared to redirection of care into palliation while parents are present. Involving all stakeholders in every step of decision making was regarded as emotionally helpful.
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Affiliation(s)
- Christof Dame
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Kerstin von der Hude
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Markus Kliemann
- Region Nord-Ost, Deutsche Stiftung Organtransplantation, Frankfurt, Deutschland
| | - Bianka Rösner
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Christoph Bührer
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Lars Garten
- Klinik für Neonatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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Hollander SA, Nandi D, Bansal N, Godown J, Zafar F, Rosenthal DN, Lorts A, Jeewa A. A coordinated approach to improving pediatric heart transplant waitlist outcomes: A summary of the ACTION November 2019 waitlist outcomes committee meeting. Pediatr Transplant 2020; 24:e13862. [PMID: 32985785 DOI: 10.1111/petr.13862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
The number of children needing heart transplantation continues to rise. Although improvements in heart failure therapy, particularly durable mechanical support, have reduced waitlist mortality, the number of children who die while waiting for a suitable donor organ remains unacceptably high. Roughly, 13% of children and 25% of infants on the heart transplant waitlist will not survive to transplantation. With this in mind, the Advanced Cardiac Therapies Improving Outcomes Collaborative Learning Network (ACTION), through its Waitlist Outcomes Committee, convened a 2-day symposium in Ann Arbor, Michigan, from 2-3 November 2019, to better understand the factors that contribute to pediatric heart transplant waitlist mortality and to focus future efforts on improving the organ allocation rates for children needing heart transplantation. Using improvement science methodology, the heart failure-transplant trajectory was broken down into six key steps, after which modes of failure and opportunities for improvement at each step were discussed. As a result, several projects aimed at reducing waitlist mortality were initiated.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Deipanjan Nandi
- Division of Pediatrics (Cardiology), Nationwide Children's Hospital, Columbus, OH, USA
| | - Neha Bansal
- Division of Pediatrics Cardiology, Children's Hospital at Montefiore, Bronx, NY, USA
| | - Justin Godown
- Department of Pediatrics (Cardiology), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University, Palo Alto, CA, USA
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aamir Jeewa
- Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, USA
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Baez Hernandez N, Kirk R, Davies R, Bano M, Sutcliffe D, Pirolli T, Jaquiss R, Daneman S, Butts RJ. A comprehensive strategy in donor acceptance: Impact on pediatric waitlist and heart transplant outcomes. Pediatr Transplant 2020; 24:e13764. [PMID: 32536034 DOI: 10.1111/petr.13764] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
Significant inter- and intra-center practice variability is present in pediatric donor heart acceptability. This may contribute to variation in the donor refusal rate and may impact waitlist time, morbidity, mortality, and transplant rates. In order to reduce practice variability, our center developed and implemented a comprehensive strategy regarding donor acceptance in September 2017. The aim of this study was to assess the impact of this strategy on waitlist time and outcomes as well as early post-transplant outcomes. We performed a single-center, retrospective analysis of all pediatric (<18 years) patients listed for single-organ heart transplant at our center from September 2015 to September 2018. Patients were divided into those listed before (Group 1) and after implementation of the comprehensive strategy (Group 2). The primary end-point was waitlist time. Secondary end-points included waitlist removal due to death or clinical deterioration, donor refusals per listed patient, early post-transplant outcomes (graft failure, mechanical ventilation time, inotropic support, length of hospital stay) and 1-year post-transplant survival. Of 78 listed patients, 54 were transplanted (29 in Group 1), 9 were removed due to death or clinical deterioration (7 in Group 1) and 15 were removed due to clinical improvement (12 in Group 1). The waitlist time was significantly shorter in Group 2 (17 days, IQR 7-53) vs Group 1 (90 days, IQR 14-162); P = .006. The number of donor refusals was lower in Group 2 (1, IQR 0-2.2) vs Group 1 (4, IQR 2-19); P < .001. The percentage of refused donors with normal function (Left ventricular ejection fraction > 50%) was lower in Group 2 vs Group 1 (53% vs 84%; P < .001). Difference in removal from the waitlist for death or deterioration in Group 2 vs Group 1 (n = 2, 7% vs n = 7, 20%, P = .18) did not reach statistical significance. There was no difference in post-transplant outcomes between groups. The waitlist time and donor refusals significantly decreased after implementation of a comprehensive donor acceptance strategy without impacting transplant outcomes. This analysis supports the need for a comprehensive approach to donor organ acceptance within a pediatric transplant center.
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Affiliation(s)
| | - Richard Kirk
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryan Davies
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Maria Bano
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Sutcliffe
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Timothy Pirolli
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert Jaquiss
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Susan Daneman
- Children's Health, Children's Medical Center, Dallas, TX, USA
| | - Ryan J Butts
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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