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Salim A, Cotton BA. Victory out of tragedy: organ donation. Trauma Surg Acute Care Open 2024; 9:e001408. [PMID: 38646028 PMCID: PMC11029243 DOI: 10.1136/tsaco-2024-001408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Major improvements in trauma care during the last decade have improved survival rates in the severely injured. The unintended consequence is the presentation of patients with non-survivable injuries in a time frame in which intervention is considered and often employed due to prognostic uncertainty. In light of this, discerning survivability in these patients remains increasingly problematic. Evidence-based cut-points of futility can guide early decisions for discontinuing aggressive treatment and use of precious resources in severely injured patients arriving in extremis.
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Affiliation(s)
- Ali Salim
- Trauma, Burn, Surgical Critical Care and Emergency General Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Bryan A Cotton
- Surgery, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas, USA
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Mahdi S, Marzieh L, Habib R, Elahe P, Sanaz D. The role of healthcare professionals to improve organ donation and transplantation outcome: a national study. Cell Tissue Bank 2024; 25:159-165. [PMID: 36707455 PMCID: PMC9883121 DOI: 10.1007/s10561-023-10071-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 01/10/2023] [Indexed: 01/29/2023]
Abstract
BACKGROUND Improve the quality of donor coordination activities caused by an increased organ donation rate. The aim of this study was to assess the influence of organ donation coordinators' characteristics on rate of donation and family consent rate in Recognition Centers (RCs) and Organ Procurement Units (OPUs) in Iran by analyzing the organ procurement and transplantation data. MATERIALS AND METHODS Based on a questionnaire, this retrospective study evaluated the number of confirmed brain deaths, family consent rate, organ recoveries, rate of expired brain death cases before and after family consent in Iran. RESULTS According to results, the overall family consent rate in the entire country is equal to 60.63%. The work experience had a significant effect on the number of procured organs (P < 0.004), death rate after family consent (P < 0.04), and eligible donor death before family consent (P < 0.03). The type of unit (RCs or OPUs) had significant difference on death after family consent (P < 0.023), the death before family consent (P < 0.014), the sum of procured organ (P < 0.04). CONCLUSION The consent rate and donor management in the cases of brain death are unacceptable. The coordinators need training to increase their efficiency in terms of family approach and maintenance of brain death. Only by improving the level of family consent and increasing the coordinators' maintenance skills for brain death cases can the amount of organ donation in Iran be doubled to the current amount.
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Affiliation(s)
- Shadnoush Mahdi
- Nutrition & Food Technology, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Latifi Marzieh
- Organ Procurement Unit, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rahban Habib
- Cardiovascular Research Foundation of Southern California, Beverly Hills, CA USA
- Southern California Medical Education Consortium, Universal Health System, Temecula, CA USA
| | - Pourhosein Elahe
- Organ Procurement Unit, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Dehghani Sanaz
- Organ Procurement Unit, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Iranian Tissue Bank & Research Center, Tehran University of Medical Sciences, Sina University Hospital, Hassan-abad Sq. Emam Khomeini St, Tehran, Iran
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Silva AMD, Ferreira Júnior MA, Cardoso AIDQ, Ivo ML, Almeida JPF, Melo RDS. Costs related to obtaining organs for transplantation: A systematic review. Transplant Rev (Orlando) 2022; 36:100724. [PMID: 36029555 DOI: 10.1016/j.trre.2022.100724] [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: 06/03/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The number of transplants in the world is growing, although there is a demand that exceeds supply. It is worth mentioning that the costs for obtaining organs are considered high. However, few studies have been developed on analyzing the costs of obtaining organs and tissues for transplants in order to support the decision-making of managers and health professionals. OBJECTIVE To summarize the studies related to the cost of obtaining organs for transplants from a deceased donor. METHOD A systematic literature review was conducted in the following databases: PubMed, Cochrane Library CINAHAL, Virtual Health Library (BVS), SCOPUS, Web of Science and EMBASE, using the following descriptors: Costs and cost analysis; Donor Selection; Tissue and Organ Procurement; Tissue and Organ Harvesting; and Tissue Donors, in studies published until April 2021. The risk of bias assessment was performed using the Joanna Briggs Institute's Checklist for Economic Assessments. It was not possible to perform a meta-analysis due to the heterogeneity of the studies. RESULTS A total of 1731 studies were identified, of which 11 were analyzed. The cost of kidneys in US dollars (USD) ranged between USD $1672 and USD $25,058. Obtaining a liver ranged from USD $586 to USD $44,478. Heart procurement ranged from USD $633 to USD $24,264. The combined heart-lung transplant ranged from USD $860 to USD $23,203. Obtaining the pancreas ranged from USD $413 to USD $29,708. CONCLUSIONS Cost of obtaining organs for transplants from a deceased donor is substantial and varies widely across different studies. The overall cost of failures to obtain organs is currently unknown. Understanding organ procurement expenses can help clarify areas in which organ and tissue procurement can improve in cost and efficiency.
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Affiliation(s)
- Aline Moraes da Silva
- Health and Development of the Midwest Region at the Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil.
| | - Marcos Antonio Ferreira Júnior
- Graduate Program in Nursing, Integrated Health Institute, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
| | | | - Maria Lucia Ivo
- Graduate Program in in Health and Development of the Midwest Region at the Federal University of Mato Grosso do Sul, Federal University of Mato Grosso do Sul, Campo Grande, MS, Brazil
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Timar J, Bleil M, Daly T, Koomar S, Hasz R, Nathan H. Successful strategies to increase organ donation: the Gift of Life Donor Program Philadelphia model. Indian J Thorac Cardiovasc Surg 2021; 37:380-394. [PMID: 34629767 PMCID: PMC8464643 DOI: 10.1007/s12055-021-01219-9] [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: 03/16/2021] [Revised: 05/19/2021] [Accepted: 05/23/2021] [Indexed: 10/20/2022] Open
Abstract
Organ donation connects the ending of one life with the renewal of another. Acute care hospitals care for the organ donor and transplant organizations complete life-saving surgeries. Between them is a vital component: a less-known medical team dedicated to ensuring that organ donation and transplantation are possible. Organ procurement organizations (OPOs) support grieving families during a painful time of loss, providing a rare and precious opportunity in donation. The OPO is simultaneously poised to ensure that organs successfully begin their journey to renewing life and restoring hope for recipients and their loved ones. Every OPO faces a myriad of challenges in meeting its responsibilities. A recognized leader in the field, Gift of Life Donor Program (GLDP) in Philadelphia, Pennsylvania has been committed to meeting these challenges for nearly fifty years. The successes of this OPO reflect the legacies of organ donors, recipients, and their cherished loved ones.
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Affiliation(s)
- Jennifer Timar
- Gift of Life Donor Program, 401 N. 3rd St, Philadelphia, PA 19123 USA
| | - Maria Bleil
- Gift of Life Donor Program, 401 N. 3rd St, Philadelphia, PA 19123 USA
| | - Theresa Daly
- Gift of Life Donor Program, 401 N. 3rd St, Philadelphia, PA 19123 USA
| | - Susan Koomar
- Gift of Life Donor Program, 401 N. 3rd St, Philadelphia, PA 19123 USA
| | - Richard Hasz
- Gift of Life Donor Program, 401 N. 3rd St, Philadelphia, PA 19123 USA
| | - Howard Nathan
- Gift of Life Donor Program, 401 N. 3rd St, Philadelphia, PA 19123 USA
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Chandar J, Chen L, Defreitas M, Ciancio G, Burke G. Donor considerations in pediatric kidney transplantation. Pediatr Nephrol 2021; 36:245-257. [PMID: 31932959 DOI: 10.1007/s00467-019-04362-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/18/2019] [Accepted: 09/06/2019] [Indexed: 01/10/2023]
Abstract
This article reviews kidney transplant donor options for children with end-stage kidney disease (ESKD). Global access to kidney transplantation is variable. Well-established national policies, organizations for organ procurement and allocation, and donor management policies may account for higher deceased donor (DD transplants) in some countries. Living donor kidney transplantation (LD) predominates in countries where organ donation has limited national priority. In addition, social, cultural, religious and medical factors play a major role in both LD and DD kidney transplant donation. Most children with ESKD receive adult-sized kidneys. The transplanted kidney has a finite survival and the expectation is that children who require renal replacement therapy from early childhood will probably have 2 or 3 kidney transplants in their lifetime. LD transplant provides better long-term graft survival and is a better option for children. When a living related donor is incompatible with the intended recipient, paired kidney exchange with a compatible unrelated donor may be considered. When the choice is a DD kidney, the decision-making process in accepting a donor offer requires careful consideration of donor history, kidney donor profile index, HLA matching, cold ischemia time, and recipient's time on the waiting list. Accepting or declining a DD offer in a timely manner can be challenging when there are undesirable facts in the donor's history which need to be balanced against prolonging dialysis in a child. An ongoing global challenge is the significant gap between organ supply and demand, which has increased the need to improve organ preservation techniques and awareness for organ donation.
