1 / 46

Donation After Cardiac Death 2016 Transplant Workshop: Trending Issues in Transplantation

Explore the latest trends in organ donation after cardiac death at the 2016 Transplant Workshop. Topics include organ allocation, death criteria, pediatric considerations, ethical barriers, and more.

anaw
Download Presentation

Donation After Cardiac Death 2016 Transplant Workshop: Trending Issues in Transplantation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Donation After Cardiac Death2016 Transplant Workshop: Trending Issues in Transplantation Nora Colman Oct 22, 2016

  2. Organ Donation https://youtu.be/3ONunH_ql5M • Published on Feb 1, 2016 • A mom in Arizona donated her son's organs after he died in 2013. Recently, she met with the family of one of the lives he saved.

  3. Outline • Organ donation statistics • Pediatric considerations • Organ allocation • History of determining death • Death criteria • Brain Death • Cardiac Death • Organ donation after cardiac death • Certification of death • DCD candidates • Organ procurement and transplant • Ethical considerations and barriers • DCD at CHOA

  4. Statistics at a Glance www.UNOS.org

  5. Statistics at a Glance www.UNOS.org

  6. Organ wait list www.UNOS.org

  7. Pediatric Organ Transplant • In 2011, 2000 pediatric patients were awaiting a solid organ transplant • Children from birth to 17 years old account for 2-3% of the national waiting list • More than 70% of children are waiting for a liver or kidney • Small bowel is the organ with the greatest increase in need

  8. Organ Donation • Advances in surgical techniques, perioperative management, and immunosuppression contribute to an ever-widening gap between the number of children eligible for transplantation and the number of organs available • In the past 15 years, about 4000 children have died without receiving a transplant

  9. Organ Wait List Yoo P, Olthoff K, Abt P. (2011) Donation after cardiac death in pediatric organ donation Curr op organ trans 16(5):483-8

  10. History of Organ Donation • In 1951 Dr. David Hume performed the first donation after circulatory determination of death kidney transplant in Boston • In 1968 Harvard Medical School proposed a brain based definition of death • The uniform anatomical gift act of 1968 and the Uniform determination of death act of 1980 further cemented the standards by which death was established • By the 1990’s organ transplantation was recognized as an effective therapy for end stage organ failure. • In 1992 Physicians at the University of Pittsburgh released a protocol outlining the first formal policy on organ donation after elective withdrawal of life sustaining measures

  11. History of Organ Donation • In 1997, the Institute of Medicine determined that DCD was safe, ethically acceptable, and a medically useful method to increase the supply of available organs for transplant • In 1998, hospitals participating in Medicare and Medicaid programs were required to refer potential organ donors to their local OPO (organ procurement organization)

  12. History of Organ Donation • The Children’s Health Act was passed in October of 2000 • Called on the OPTN to develop specific criteria, policies, and procedures to address the unique needs of children and adults • By 2007, the Joint Commission mandated that all hospitals develop and maintain a DCD protocol • All families of potential organ donors be made aware of their option to donate • Legislation also requires all hospitals to have trained designated requestors available to discuss organ donation with families of potential donors

  13. Infrastructure • Organ Procurement and Transplantation Network • Nation’s organ procurement, donation, and transplantation system • The United Network of Organ Sharing (UNOS) • Nonprofit organization that operates under OTN under a contract from the federal government

  14. Infrastructure • American Academy of Pediatrics supports the role of OPOs by recommending that: • All potential donor families be approached in a systematic method • That individuals trained in the psychological, social, and medical aspects of organ donation • The team must separate the death notification from the organ donation consent process

  15. Death Criteria • Death is legally established by one of two sets of criteria • Brain Death • Cessation of whole brain function • Cardiac Death • Cessation of cardiopulmonary function

  16. Brain Death Criteria • Irreversible loss of all functions of the entire brain, including brain stem • Donors are on ventilators but their heart continues to function

  17. Brain Death Criteria Nakagawa TA, Ashwal S, Mathur M et al. (2011)Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations Pediatrics 128(3):e720-740

  18. Cardiac Death Criteria • When death is declared on the basis of cardiopulmonary criteria • Diagnosis of Death requires • Cessation of Functions • Irreversibility

  19. Potential DCD patients • DCD occurs in a patient with a catastrophic brain injury who has not deteriorated to brain death • devastating irreversible brain injuries caused by trauma or intracranial bleeding, • high spinal cord injuries • end stage musculoskeletal disease

