Jerome McCann
Arpan Guha
21 st May 2013
Organ Donation Past, Present and Future 1

Session Objectives
• Present regional data for DBD
• Understand that DBD gives better organs than DCD
• Increase rate of neurological confirmation of death by increasing confidence in the Diagnosis of Death
• Increase quality of DBD organs
– adoption of extended care bundle and compliance with the six early interventions in donor optimisation
– collaboration in Scout pilot
2 Organ Donation Past, Present and Future

NORTH
WEST
Jerome McCann
Organ Donation Past, Present and Future 3

NORTH
WEST
Mechanically ventilated patient where death has been confirmed using neurological criteria.
74 donors
-5.1% increase
Lungs
Heart
Small Intestine
Kidneys
Liver
Pancreas
Organ Donation Past, Present and Future

60
40
20
0
NORTH
WEST
140
120
100
80
Donations over time: North West Team
-5.1%
181.3%
26.6%
Total Deceased
Donation
Donation after Brain
Death
Donation after
Circulatory Death
Organ Donation Past, Present and Future 5

DCD kidneys lungs pancreas liver
Organ Donation Past, Present and Future
DBD intestine heart

NORTH 100
WEST
80
87
82
DBD- Neurological death testing rate
Tied 9th with 3 others
86
76
74
78
73
76 76
74
76
74
60
40
20
0
1 April 2012 to 31 March 2013, data as at 4 April 2013
Team
Organ Donation Past, Present and Future
-------- National rate
7

DBD- North West Neurological death testing rate
100
80
60
40
20
2
28
30
4
1
15
7
6
23
16
12
26
0
0
18 21 5 27
5 10 15 20 25
Number of neurological death suspected patients
Hospital
95% Upper CL
National rate
99.8% Lower CL
1 April 2012 to 31 March 2013, data as at 4 April 2013
95% Lower CL
99.8% Upper CL
1 Barrow-In-Furness, Furness General Hospital
2 Douglas, Nobles I-O-M Hospital
3 Chester, Countess Of Chester Hospital
4 Crewe, Leighton Hospital
5 Macclesfield, Macclesfield District General Hospital
6 Warrington, Warrington Hospital
7 Liverpool, Royal Liverpool University Hospital
8 Liverpool, Alder Hey Children's Hospital
9 Prescot, Whiston Hospital
10 Southport, Southport District General Hospital
11 Liverpool, University Hospital Aintree
12 Liverpool, Walton Centre For Neurology And Neurosurgery
13 Wirral, Arrowe Park Hospital
14 Lancaster, Royal Lancaster Infirmary
15 Blackpool, Blackpool Victoria Hospital
16 Preston, Royal Preston Hospital
17 Blackburn, Royal Blackburn Hospital
18 Chorley, Chorley And South Ribble District General Hospital
19 Bolton, Royal Bolton Hospital
20 Bury, Fairfield General Hospital
21 Manchester, North Manchester General Hospital
22 Manchester, Manchester Royal Infirmary
23 Manchester, Royal Manchester Children's Hospital
24 Manchester, Wythenshawe Hospital
25 Oldham, Royal Oldham Hospital(Rochdale Road)
26 Salford, Salford Royal
27 Stockport, Stepping Hill Hospital
28 Ashton-Under-Lyne, Tameside General Hospital
29 Manchester, Trafford General Hospital
30 Wigan, Royal Albert Edward Infirmary
31 Bodelwyddan, Glan Clwyd District General Hospital
32 Wrexham, Maelor General Hospital
33 Bangor, Ysbyty Gwynedd District General Hospital
30
8 Organ Donation Past, Present and Future

Mean no. of organs donated per donor
4,3
4,2
4,1
4,0
3,9
3,8
3,7
3,6
3,5
3,4
3,3
NORTH
WEST
1 April 2012 to 31 March 2013, data as at 4 April 2013
Organ Donation Past, Present and Future 9

1976
2008
Organ Donation Past, Present and Future 10

Organ Donation Past, Present and Future 11

Harvey Cushing describes increased brain pressure provoking respiratory arrest with preserved heartbeat.
Organ Donation Past, Present and Future 12