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Affiliation(s)
- Jayanthi Chandar
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami Transplant Institute, PO Box 016960 (M714), Miami, FL, 33101, USA.
| | - Linda Chen
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
| | - Marissa Defreitas
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami Miller School of Medicine, Miami Transplant Institute, PO Box 016960 (M714), Miami, FL, 33101, USA
| | - Gaetano Ciancio
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
| | - George Burke
- Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami Transplant Institute, Miami, FL, USA
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Westphal GA, Robinson CC, Cavalcanti AB, Gonçalves ARR, Guterres CM, Teixeira C, Stein C, Franke CA, da Silva DB, Pontes DFS, Nunes DSL, Abdala E, Dal-Pizzol F, Bozza FA, Machado FR, de Andrade J, Cruz LN, de Azevedo LCP, Machado MCV, Rosa RG, Manfro RC, Nothen RR, Lobo SM, Rech TH, Lisboa T, Colpani V, Falavigna M. Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System. Ann Intensive Care 2020; 10:169. [PMID: 33315161 PMCID: PMC7736434 DOI: 10.1186/s13613-020-00787-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.
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Affiliation(s)
- Glauco Adrieno Westphal
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil. .,Hospital Municipal São José (HMSJ), Joinville, SC, Brazil. .,Centro Hospitalar Unimed, Joinville, SC, Brazil.
| | | | | | - Anderson Ricardo Roman Gonçalves
- Universidade da Região de Joinville (UNIVILLE), R. Paulo Malschitzki, 10, Joinville, SC, 89219710, Brazil.,Clínica de Nefrologia de Joinville, R. Plácido Gomes, 370, Joinville, SC, 89202-050, Brazil
| | - Cátia Moreira Guterres
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cassiano Teixeira
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Sarmento Leite, 245, Porto Alegre, RS, 90050-170, Brazil
| | - Cinara Stein
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Cristiano Augusto Franke
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Daiana Barbosa da Silva
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Daniela Ferreira Salomão Pontes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Diego Silva Leite Nunes
- General Coordination Office of the National Transplant System, Brazilian Ministry of Health, Esplanada dos Ministérios, Bloco G, Edifício Sede, Brasília, DF, 70058900, Brazil
| | - Edson Abdala
- Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr, Arnaldo 455, Sala 3206, São Paulo, SP, 01246903, Brazil
| | - Felipe Dal-Pizzol
- Universidade do Extremo Sul Catarinense (UNESC), Av. Universitária, 1105, Criciúma, SC, 88806000, Brazil.,Intensive Care Unit, Hospital São José, R. Cel. Pedro Benedet, 630, Criciúma, SC, 88801-250, Brazil
| | - Fernando Augusto Bozza
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Av. Brasil, 4365, Rio de Janeiro, RJ, 21040360, Brazil.,Instituto D'Or de Pesquisa e Ensino (IDOR), R. Diniz Cordeiro, 30, Rio de Janeiro, RJ, 22281100, Brazil
| | - Flávia Ribeiro Machado
- Hospital São Paulo (HU), Universidade Federal de São Paulo (UNIFESP), R. Napoleão de Barros 737, São Paulo, SP, 04024002, Brazil
| | - Joel de Andrade
- Organização de Procura de Órgãos e Tecidos de Santa Catarina (OPO/SC), Rua Esteves Júnior, 390, Florianópolis, SC, 88015130, Brazil
| | - Luciane Nascimento Cruz
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | | | | | - Regis Goulart Rosa
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Roberto Ceratti Manfro
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil.,Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Rosana Reis Nothen
- Universidade Federal do Rio Grande do Sul (UFRGS), Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Suzana Margareth Lobo
- Faculdade de Medicina de São José do Rio Preto, Av Faria Lima, 5544, São José do Rio Preto, SP, 15090000, Brazil
| | - Tatiana Helena Rech
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Thiago Lisboa
- Hospital de Clínicas de Porto Alegre (HCPA), R. Ramiro Barcelos, 2350, Porto Alegre, RS, 90035007, Brazil
| | - Verônica Colpani
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil
| | - Maicon Falavigna
- Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, Porto Alegre, RS, 90035000, Brazil.,National Institute for Health Technology Assessment, UFRGS, Rua Ramiro Barcelos, 2350, Porto Alegre, RS, 90035903, Brazil.,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, 1280 Main St W, Hamilton, ON, Canada
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Giordani NE, Robinson CC, Westphal GA, Rosa RG, Sganzerla D, Cavalcanti AB, Machado FR, Azevedo LCP, Bozza FA, Teixeira C, de Andrade J, Franke CA, Guterres CM, Madalena IC, Rohden AI, da Silva SS, Andrighetto LV, Rech GS, Gimenes BDP, Hammes LS, Pontes DFS, Meade MO, Falavigna M. Statistical analysis plan for a cluster-randomised trial assessing the effectiveness of implementation of a bedside evidence-based checklist for clinical management of brain-dead potential organ donors in intensive care units: DONORS (Donation Network to Optimise Organ Recovery Study). Trials 2020; 21:540. [PMID: 32552839 PMCID: PMC7298918 DOI: 10.1186/s13063-020-04457-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 05/25/2020] [Indexed: 11/28/2022] Open
Abstract
Background The quality of clinical care of brain-dead potential organ donors may help reduce donor losses caused by irreversible or unreversed cardiac arrest and increase the number of organs donated. We sought to determine whether an evidence-based, goal-directed checklist for donor management in intensive care units (ICUs) can reduce donor losses to cardiac arrest. Methods/design The DONORS study is a multicentre, cluster-randomised controlled trial with a 1:1 allocation ratio designed to compare an intervention group (goal-directed checklist for brain-dead potential organ donor management) with a control group (standard ICU care). The primary outcome is loss of potential donors due to cardiac arrest. Secondary outcomes are the number of actual organ donors and the number of solid organs recovered per actual donor. Exploratory outcomes include the achievement of relevant clinical goals during the management of brain-dead potential organ donors. The present statistical analysis plan (SAP) describes all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of the trial. Discussion The SAP of the DONORS study aims to describe its analytic procedures, enhancing the transparency of the study. At the moment of SAP subsmission, 63 institutions have been randomised and were enrolling study participants. Thus, the analyses reported herein have been defined before the end of the study recruitment and database locking. Trial registration ClinicalTrials.gov, NCT03179020. Registered on 7 June 2017.