Brain death: Discovered not Invented (by intensive care)
1940s
Danish medical students hand ventilate polio victims
Mouth to Mouth
Resuscitation gains prominence &
Mechanical Ventilation becomes possible
1954
1 st successful kidney transplant between identical twins
Organ Donation Past, Present and Future
1959, doctors discover empirical proof by the identification of mechanically ventilated patients in coma dépassé.
13

1962
1 st successful deceased donor kidney Tx
1963
1 st successful deceased donor liver & lung Tx
1966
1 st successful deceased donor pancreas Tx
1968
1 st successful deceased donor heart Tx
Proposed that the
EEG can demonstrate death of the Central
Nervous System.
1964, Keith Simpson
“there is life so long as circulation of oxygenated blood is maintained to live brainstem centres”
Organ Donation Past, Present and Future 14

Modern intensive care practice grows.
Organ Donation from Brain Dead donors increases worldwide.
1976 (clarified 1979)
UK Criteria for
Diagnosing Death using Neurological
Criteria Published.
Organ Donation Past, Present and Future 15

Growing use of ECMO and other techniques to support the circulation, establish that it is possible to be alive, without a heart-beat.
Rene
´ Laennec
1819
Eugene Bouchut
1846
Organ Donation Past, Present and Future
2008
UK Criteria for
Circulatory Criteria published for the 1 st time. 5 minutes.
16

UK Definition of Death
“The definition of death should be regarded as the irreversible loss of the capacity for consciousness, combined with irreversible loss of the capacity to breathe… therefore irreversible cessation of the integrative function of the brain-stem equates with the death of the individual.”
All human death is anatomically located to the brain.
17 Organ Donation Past, Present and Future

Neurological Criteria
Circulatory Criteria
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Somatic Criteria
Organ Donation Past, Present and Future

Dx Death using Neurological Criteria
1.
An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
DEATH
Irreversible loss of the capacity for consciousness
• Cause tells you irreversibility, based on the natural history of the disease
• Cause tells you how long you should observe before testing:
• SAH 6 hours
• Hypoxia 24 hours
Irreversible loss of the capacity to breathe
19 Organ Donation Past, Present and Future

Dx Death using Neurological Criteria
1.
An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
DEATH
Irreversible loss of the capacity for consciousness
2.
An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria.
Irreversible loss of the capacity to breathe
20 Organ Donation Past, Present and Future

Dx Death using Neurological Criteria
• Clinical judgement essential
2.
An exclusion of reversible conditions
• Impossible to create rules covering every situation capable of mimicking or confounding the diagnosis of death
• Difficulties mainly with using neurological criteria.
thiopentone and midazolam
• Plasma concentrations not good predictors of effect
DEATH
• Use of antagonists may help
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
21 Organ Donation Past, Present and Future

Dx Death using Neurological Criteria
1.
An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
2.
An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria.
98.5%
Death confirmed in 1220 of
1238 tests
(2012 data)
22 Organ Donation Past, Present and Future

Dx Death using Neurological Criteria
1.
An established aetiology capable of causing structural damage to the brain which has led to the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe.
2.
An exclusion of reversible conditions capable of mimicking or confounding the diagnosis of death using neurological criteria.
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the
3.
A clinical examination of the patient, which demonstrates profound coma, apnoea and absent brainstem reflexes. capacity to breathe
23 Organ Donation Past, Present and Future







Pupils (II, III)
Corneal (V, VII)
Pain (V, VII)
Gag (IX, X)
Cough (IX, X)
Oculovestibular (III, VI, VIII)


Oculocephalic
Suck
Paediatric
Organ Donation Past, Present and Future 24

Starting paCO
2
StartingpH<7.4
> 6.0 KPa
5 minutes with paCO
2
> 0.5 KPa
Recommended method: After pre-oxygenation, disconnect the patient from the ventilator and administer oxygen via a suction catheter in the endotracheal tube at a rate of >6 L/minute. If oxygenation is a problem, consider the use of a CPAP circuit (egMapleson B).
The apnoea test is performed only twice in total.
Organ Donation Past, Present and Future 25