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Affiliation(s)
- Natalia Elis Giordani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil. .,Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.
| | - Caroline Cabral Robinson
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Glauco Adrieno Westphal
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil.,Hospital Municipal São José, Joinville, SC, Brazil.,Centro Hospitalar Unimed, Joinville, SC, Brazil
| | | | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | | | - Flávia Ribeiro Machado
- Department of Anaesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | | | - Fernando Augusto Bozza
- Department of Critical Care and Postgraduate Programme in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, RJ, Brazil.,Evandro Chagas National Institute of Infectious Diseases, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, RJ, Brazil
| | - Cassiano Teixeira
- Department of Internal Medicine and Postgraduate Programme in Rehabilitation Science, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
| | - Joel de Andrade
- Organ Procurement Organisation of Santa Catarina (OPO/SC), Florianópolis, SC, Brazil
| | - Cristiano Augusto Franke
- Adult Intensive Care Unit, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.,Trauma Intensive Care Unit, Hospital de Pronto de Socorro (HPS), Porto Alegre, RS, Brazil
| | - Cátia Moreira Guterres
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Itiana Cardoso Madalena
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Adriane Isabel Rohden
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Sabrina Souza da Silva
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Luiza Vitelo Andrighetto
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Gabriela Soares Rech
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | - Bruna Dos Passos Gimenes
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil
| | | | | | - Maureen O Meade
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maicon Falavigna
- Research Projects Office, Hospital Moinhos de Vento (HMV), Rua Ramiro Barcelos, 910, Porto Alegre, RS, 90035-001, Brazil.,Postgraduate Programme in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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Anesi JA, Blumberg EA, Han JH, Lee DH, Clauss H, Climaco A, Hasz R, Molnar E, Alimenti D, West S, Bilker WB, Tolomeo P, Lautenbach E. Risk factors for multidrug-resistant organisms among deceased organ donors. Am J Transplant 2019; 19:2468-2478. [PMID: 31162785 PMCID: PMC6711782 DOI: 10.1111/ajt.15488] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/26/2019] [Accepted: 05/15/2019] [Indexed: 01/25/2023]
Abstract
Donor infection or colonization with a multidrug-resistant organism (MDRO) affects organ utilization and recipient antibiotic management. Approaches to identifying donors at risk of carrying MDROs are unknown. We sought to determine the risk factors for MDROs among transplant donors. A multicenter retrospective cohort study was conducted at four transplant centers between 2015 and 2016. All deceased donors who donated at least one organ were included. Cultures obtained during the donor's terminal hospitalization and organ procurement were evaluated. The primary outcome was isolation of an MDRO on culture. Multivariable Cox regression was used to determine risk factors associated with time to donor MDRO. Of 440 total donors, 64 (15%) donors grew an MDRO on culture. Predictors of an MDRO on donor culture included hepatitis C viremia (hazard ratio [HR] 4.09, 95% confidence interval [CI] 1.71-9.78, P = .002), need for dialysis (HR 4.59, 95% CI 1.09-19.21, P = .037), prior hematopoietic cell transplant (HR 7.57, 95% CI 1.03-55.75, P = .047), and exposure to antibiotics with a narrow gram-negative spectrum (HR 1.13, 95% CI 1.00-1.27, P = .045). This is the first study to determine risk factors for MDROs among deceased donors and will be important for risk stratifying potential donors and informing transplant recipient prophylaxis.
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Affiliation(s)
- Judith A. Anesi
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania
| | - Emily A. Blumberg
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Jennifer H. Han
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania;,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Dong Heun Lee
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Drexel University College of Medicine
| | - Heather Clauss
- Section of Infectious Diseases, Department of Medicine, Lewis Katz School of Medicine, Temple University
| | - Antonette Climaco
- Division of Infectious Diseases, Department of Medicine, Albert Einstein Medical Center
| | - Richard Hasz
- Gift of Life Donor Program, Philadelphia, PA, USA
| | - Esther Molnar
- Section of Infectious Diseases, Department of Medicine, Lewis Katz School of Medicine, Temple University
| | - Darcy Alimenti
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania
| | - Sharon West
- Gift of Life Donor Program, Philadelphia, PA, USA
| | - Warren B. Bilker
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania;,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania;,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania;,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania;,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania
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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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Westphal GA, Robinson CC, Biasi A, Machado FR, Rosa RG, Teixeira C, de Andrade J, Franke CA, Azevedo LCP, Bozza F, Guterres CM, da Silva DB, Sganzerla D, do Prado DZ, Madalena IC, Rohden AI, da Silva SS, Giordani NE, Andrighetto LV, Benck PS, Roman FR, de Melo MDFRB, Pereira TB, Grion CMC, Diniz PC, Oliveira JFP, Mecatti GC, Alves FAC, Moraes RB, Nobre V, Hammes LS, Meade MO, Nothen RR, Falavigna M. DONORS (Donation Network to Optimise Organ Recovery Study): Study protocol to evaluate the implementation of an evidence-based checklist for brain-dead potential organ donor management in intensive care units, a cluster randomised trial. BMJ Open 2019; 9:e028570. [PMID: 31243035 PMCID: PMC6597655 DOI: 10.1136/bmjopen-2018-028570] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest. METHODS AND ANALYSIS The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor. ETHICS AND DISSEMINATION The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER NCT03179020; Pre-results.
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Affiliation(s)
- Glauco Adrieno Westphal
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
- Hospital Municipal São José, Joinville, Santa Catarina, Brazil
- Centro Hospitalar Unimed, Joinville, Santa Catarina, Brazil
| | | | - Alexandre Biasi
- Research Institute, Hospital do Coração (HCor), São Paulo, São Paulo, Brazil
| | - Flávia Ribeiro Machado
- Department of Anaesthesiology, Pain and Intensive Care, Universidade Federal de São Paulo (UNIFESP), São Paulo, São Paulo, Brazil
| | - Regis Goulart Rosa
- Adult Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Cassiano Teixeira
- Adult Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
- Department of Internal Medicine and Post Graduate Program in Rehabilitation Science, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, Rio Grande do Sul
| | - Joel de Andrade
- Organ Procurement Organisation of Santa Catarina (OPO/SC), Florianópolis, Brazil
| | - Cristiano Augusto Franke
- Adult Intensive Care Unit, Hospital das Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Trauma Intensive Care Unit, Hospital de Pronto de Socorro (HPS), Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Fernando Bozza
- Department of Critical Care and Graduate Programme in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil, Rio de Janeiro, Brazil
- National Institute of Infectious Disease Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Daiana Barbosa da Silva
- Adult Intensive Care Unit, Hospital Moinhos de Vento (HMV), Porto Alegre, Rio Grande do Sul, Brazil
| | - Daniel Sganzerla
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
| | | | | | | | | | - Natalia Elis Giordani
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
- Post Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | | | | | | | - Cintia Magalhães Carvalho Grion
- Adult Intensive Care Unit, Hospital Evangélico de Londrina, Londrina, Brazil
- Adult Intensive Care Unit, Hospital Universitário Regional do Norte do Paraná, Londrina, Brazil
| | - Pedro Carvalho Diniz
- Adult Intensive Care Unit, Hospital de Ensino Doutor Washington Antônio de Barros, Petrolina, Brazil
| | | | - Giovana Colozza Mecatti
- Adult Intensive Care Unit, Hospital Universitário São Francisco da Providência de Deus de Bragança Paulista, Bragança Paulista, Brazil
| | | | - Rafael Barberena Moraes
- Adult Intensive Care Unit, Hospital das Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Vandack Nobre
- Adult Intensive Care Unit, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Maureen O Meade
- Department of Medicine and Department of Health Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rosana Reis Nothen
- General Hospital of the School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- General Coordination Office of the National Transplant System, Ministério da Saúde, Brasília, Brazil
| | - Maicon Falavigna
- Research Projects Office, Hospital Moinhos de Vento (HMV), Porto Alegre, Brazil
- Post Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
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12
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[Critical care management of the potential organ donor : Current recommendation for adults]. Med Klin Intensivmed Notfmed 2018; 114:132-138. [PMID: 30552454 DOI: 10.1007/s00063-018-0516-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 11/22/2018] [Indexed: 10/27/2022]
Abstract
The shortage of donor organs has not improved in recent years. To increase the number and success of transplantation it is crucial to optimize the processes of early identification of potential organ donors and structured critical care management. The therapy starts long before brain death is diagnosed. Structured in-house organ donor management protocols ensure a highly qualified critical care that has a direct impact on the transplantation outcome. The therapy is based on the established standards. The main focus is on differentiated catecholamine and volume therapy. Vasopressin, in combination with norepinephrine, is effective for both treating vasoplegia and electrolyte disturbances. Despite poor evidence, steroids are useful for stabilizing hemodynamics and treating the consequences of neuroendocrine dysfunction. Overall, prospective studies are required to give general recommendations for critical care.