“This form is consistent with and should be used in conjunction with, the
AoMRC (2008) A Code of Practice for the Diagnosis and Confirmation of Death and has been endorsed for use by the following institutions: Faculty of
Intensive Care Medicine, Intensive Care Society and the National Organ
Donation Committee.”
Abbreviated
Organ Donation Past, Present and Future
Full
26

Organ Donation Past, Present and Future 27

Organ Donation Past, Present and Future

• Dying, is a process, which effects different functions and cells of the body at different rates of decay.
• Doctors must decide at what moment along this process there is permanence and death can be appropriately declared.
Organ Donation Past, Present and Future

Diagnose the dead
1. Safe – no coming back to life after death declared
2. Timely – no unnecessary delay
Organ Donation Past, Present and Future

Where Brain Stem Death (BSD) is suspected, it is highly desirable to confirm this by Brain Stem
Testing:
• To eliminate all possible doubt regarding survivability
• To confirm diagnosis for families
• In cases subject to medico-legal scrutiny
• To provide choice regarding organ donation
Organ Donation Past, Present and Future

diagnosis decision
Organ Donation Past, Present and Future

• National professional guidance mandates two tests to be performed regardless of organ donation (Bolam&Bolithio).
• Same two doctors carry out the second set of tests immediately after the first set (update family and stabilise patient).
• Death is retrospectively confirmed at the conclusion of the second test. Until then, as a matter of law and ethics, it is necessary to treat the patient as alive.
Organ Donation Past, Present and Future

1976 2008
Organ Donation Past, Present and Future
Lesson 1

Lesson 2
Organ Donation Past, Present and Future

Organ Donation Past, Present and Future
•Atypical presentation
•Hypoxic brain injury
>24 hours

Organ Donation Past, Present and Future

Organ Donation Past, Present and Future
Lesson 5
NO EEG

Lesson 6
Start with Lesson 2 = use your brain and examine your patient
1. Clinical brain death + NO flow
= Death
2. Clinical brain death + flow
= Wait
See Lesson 3 = take your time and ask
‘Is reversibility possible?’
Organ Donation Past, Present and Future

Organ Donation Past, Present and Future
40

Donor optimisation
• Ameliorate ‘systemic’ effects of brain stem death
• Why?
•
Increase number of donors
• Increase number of organs per donor
•
Increase quality of organs
• Who takes responsibility?
•
ICU staff: medical and nursing
• SN-ODs
•
Retrieval teams
• ‘Scout’
• Cardio-thoracic teams
Organ Donation Past, Present and Future 43

‘ Collateral damage ’
• Hormonal
• Diabetes insipidus
• Hypovolaemia
•
Hypernatraemia
• T3 / T4 reduces
• ACTH
• Blood glucose
• Hypothermia
Organ Donation Past, Present and Future 44

Incidence of organ involvement
• Hypotension
• Diabetes insipidus65%
• DIC
• Cardiac dysrrhythmias
• Pulmonary oedema
• Metabolic acidosis
81%
28%
25%
18%
11%
Organ Donation Past, Present and Future
J Heart Lung Transplantation 2004 (suppl)
45

Organ Donation Past, Present and Future 46

Evidence
• Totsuka Transplant Proc. 2000; 32;322-326
•
High sodium in liver donor doubles graft loss
• Rosendale Transplantation 2003. 75 (4): 482-487
• Protocol increased organs per donor 3.1 to 3.8. Increased probability of transplant.
• Snell J Heart Lung Transplant 2008;27:662-7
• 54% of Australian lung donations used for transplant vs. 13% in UK
Organ Donation Past, Present and Future 47

Principles
• Ameliorate ‘systemic’ effects of brain stem death
• Why?
• Increase number of donors
• Increase number of organs per donor
• Increase quality of organs
• Who takes responsibility?
• ICU staff: medical and nursing
• SN-ODs
• Retrieval teams
• ‘Scout’: who are they attached to?
• Cardio-thoracic teams
• Abdominal teams
• Free standing
Organ Donation Past, Present and Future 48