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Abstract
OBJECTIVES To describe important considerations during the process of caring for critically ill children who may be potential organ donors and supporting the family during the death of their child. DESIGN Literature review and expert commentary. MEASUREMENT AND MAIN RESULTS Medical literature focusing on pediatric donation, best pediatric donation practices, donor management, and factors influencing donation were reviewed. Additional pediatric data were obtained and reviewed from the U.S. Organ Procurement and Transplantation Network. Achieving successful organ donation requires the coordinated efforts of the critical care team, organ donation organization, and transplant team to effectively manage a potential donor and recover suitable organs for transplantation. Collaboration between these teams is essential to ensure that all potential organs are recovered in optimal condition, to reduce death and morbidity in children on transplantation waiting lists as well as fulfilling the family's wishes for their dying child to become a donor. CONCLUSIONS Organ donation is an important component of end-of-life care and can help the healing process for families and medical staff following the death of a child. The process of pediatric organ donation requires healthcare providers to actively work to preserve the option of donation before the death of the child and ensure donation occurs after consent/authorization has been obtained from the family. Medical management of the pediatric organ donor requires the expertise of a multidisciplinary medical team skilled in the unique needs of caring for children after neurologic determination of death and those who become donors following circulatory death after withdrawal of life-sustaining medical therapies.
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Early declaration of death by neurologic criteria results in greater organ donor potential. J Surg Res 2017; 218:29-34. [PMID: 28985863 DOI: 10.1016/j.jss.2017.05.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/20/2017] [Accepted: 05/05/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Aggressive management of patients prior to and after determination of death by neurologic criteria (DNC) is necessary to optimize organ recovery, transplantation, and increase the number of organs transplanted per donor (OTPD). The effects of time management are understudied but potentially pivotal component. The objective of this study was to analyze specific time points (time to DNC, time to procurement) and the time intervals between them to better characterize the optimal timeline of organ donation. METHODS Using data over a 5-year time period (2011-2015) from the largest US OPO, all patients with catastrophic brain injury and donated transplantable organs were retrospectively reviewed. Active smokers were excluded. Maximum donor potential was seven organs (heart, lungs [2], kidneys [2], liver, and pancreas). Time from admission to declaration of DNC and donation was calculated. Mean time points stratified by specific organ procurement rates and overall OTPD were compared using unpaired t-test. RESULTS Of 1719 Declaration of Death by Neurologic Criteria organ donors, 381 were secondary to head trauma. Smokers and organs recovered but not transplanted were excluded leaving 297 patients. Males comprised 78.8%, the mean age was 36.0 (±16.8) years, and 87.6% were treated at a trauma center. Higher donor potential (>4 OTPD) was associated with shorter average times from admission to brain death; 66.6 versus 82.2 hours, P = 0.04. Lung donors were also associated with shorter average times from admission to brain death; 61.6 versus 83.6 hours, P = 0.004. The time interval from DNC to donation varied minimally among groups and did not affect donation rates. CONCLUSIONS A shorter time interval between admission and declaration of DNC was associated with increased OTPD, especially lungs. Further research to identify what role timing plays in the management of the potential organ donor and how that relates to donor management goals is needed.
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Organ donor management: Eight common recommendations and actions that deserve reflection. Med Intensiva 2017; 41:559-568. [PMID: 28318674 DOI: 10.1016/j.medin.2017.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 01/18/2023]
Abstract
Despite major advances in our understanding of the physiopathology of brain death (BD), there are important controversies as to which protocol is the most appropriate for organ donor management. Many recent reviews on this subject offer recommendations that are sometimes contradictory and in some cases are not applied to other critically ill patients. This article offers a review of the publications (many of them recent) with an impact upon these controversial measures and which can help to confirm, refute or open new areas of research into the most appropriate measures for the management of organ donors in BD, and which should contribute to discard certain established recommendations based on preconceived ideas, that lead to actions lacking a physiopathological basis. Aspects such as catecholamine storm management, use of vasoactive drugs, hemodynamic objectives and monitoring, assessment of the heart for donation, and general care of the donor in BD are reviewed.
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Shaheen FAM, Shalabi M, Zain A, Hasanain M, Al Sayyari A. Immediately Functioning Grafts from Brain-Dead Donors Treated with Extracorporeal Membrane Oxygenation. EXP CLIN TRANSPLANT 2017; 17:404-407. [PMID: 28229804 DOI: 10.6002/ect.2016.0369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A brain-dead donor experienced repeated cardiac arrests followed by severe hypotension requiring multiple vasoactive agents. These events were associated with severe lactic acidosis and dysregulated kidney function in the donor. A 10-hour treatment with extracorporeal membranous oxygenation was instituted, which was able to hemodynamically stabilize the donor. This treatment protocol resulted in the procurement of 2 viable kidney grafts transplanted into 2 recipients, who had immediate kidney graft function and excellent serum creatinine levels upon hospital discharge. These results are all the more significant considering that both cases involved long cold ischemia times, and one of the recipients had diabetes and was receiving his second kidney graft.
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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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Positive impact of a clinical goal-directed protocol on reducing cardiac arrests during potential brain-dead donor maintenance. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:323. [PMID: 27724931 PMCID: PMC5057215 DOI: 10.1186/s13054-016-1484-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 09/13/2016] [Indexed: 01/07/2023]
Abstract
Background The disproportion between the large organ demand and the low number of transplantations performed represents a serious public health problem worldwide. Reducing the loss of transplantable organs from deceased potential donors as a function of cardiac arrest (CA) may contribute to an increase in organ donations. Our purpose was to test the hypothesis that a goal-directed protocol to guide the management of deceased donors may reduce the losses of potential brain-dead donors (PBDDs) due to CA. Methods The quality improvement project included 27 hospitals that reported deceased donors prospectively to the Transplant Center of the State of Santa Catarina, Brazil. All deceased donors reported prospectively between May 2012 and April 2014 were analyzed. Hospitals were encouraged to use the VIP approach checklist during the management of PBDDs. The checklist was composed of the following goals: protocol duration 12–24 hours, temperature > 35 °C, mean arterial pressure ≥ 65 mmHg, diuresis 1–4 ml/kg/h, corticosteroids, vasopressin, tidal volume 6–8 ml/kg, positive end-expiratory pressure 8–10 cmH2O, sodium < 150 mEq/L, and glycemia < 180 mg/dl. A logistic regression model was used to identify predictors of CA. Results There were 726 PBDD notifications, of which 324 (44.6) were actual donors, 141 (19.4 %) CAs, 226 (31.1 %) family refusals, and 35 (4.8 %) contraindications. Factors associated with CA reduction included use of the checklist (odds ratio (OR) 0.43, p < 0.001), maintenance performed inside the ICU (OR 0.49, p = 0.013), and vasopressin administration (OR 0.56, p = 0.04). More than three interventions had association with less CAs (OR 0.19, p < 0.001). After 24 months, CAs decreased from 27.3 % to 14.6 % (p = 0.002), reaching 12.1 % in the following two 4-month periods (p < 0.001). Simultaneous increases in organ recovered per donor and in actual donors were observed. Conclusions A quality improvement program based on education and the use of a goal checklist for the management of potential donors inside the ICU is strongly associated with a decrease in donor losses and an increase in organs recovered per donor. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1484-1) contains supplementary material, which is available to authorized users.
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Cellular Engineering and Disease Modeling with Gene-Editing Nucleases. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016. [DOI: 10.1007/978-1-4939-3509-3_12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Rodrigue JR, Feng S, Johansson AC, Glazier AK, Abt PL. Deceased Donor Intervention Research: A Survey of Transplant Surgeons, Organ Procurement Professionals, and Institutional Review Board Members. Am J Transplant 2016; 16:278-86. [PMID: 26484950 DOI: 10.1111/ajt.13482] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/09/2015] [Accepted: 08/10/2015] [Indexed: 01/25/2023]
Abstract
Innovative deceased donor intervention strategies have the potential to increase the number and quality of transplantable organs. Yet there is confusion over regulatory and legal requirements, as well as ethical considerations. We surveyed transplant surgeons (n = 294), organ procurement organization (OPO) professionals (n = 83), and institutional review board (IRB) members (n = 317) and found wide variations in their perceptions about research classification, risk assessment for donors and organ transplant recipients, regulatory oversight requirements, and informed consent in the context of deceased donor intervention research. For instance, when presented with different research scenarios, IRB members were more likely than transplant surgeons and OPO professionals to feel that study review and oversight were necessary by the IRBs at the investigator, donor, and transplant center hospitals. Survey findings underscore the need to clarify ethical, legal, and regulatory requirements and their application to deceased donor intervention research to accelerate the pace of scientific discovery and facilitate more transplants.