What do we aim for ?
• General stability
• Examples of target values
• MAP: 60 – 80 mm Hg
• Heart rate: 60 – 100 / min SR
• CI: > 2.1 l/min/m 2
• Guidelines
• Australian
• Canadian
• Map of Medicine
• ICS
• NHSBT
Organ Donation Past, Present and Future 49

Cardiovascular management
• Summary of cardio vascular target values
• MAP: 60 – 80 mm Hg
• CVP: 4 – 10 mm Hg
• Heart rate: 60 – 100/min SR
• CI: > 2.1 l/min/m 2 (can be higher, be aware of myocardial stunning)
• Filling targets: no good evidence for any specific targets, depends on device
• SvO
2
> 60%
• SVRI target
• Secondary target
• Dehydration  temptation to maintain MAP with vasopressors rather than filling
Organ Donation Past, Present and Future 50

Respiratory management
• Recruitment manoeuvre
• Post BSD testing: apnoea test resulting in atelectasis
• After suctioning / disconnection
• When SpO
2 drops / FiO
2 increases
• Lung protective ventilation: 4 – 8 ml/kg ideal body weight
• Permissive hypercapnia with pH > 7.25
• Optimum PEEP (5 – 10 cm H
2
O) and FiO
2
(aim for < 0.4 as able)
• Head –up positioning (30 - 45 ° )
• Suctioning, physiotherapy as required
• Antibiotics for purulent secretions: local microbiology surveillance
• Avoid over-hydration
Organ Donation Past, Present and Future 51

Managing Diabetes insipidus
• Very common occurrence
• Pathophysiology
• Posterior pituitary failure
• Polyuria: output > 4ml/kg/h
• Dehydration with  Na +
• Usually at least partially addressed with stabilisation for BSD testing
• Treatment:
• Fluids
• Vasopressin
• DDAVP
• Aim for u-output 0.5 – 2.0 ml / kg / h
52 Organ Donation Past, Present and Future

Hormonal treatment
• Vasopressin
• Reduction in other vaso-active drugs
• Dose: 1 – 4 units/h (can start with boluses of 1 unit at a time)
• Liothyronine (T3)
• No clear evidence yet for either use or not
• May add haemodynamic stability in very unstable donor
• Dose: 3 units/h, sometimes bolus of 4 units asked for by retrieval team
• Methylprednisolone in all cases
• Dose: 15 mg/kg up to 1g
• Insulin
• At least 1 unit/h (Occasionally may need to add glucose infusion)
• ‘Tight’ glycaemic control (4 - 10 mmol/l)
Organ Donation Past, Present and Future 53

Haematological management
• DIC seen occasionally as direct consequence of BSD
• May require correcting prior to BSD testing if bleeding
• Hb> 8 g/dl (~ 10 g/dl traditionally advocated) (even > 7g/dl ?)
• No evidence on harm with lower Hb, but some evidence of harm with blood transfusions and organ function post transplant
• Where Hb borderline, ensure blood available for retrieval procedure: local protocols and antibodies will determine whether G&S only, or units to be cross matched
• Use of clotting factors
•
Only where bleeding is an issue
• Monitor clotting status
• Use local hospital protocol
• Retrieval procedure may require additional products
Organ Donation Past, Present and Future 54

General measures
• Maintain normothermia (active warming may be required)
• Thrombo-embolism prophylaxis
• Stockings
• Sequential compression devices
• LMWH
• Positioning
• Head-up
• Side to side
• Attention to cuff pressures and leaks to prevent aspiration
• Continue NG feeding (may be reduced/ stopped for bowel transplant)
• Antibiotics according to sensitivities or empirical according to Trust guidelines
Organ Donation Past, Present and Future 55

Monitoring optimisation
• Implementation: use of care bundle
• Adherence easy to monitor
• Audit first 5 priorities
• Results of optimisation evaluated
• Number of organs retrieved
• Increase in cardiothoracic organs retrieved
• Quality of organs: organ function in recipients
• Delayed graft function
• Quality: biomarkers
• Duration of graft function: long term project
Organ Donation Past, Present and Future 56