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Affiliation(s)
- J R Rodrigue
- Center for Transplant Outcomes and Quality Improvement, The Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA.,Harvard Medical School, Boston, MA
| | - S Feng
- Department of Surgery, University of California San Francisco, San Francisco, CA
| | - A C Johansson
- Harvard Medical School, Boston, MA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - P L Abt
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
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Peer SM, Oh NA, Nath DS. Optimizing Donor Quality Via Hormonal Therapy: An Important Strategy to Increase Successful Placement of Thoracic Organs in End-Stage Patients. Semin Thorac Cardiovasc Surg 2015; 27:133-4. [PMID: 26686438 DOI: 10.1053/j.semtcvs.2015.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Syed M Peer
- Department of Pediatric Cardiac Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas A Oh
- Department of Cardiovascular Surgery, Children's National Medical Center, Washington, District of Columbia
| | - Dilip S Nath
- Department of Cardiovascular Surgery, Children's National Medical Center, Washington, District of Columbia.
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Kim YH, Cho HR, Ko BK, Nah YW, Nam CW, Park SJ, Yang SS, Kyoung KH. Prevalence of Infection and Appropriate Antibiotic Treatmentin Brain-Dead Organ Donors. JOURNAL OF ACUTE CARE SURGERY 2015. [DOI: 10.17479/jacs.2015.5.1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Yo Hwan Kim
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hong Rae Cho
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Byung Kyun Ko
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Yang Won Nah
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Chang Woo Nam
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sang Jun Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Song-Soo Yang
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
- Department of Trauma Center, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Balsorano P, Ciapetti M, Cianchi G, Bonizzoli M, Migliaccio ML, Ferraro MC, Franci A, Peris A. Extracorporeal life support and multiorgan donation in a severe polytrauma patient: A case report. Int J Surg Case Rep 2015; 9:109-11. [PMID: 25756801 PMCID: PMC4392376 DOI: 10.1016/j.ijscr.2015.02.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 02/16/2015] [Accepted: 02/27/2015] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Organ availability represents a key factor in transplants due to an almost universal shortage of deceased donors. PRESENTATION OF CASE We present the case of a 41-year-old patients with severe polytrauma, where extracorporeal life support (ECLS) allowed brain death (BD) declaration and multiorgan retrieval and transplantation. DISCUSSION Organ procurement is of utmost importance for transplant procedures. The presented case could rise ethical doubts as ECLS could be viewed as a tool for organ preservation instead of patient support. Nonetheless, it is obvious how organ preservation represents the necessary condition for patient preservation. CONCLUSION Besides it' role in non heart beating donors, ECLS is emerging as an adjunctive tool for brain dead donors management when standard treatment fails, potentially allowing a substantial increase in organ availability.
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Affiliation(s)
- Paolo Balsorano
- Department of Health Science, Section of Anaesthesiology, Intensive Care and Pain medicine, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Marco Ciapetti
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Giovanni Cianchi
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Manuela Bonizzoli
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Maria Luisa Migliaccio
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Maria Cristina Ferraro
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Andrea Franci
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
| | - Adriano Peris
- Anestesiology and Emergency and Trauma Intensive Care Unit, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50134 Florence, Italy.
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Organspende in Deutschland – wann und wie? Med Klin Intensivmed Notfmed 2014; 109:396-402. [DOI: 10.1007/s00063-014-0366-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 06/21/2014] [Indexed: 10/24/2022]
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Ethical Controversies Surrounding the Management of Potential Organ Donors in the Emergency Department. J Emerg Med 2014; 47:232-6. [DOI: 10.1016/j.jemermed.2013.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 09/10/2013] [Accepted: 10/31/2013] [Indexed: 11/23/2022]
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Jung JH, Park SK, Lee S. Management and Evaluation Prior to Transplantation of Deceased Donor. KOREAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.4285/jkstn.2014.28.2.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jong Hwan Jung
- Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Sung Kwang Park
- Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Sik Lee
- Department of Internal Medicine, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
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Early metabolic/cellular-level resuscitation following terminal brain stem herniation: implications for organ transplantation. AACN Adv Crit Care 2013; 24:59-78. [PMID: 23343814 DOI: 10.1097/nci.0b013e31827e3031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with terminal brain stem herniation experience global physiological consequences and represent a challenging population in critical care practice as a result of multiple factors. The first factor is severe depression of consciousness, with resulting compromise in airway stability and lung ventilation. Second, with increasing severity of brain trauma, progressive brain edema, mass effect, herniation syndromes, and subsequent distortion/displacement of the brain stem follow. Third, with progression of intracranial pathophysiology to terminal brain stem herniation, multisystem consequences occur, including dysfunction of the hypothalamic-pituitary axis, depletion of stress hormones, and decreased thyroid hormone bioavailability as well as biphasic cardiovascular state. Cardiovascular dysfunction in phase 1 is a hyperdynamic and hypertensive state characterized by elevated systemic vascular resistance and cardiac contractility. Cardiovascular dysfunction in phase 2 is a hypotensive state characterized by decreased systemic vascular resistance and tissue perfusion. Rapid changes along the continuum of hyperperfusion versus hypoperfusion increase risk of end-organ damage, specifically pulmonary dysfunction from hemodynamic stress and high-flow states as well as ischemic changes consequent to low-flow states. A pronounced inflammatory state occurs, affecting pulmonary function and gas exchange and contributing to hemodynamic instability as a result of additional vasodilatation. Coagulopathy also occurs as a result of consumption of clotting factors as well as dilution of clotting factors and platelets consequent to aggressive crystalloid administration. Each consequence of terminal brain stem injury complicates clinical management within this patient demographic. In general, these multisystem consequences are managed with mechanism-based interventions within the context of caring for the donor's organs (liver, kidneys, heart, etc.) after death by neurological criteria. These processes begin far earlier in the continuum of injury, at the moment of terminal brain stem herniation. As such, aggressive, mechanism-based care, including hormonal replacement therapy, becomes clinically appropriate before formal brain death declaration to support cardiopulmonary stability following terminal brain stem herniation.
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Westphal GA, Zaclikevis VR, Vieira KD, Cordeiro RDB, Horner MBW, Oliveira TPD, Duarte R, Sperotto G, Silveira GD, Caldeira Filho M, Coll E, Yus-Teruel S. A managed protocol for treatment of deceased potential donors reduces the incidence of cardiac arrest before organ explant. Rev Bras Ter Intensiva 2013; 24:334-40. [PMID: 23917929 PMCID: PMC4031811 DOI: 10.1590/s0103-507x2012000400007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 11/20/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess the effect of the application of a managed protocol for the maintenance care of deceased potential multiple organ donors at two hospitals. METHODS A before (Phase 1)/after (Phase 2) study conducted at two general hospitals, which included consecutively potential donors admitted to two intensive care units. In Phase 1 (16 months), the data were collected retrospectively, and the maintenance care measures of the potential donors were instituted by the intensivists. In Phase 2 (12 months), the data collection was prospective, and a managed protocol was used for maintenance care. The two phases were compared in terms of their demographic variables, physiological variables at diagnosis of brain death and the end of the process, time to performance of brain death confirmatory test and end of the process, adherence to bundles of maintenance care essential measures, losses due to cardiac arrest, family refusal, contraindications, and the conversion rate of potential into actual donors. Student's t- and chi-square tests were used, and p-value < 0.05 was considered to be significant. RESULTS A total of 42 potential donors were identified (18 in Phase 1 and 24 in Phase 2). The time interval between the first clinical assessment and the recovery decreased in Phase 2 (Phase 1: 35.0±15.5 hours versus Phase 2: 24.6±6.2 hours; p = 0.023). Adherence increased to 10 out of the 19 essential items of maintenance care, and losses due to cardiac arrest also decreased in Phase 2 (Phase 1: 27.8 versus 0% in Phase 2; p = 0.006), while the convertion rate increased (Phase 1: 44.4 versus 75% in Phase 2; p = 0.044). The losses due to family refusal and medical contraindication did not vary. CONCLUSION The adoption of a managed protocol focused on the application of essential measures for the care of potential deceased donors might reduce the loss of potential donors due to cardiac arrest.
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The effect of arginine vasopressin on organ donor procurement and lung function. J Surg Res 2013; 186:452-7. [PMID: 24176209 DOI: 10.1016/j.jss.2013.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 09/02/2013] [Accepted: 09/12/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hormone replacement therapy (HRT) is becoming more common when managing brain-dead donors. Arginine vasopressin (AVP) is associated with benefits but is not consistently used. We hypothesize that AVP is associated with the maintenance of lung function and successful recovery in donors and enhanced lung graft performance in recipients. METHODS The Organ Procurement and Transplantation Network database was used. Study donors were those treated with HRT and procured from January 1, 2009 to June 30, 2011. AVP (+) and AVP (-) donors were compared. Donor lung function, the rate of successful lung procurement, and the incidence of graft failure in recipients were studied. RESULTS There were 12,322 donors included, of which 7686 received AVP (62.4%). Cerebrovascular accident (4722 [38.3%]) was the most common cause of donor death. There was a significant increase in high yield (≥4 organs) (51.0% versus 39.3%, <0.001), mean number of organs (3.75 versus 3.33, <0.001), and rate of successful lung recovery (26.3% versus 20.5%, <0.001) with AVP. Lung function was preserved to a greater degree in donors receiving AVP. Adjusting the significant factors, AVP was independently associated with lung procurement (1.220 [1.114-1.336], <0.001). The incidence of early graft failure was not changed. CONCLUSIONS AVP with HRT is associated with the maintenance of lung function and a significant increase in successful organ recovery in donors without untoward effects in the recipient. AVP should be universally adopted as a component of HRT in the management of donors with neurologic death.
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Castelo D, Campos L, Moreira P, Furriel F, Parada B, Nunes P, Figueiredo A, Mota A. Does multiorgan versus kidney-only cadaveric organ procurement affect graft outcomes? Transplant Proc 2013; 45:1248-50. [PMID: 23622670 DOI: 10.1016/j.transproceed.2013.02.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The majority of kidney grafts in most European countries still come from deceased donors who provide other organs. We analyzed whether multiorgan procurement portends a worse functional outcome compared with kidney-only harvesting. METHODS We performed a retrospective analysis of 1043 consecutive brain-dead donor kidney transplantations performed at a single academic institution from September 2002 to June 2011. The graft outcomes using kidney-only donors (n = 243) were compared with multiorgan donor grafts (n = 800) analyzing donor age, gender, cause of death, duration of mechanical ventilation, renal function, and cold ischemic interval. We compared delayed graft function and serum creatinine values at 1, 3, 6, and 12 months posttransplantation as well as graft survivals. This methodology was also applied to the subset of expanded criteria donors: 179 kidney-only versus 474 multiorgan. The influence of donor variables on graft survival was also analyzed in a Cox regression model. Immunosuppressive regimens and preservation solutions were similar in both groups. RESULTS Kidney-only donors were older than their multiorgan counterparts (53.1 versus 44.8, P < .0005) and predominantly male (76.5% versus 62.6% male donors, P < .0005). Other donor variables were comparable. Kidney-only donor grafts showed a slightly higher incidence of delayed function (27.2 versus 21.1%, P = .049), but the mean serum creatinine values were similar at all intervals. No differences were observed in 7-year graft survival: 80.7% versus 79.9%. Expanded criteria donor grafts showed overlapping results, except for a higher rate of donor oligoanuria and a lower 1-month mean creatinine among kidney-only donors. Multivariate analysis revealed that the number of harvested organs did not influence graft survival. DISCUSSION Immediate and long-term outcomes of kidney grafts did not correlate with the number of organs harvested from the donor. The longer explantation time associated with multiorgan procurement did not seem to affect graft function.
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Affiliation(s)
- D Castelo
- Department of Urology and Renal Transplantation, Coimbra University Hospital Centre, Coimbra, Portugal
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Arbour RB. Early Metabolic/Cellular-Level Resuscitation Following Terminal Brain Stem Herniation. AACN Adv Crit Care 2013. [DOI: 10.4037/nci.0b013e31827e3031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Patients with terminal brain stem herniation experience global physiological consequences and represent a challenging population in critical care practice as a result of multiple factors. The first factor is severe depression of consciousness, with resulting compromise in airway stability and lung ventilation. Second, with increasing severity of brain trauma, progressive brain edema, mass effect, herniation syndromes, and subsequent distortion/displacement of the brain stem follow. Third, with progression of intracranial pathophysiology to terminal brain stem herniation, multisystem consequences occur, including dysfunction of the hypothalamic-pituitary axis, depletion of stress hormones, and decreased thyroid hormone bioavailability as well as biphasic cardiovascular state. Cardiovascular dysfunction in phase 1 is a hyperdynamic and hypertensive state characterized by elevated systemic vascular resistance and cardiac contractility. Cardiovascular dysfunction in phase 2 is a hypotensive state characterized by decreased systemic vascular resistance and tissue perfusion. Rapid changes along the continuum of hyperperfusion versus hypoperfusion increase risk of end-organ damage, specifically pulmonary dysfunction from hemodynamic stress and high-flow states as well as ischemic changes consequent to low-flow states. A pronounced inflammatory state occurs, affecting pulmonary function and gas exchange and contributing to hemodynamic instability as a result of additional vasodilatation. Coagulopathy also occurs as a result of consumption of clotting factors as well as dilution of clotting factors and platelets consequent to aggressive crystalloid administration. Each consequence of terminal brain stem injury complicates clinical management within this patient demographic. In general, these multisystem consequences are managed with mechanism-based interventions within the context of caring for the donor’s organs (liver, kidneys, heart, etc.) after death by neurological criteria. These processes begin far earlier in the continuum of injury, at the moment of terminal brain stem herniation. As such, aggressive, mechanism-based care, including hormonal replacement therapy, becomes clinically appropriate before formal brain death declaration to support cardiopulmonary stability following terminal brain stem herniation.
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Affiliation(s)
- Richard B. Arbour
- Richard B. Arbour is Critical Care Clinical Nurse Specialist, Philadelphia, Pennsylvania, and Clinical Adjunct Faculty, La Salle University and Holy Family University, 5928 N 11th St, Philadelphia, PA 19141
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Donor hormone and vasopressor therapy: closing the gap in a transplant organ shortage. J Trauma Acute Care Surg 2012; 73:689-94. [PMID: 22710780 DOI: 10.1097/ta.0b013e318250b122] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hormone replacement therapy (HRT) use for donors with hemodynamic instability is common. The purpose of this study was to determine the effect of HRT in donors without significant cardiovascular dysfunction and examine outcomes according to vasopressor exposure. METHODS All successfully procured donors admitted between January 1, 2006, and March 31, 2011, were included. HRT group I were donors without significant hemodynamic instability at the initiation of HRT. Comparison was made to all other donors receiving HRT (HRT group II). Vasopressor use was also examined and compared. High-yield procurement was the successful recovery of ≥ 4 organs. RESULTS Forty-seven donors were studied. Most were male (36 [76.6%]) and trauma (41% [87.2%]) predominated. Twenty-two (46.8%) patients were in HRT group I. There were no differences in gender, admission diagnosis, or complications; however, HRT group I had a significantly greater number of organs recovered (4.73 ± 1.42 vs. 3.08 ± 1.19, p < 0.001). Differences in rates for the heart (68.2% vs. 24%, p = 0.002) and lung (40.9% vs. 8.0%, p = 0.008) were marked. HRT group I was more likely managed on a single agent (45.5% vs. 8.0%, p = 0.003). Norepinephrine was associated with a decreased rate of high-yield procurement (48.0% vs. 77.3%, p = 0.039), while vasopressin exposure was associated with an absolute increase (72.0% vs. 59.1%, p = 0.351). After adjusting for differences between groups (particularly age), HRT group I status was independently associated with high-yield procurement. CONCLUSION A more liberal strategy of HRT seems to significantly increase procurement rates. Vasopressor selection favoring vasopressin as opposed to norepinephrine may also play a role. LEVEL OF EVIDENCE Therapeutic study, level III.
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Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors. Am J Surg 2012; 204:856-60; discussion 860-1. [PMID: 23116641 DOI: 10.1016/j.amjsurg.2012.05.011] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 03/29/2012] [Accepted: 05/22/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hormone replacement therapy increases the number and quality of grafts recovered from brain-dead organ donors. Arginine vasopressin (AVP) has also been shown to have beneficial effects. The aim of this study was to determine the effect of AVP on recovery rates. METHODS The Organ Procurement and Transplantation Network database was used. Donors treated with hormone replacement therapy and vasopressor agents who were successfully procured between January 1, 2009, and June 30, 2011, were studied. AVP-positive and AVP-negative donors were compared. The primary study end point was the rate of high-yield procurement (≥4 organs). RESULTS A total of 10,431 donors were included. AVP was infused in 7,873 (75.5%) and was associated with an increased rate of high-yield procurement (50.5% vs 35.6%, P < .001). There was less overall graft refusal due to poor function (38.9% vs 45.6%, P < .001). AVP independently predicted high yield procurement. CONCLUSIONS The use of AVP with hormone replacement therapy is independently associated with an increased rate of organ recovery. This strategy should be universally adopted in the management of donors progressing to neurologic death.
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Malinoski DJ, Patel MS, Lush S, Willis ML, Navarro S, Schulman D, Querantes T, Leinen-Duren R, Salim A. Impact of compliance with the American College of Surgeons trauma center verification requirements on organ donation-related outcomes. J Am Coll Surg 2012; 215:186-92. [PMID: 22626913 PMCID: PMC3402605 DOI: 10.1016/j.jamcollsurg.2012.03.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 02/02/2012] [Accepted: 03/07/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND In order to maximize organ donation opportunities, the American College of Surgeons (ACS) requires verified trauma centers to have a relationship with an organ procurement organization (OPO), a policy for notification of the OPO, a process to review organ donation rates, and a protocol for declaring neurologic death. We hypothesized that meeting the ACS requirements will be associated with improved donation outcomes. STUDY DESIGN Twenty-four ACS-verified Level I and Level II trauma centers were surveyed for the following registry data points from 2004 to 2008: admissions, ICU admissions, patients with a head Abbreviated Injury Score ≥ 5, deaths, and organ donors. Centers were also queried for the presence of the ACS requirements as well as other process measures and characteristics. The main outcomes measure was the number of organ donors per center normalized for patient volume and injury severity. The relationship between center characteristics and outcomes was determined. RESULTS Twenty-one centers (88%) completed the survey and referred 2,626 trauma patients to the OPO during the study period, 1,008 were eligible to donate, and 699 became organ donors. Compliance with the 4 ACS requirements was not associated with increased organ donation outcomes. However, having catastrophic brain injury guidelines (CBIGs) and the presence of a trauma surgeon on a donor council were associated with significantly more organ donors per 1,000 trauma admissions (6.3 vs 4.2 and 6.0 vs 4.2, respectively, p < 0.05). CONCLUSIONS Although the ACS trauma center organ donation-related requirements were not associated with improved organ donor outcomes, involvement of trauma surgeons on donor councils and CBIGs were and should be encouraged. Additionally, incorporation of quantitative organ donation measures into the verification process should be considered.
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Affiliation(s)
- Darren J Malinoski
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Salim A, Berry C, Ley EJ, Schulman D, Bukur M, Margulies DR, Navarro S, Malinoski D. The Effect of Trauma Center Designation on Organ Donor Outcomes in Southern California. Am Surg 2012. [DOI: 10.1177/000313481207800533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We sought to investigate the effect of trauma center designation on organ donor outcomes during a 5-year period. A retrospective study of the southern California regional Organ Procurement Organization database comparing trauma centers (n = 25) versus nontrauma centers (n = 171) and Level I (n = 7) versus Level II (n = 18) trauma centers between 2004 and 2008 was performed. A total of 16,830 referrals were evaluated and 44 per cent were from trauma centers. When compared with nontrauma centers (n = 171), trauma centers (n = 25) had a higher percentage of medically suitable eligible deaths (29 vs 16%, P < 0.001), total eligible deaths (22 vs 12%, P < 0.001), and eligible donors (14 vs 7%, P < 0.001). Trauma Centers had a significantly higher number of organs procured per donor (4.0 ± 1.6 vs 3.5 ± 1.6, P < 0.001), organs transplanted per donor (OTPD) (3.6 ± 1.8 vs 2.8 ± 1.8, P < 0.001), and higher organ yield (per cent 4 or greater OTPD [48 vs 31%, P < 0.001]). No significant differences were found between Level I and Level II trauma centers. Trauma centers demonstrate significantly better organ donor outcomes compared with nontrauma centers. Factors responsible for improved outcomes at trauma centers should be evaluated, reproduced, and disseminated to nontrauma centers to alleviate the growing organ shortage crisis.
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Affiliation(s)
- Ali Salim
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cherisse Berry
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danielle Schulman
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Marko Bukur
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Sonia Navarro
- OneLegacy Organ Procurement Organization, Los Angeles, California
| | - Darren Malinoski
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Abstract
Acute kidney injury occurs with kidney transplantation and too frequently progresses to the clinical diagnosis of delayed graft function (DGF). Poor kidney function in the first week of graft life is detrimental to the longevity of the allograft. Challenges to understand the root cause of DGF include several pathologic contributors derived from the donor (ischemic injury, inflammatory signaling) and recipient (reperfusion injury, the innate immune response and the adaptive immune response). Progressive demand for renal allografts has generated new organ categories that continue to carry high risk for DGF for deceased donor organ transplantation. New therapies seek to subdue the inflammatory response in organs with high likelihood to benefit from intervention. Future success in suppressing the development of DGF will require a concerted effort to anticipate and treat tissue injury throughout the arc of the transplantation process.
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Affiliation(s)
- Andrew Siedlecki
- Nephrology Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St Louis, MO
| | - William Irish
- CTI, Clinical Trial and Consulting Services, Raleigh, NC
| | - Daniel C. Brennan
- Nephrology Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St Louis, MO
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Hsieh CE, Lin HC, Tsui YC, Lin PY, Lin KH, Chang YY, Chen YL. Extracorporeal Membrane Oxygenation Support in Potential Organ Donors for Brain Death Determination. Transplant Proc 2011; 43:2495-8. [DOI: 10.1016/j.transproceed.2011.06.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 05/28/2011] [Accepted: 06/06/2011] [Indexed: 10/17/2022]
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Singbartl K, Murugan R, Kaynar AM, Crippen DW, Tisherman SA, Shutterly K, Stuart SA, Simmons R, Darby JM. Intensivist-led management of brain-dead donors is associated with an increase in organ recovery for transplantation. Am J Transplant 2011; 11:1517-21. [PMID: 21449934 DOI: 10.1111/j.1600-6143.2011.03485.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The disparity between the number of patients in need of organ transplantation and the number of available organs is steadily rising. We hypothesized that intensivist-led management of brain dead donors would increase the number of organs recovered for transplantation. We retrospectively analyzed data from all consented adult brain dead patients in the year before (n = 35) and after (n = 43) implementation of an intensivist-led donor management program. Donor characteristics before and after implementation were similar. After implementation of the organ donor support team, the overall number of organs recovered for transplantation increased significantly (66 out of 210 potentially available organs vs. 113 out of 258 potentially available organs, p = 0.008). This was largely due to an increase in the number of lungs (8 out of 70 potentially available lungs vs. 21 out of 86 potentially available lungs; p = 0.039) and kidneys (31 out of 70 potentially available kidneys vs. 52 out of 86 potentially available kidneys; p = 0.044) recovered for transplantation. The number of hearts and livers recovered for transplantation did not change significantly. Institution of an intensivist-led organ donor support team may be a new and viable strategy to increase the number of organs available for transplantations.
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Affiliation(s)
- K Singbartl
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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[Organ donation: point of view of private practice physicians in the region Nord-Pas de Calais in France]. Rev Epidemiol Sante Publique 2011; 59:143-7. [PMID: 21531518 DOI: 10.1016/j.respe.2010.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 09/14/2010] [Accepted: 12/09/2010] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In 2008, in France, 222 patients died because they did not receive the graft they expected. The main objective of this study was to determine the attitude of private practice physicians concerning organ donation. METHODS A postal questionnaire was sent to all private practice office-based physicians in the Nord-Pas de Calais region. This questionnaire was elaborated with a panel of physicians and sociologists. It was sent with the monthly journal of the regional union of private physicians of June 2008. RESULTS Two hundred and seventy eight questionnaires were returned. One hundred and thirty four (48.2%) respondents declared they knew what the regulations about organ donation were. The majority of respondents approved organ donation. Information to patients was provided during visits by 34.53% (96) of practitioners. For those who were knowledgeable about regulations, 50.75% of them talked about organ donation. Physicians who had already had experience with organ donation were more inclined to talk about it with other patients. The practitioners described three actions they felt could have a positive influence on family acceptance: providing information before death, talking about organ donation in an appropriate sensitive way, and relying on the confidence established by a solid patient-physician relationship. CONCLUSION Almost 90% of private physicians who responded to the survey were in favor of organ donation but only 34.5% delivered information and discussed the issue with their patients. The physicians coped with the topics more easily when they had experienced cases and when they were informed about existing regulations. A specific educational program on the current regulations and how to interact with patients on this subject during a visit could be a first answer to the problem and would be welcomed by practitioners.
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Abstract
BACKGROUND Donor availability remains the primary limiting factor for organ transplantation today. The purpose of this study was to examine the causes of procurement failure amongst potential organ donors. METHODS After Institutional Review Board approval, all surgical intensive care unit (SICU) patients admitted to the LAC+USC Medical Center from 01/2006 to 12/2008 who became potential organ donors were identified. Demographics, clinical data, and procurement data were abstracted. In non-donors, the causes of procurement failure were documented. RESULTS During the 3-year study period, a total of 254 patients were evaluated for organ donation. Mean age was 44.8±18.7 years; 191 (75.2%) were male, 136 (53.5%) were Hispanic, and 148 (58.3%) were trauma patients. Of the 254 patients, 116 (45.7%) were not eligible for donation: 34 had multi-system organ failure, 24 did not progress to brain death and had support withdrawn, 18 had uncontrolled sepsis, 15 had malignancy, 6 had human immunodeficiency virus or hepatitis B or C, and 19 patients had other contraindications to organ donation. Of the remaining 138 eligible patients, 83 (60.2%) did not donate: 56 because the family denied consent, 9 by their own choice. In six, next of kin could not be located, five died because of hemodynamic instability before organ procurement was possible, four had organs that could not be placed, and three had their organs declined by the organ procurement organization. The overall consent rate was 57.5% (n=67). From the 55 donors, 255 organs were procured (yield 4.6 organs/donor). CONCLUSIONS Of all patients screened for organ donation, only a fifth actually donated. Denial of consent was the major potentially preventable cause of procurement failure, whereas hemodynamic instability accounted for only a small percentage of donor losses. With such low conversion rates, the preventable causes of procurement failure warrant further study.
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Mittag D, Proietto AI, Loudovaris T, Mannering SI, Vremec D, Shortman K, Wu L, Harrison LC. Human Dendritic Cell Subsets from Spleen and Blood Are Similar in Phenotype and Function but Modified by Donor Health Status. THE JOURNAL OF IMMUNOLOGY 2011; 186:6207-17. [DOI: 10.4049/jimmunol.1002632] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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The role of innate immunity in donor organ procurement. Semin Immunopathol 2011; 33:169-84. [DOI: 10.1007/s00281-011-0254-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 01/13/2011] [Indexed: 12/18/2022]
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Fatal gunshot wounds to the head: a critical appraisal of organ donation rates. Am J Surg 2011; 200:728-33; discussion 733. [PMID: 21146012 DOI: 10.1016/j.amjsurg.2010.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 09/28/2010] [Accepted: 09/28/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients sustaining fatal gunshot wounds to the head are often young, without associated comorbidities, and are potentially ideal transplantation candidates. METHODS A 5-year review of a level I trauma center's prospective database was performed for all patients sustaining fatal gunshot wounds to the head. Demographic, physiologic, anatomic, and laboratory variables were collected. RESULTS Sixty-eight patients were identified, of whom 10 (14.7%) were organ donors. Of 25 admitted to the intensive care unit who eventually did not become donors, 15 (60%) were due to lack of consent. CONCLUSIONS Despite frequent intensive care unit admissions, organ donation is infrequent following fatal gunshot wounds to the head, primarily because of lack of consent. Improved communication with next of kin could improve organ recovery and reduce futile care in this group.
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Martikainen T, Kurola J, Kärjä V, Parviainen I, Ruokonen E. Vasopressor Agents After Experimental Brain Death: Effects of Dopamine and Vasopressin on Vitality of the Small Gut. Transplant Proc 2010; 42:2449-56. [DOI: 10.1016/j.transproceed.2010.04.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 04/01/2010] [Indexed: 11/29/2022]
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Franklin GA, Santos AP, Smith JW, Galbraith S, Harbrecht BG, Garrison RN. Optimization of donor management goals yields increased organ use. Am Surg 2010; 76:587-94. [PMID: 20583513 DOI: 10.1177/000313481007600621] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Multiple strategies have been used in an effort to increase the pool of organs for transplantation. Standardizing donor management has produced promising results. Donor management goals (DMGs) are now being used as end points of intensive care unit care during the prerecovery phase but no prospective results have been reported. Data from the United Network for Organ Sharing Region 11 were collected for successful achievement of eight common donor management goals (mean airway pressure [MAP], central venous pressure [CVP], pH, PaO2, sodium, glucose, single pressor use, and urine output) before organ recovery. Two time periods were studied with different panels of DMGs. The analysis identified the success rate of transplantation. Goals were stratified by their statistical correlation with the number of organs transplanted per donor (OTPD) in an effort to identify the most important parameter(s). Eight hundred five organ donors were studied with 2685 organs transplanted. DMGs were assessed through two phases of the study. Achieving DMGs rose from 18 to 66 per cent associated with significant improvement in OTPD (range, 2.96 to 3.45). The success of transplantation was primarily associated with limitations in vasopressor use and PaO2. Tight glucose control did affect the rate of pancreatic transplants. Thoracic organs were the most sensitive to DMGs with a 10- to 15-fold increase in lung transplantation when PaO2 rose above 100 mmHg. MAP, CVP, pH, sodium, and urine output had little effect on transplantation. Standardization of end points of donor management was associated with increased rates of transplantation. Surprisingly, not all standard goals are necessary for optimal organ use. The most significant parameters were the low use of vasopressor agents and oxygenation. Donor management strategies should strive to optimize these goals.
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Affiliation(s)
- Glen A Franklin
- Department of Surgery, University of Louisville, Louisville, Kentucky 40202, USA.
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Feng S. Donor intervention and organ preservation: where is the science and what are the obstacles? Am J Transplant 2010; 10:1155-62. [PMID: 20420628 DOI: 10.1111/j.1600-6143.2010.03100.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The organ shortage is widely acknowledged as the most critical factor hindering the full realization of success for solid organ transplantation. Innovation in the areas of donor management and organ preservation offers the most realistic hope to improve both the quality and size of the current organ supply. Although the basic science dissecting the complex processes of brain death and ischemia/reperfusion injury is replete with exciting discoveries, the clinical science investigating donor management and organ preservation is sparse in contrast. This review will survey the current landscape of trials to mitigate organ injury through interventions administered to donors in vivo or organs ex vivo. Consideration will then be given to the scientific, logistical and ethical obstacles that impede the transformation of laboratory breakthroughs into innovative treatments that simultaneously improve organ quality and supply.
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Affiliation(s)
- S Feng
- University of California San Francisco, San Francisco, CA, USA.
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Innovative surgical techniques address the organ donation crisis, ... don't they? Curr Opin Organ Transplant 2010; 14:507-14. [PMID: 19623071 DOI: 10.1097/mot.0b013e32833067f3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Retrospectively analysing the role that innovative technique and strategies have played to face organ shortage during the last decades, and elaborating rationally about their potential contribution to expand organ availability in the coming future. RECENT FINDINGS Current organ donation crisis proceeds from both decreasing offers, qualitatively and quantitatively, and steadily increasing demand. Innovative surgical techniques using the existing donor pool have been extensively used for paediatric transplantation, but these techniques both have been insufficiently implemented in overall transplant activity to meet the demand, and are less usable on the emerging potential pool of donors ('extended-criteria' and nonheart-beating donors), as combining both approaches could carry a higher risk of complications. SUMMARY The future is emerging through complementary approaches and strategies in which innovative techniques have a role to play to match the existing pool with the paediatric demand, with an increasing attention to donor management and organ care and with development of preprocurement and postprocurement new therapies.
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