  20. Donation after Cardiac Death • Evidence based clinical judgment should be used to assess whether cardiac death will occur within 1 hour after withdrawal of life support • DCD discussions can only occur after the family and medical team have made the decision to withdraw support and terminate care

  21. Dead Donor Rule • Affirms that it is unethical to procure organs before death • Occurs when a family has come to terms with the consequences of the injury and has elected to withdraw support • Consent can only be given after the decision to withdraw support has been made

  22. DCD Organs • Initial studies suggested that implementation of widespread DCD could increase the number of organ donors by 20-25% • One pediatric center reported a 58% increase in organ donors when DCD was used

  23. UNOS Criteria for identifying potential DCD patients Estimated Supply of Organ Donors After Circulatory Determination of Death: A Population-Based Cohort Study JAMA. 2010;304(23):2592-2594. doi:10.1001/jama.2010.1824

  24. Criteria for Defining Potential DCDD Estimated Supply of Organ Donors After Circulatory Determination of Death: A Population-Based Cohort Study JAMA. 2010;304(23):2592-2594. doi:10.1001/jama.2010.1824

  25. Donation after Cardiac Death • Location of withdrawal of support varies and is driven by the practical need to rapidly recover organs once death occurs • Support may be withdrawn in the operating suite, recovery room, or ICU provided that the patient can be moved and prepared for organ recovery within 5-10 minutes of cardiac death • If the child does not succumb to cardiac death within the allotted time, he or she cannot be a solid organ donor, although tissue donation may remain an option

  26. Certification of Death • After extubation, the physician monitors the patient for absence of pulse pressure , absence of heart tones, apnea, and unresponsiveness • The IOM recommends 5 minutes of observation to minimize the risk of autoresuscitation • Society of Critical Care Medicine recommends >2 minutes of observation with >5 minutes not recommended

  27. DCD Organ Procurement • Administration of pharmacologic agents • Minimize ischemic and reperfusion injury • Improve organ function after DCD

  28. Organ Procurement • Warm Ischemic Time • In DCD there is a time between the cessation of mechanical ventilation and the initial of cold perfusion • During this time organs experience metabolic and inflammatory derangements which leads to the potential functioning differences between DCD and DBD organs

  29. Ischemic Time

  30. Pediatric Organ Scarcity Yoo P, Olthoff K, Abt P. (2011) Donation after cardiac death in pediatric organ donation Curr op organ trans 16(5):483-8

  31. Distribution of Pediatric DCD Organs Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6

  32. Distribution of Pediatric DCD Organs Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6

  33. Distribution of Pediatric DCD Organs Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6

  34. Heart • Denver Children’s Hospital recovered 3 hearts after DCD • Mean donor age was 3.7 years • Mean time to death was 18.3 minutes • 6 month survival was 100% compared to 84% among controls that underwent donation after transplantation with DBD organs • No difference in rejection or ventricular function at 6 months • This protocol remains to be replicated at other centers

  35. Lung • Only case reports detailing lung transplants from DCD donors • Lung may be especially suited to DCD recovery due to its low metabolic rate when compared to other transplantable organs

  36. Liver • Abt et al recorded US experience of liver transplants in children from 1995-2005 • 4991 liver transplants were performed in children • 0.4% were from DCD donors • Of these, 84% received livers from pediatric donors and 15% from adult donors • Graft survival at 1 and 5 years was 89.2 and 79.3% from DCD livers compared to 75.6 and 65.8% from controls with livers from DBD donors • This study concluded that selective use of livers from DCD donors can yield graft survival rates comparable to results seen with DBD livers

  37. Kidney • 4026 kidney transplants were performed in children in the US between 1995-2005 • 26% of the allografts were from DCD donors • 10 DCD organs were retrieved from pediatric patients, and the remained from adults • Graft survival at 1 and 5 years was 82.5 and 74.3% • Compared to 89.6 and 64.8% for kidneys from DBD donors

  38. Kidney • A Dutch group reported 88 patients who received kidney transplants from DCD donors • Incidence of immediate function was 49%, delayed graft function was 44% and primary non function was 7% • Only significant risk factor for primary non function was warm ischemic of > 25 minutes • Graft and patient survival and 1 and 5 years was 80 and 88%

  39. Barriers to DCD • Lack of Knowledge • Concerns about dead donor rule • Potential for conflict of interest • “Making donation happen” for those who want it • Call for standardized protocols

  40. CHOA Policy: DCD • Policy • The patient/family has elected to withdraw life support independent of the discussion of organ donation • The ME must be called for permission to proceed with donation, prior to offering option to the family • The organ recovery team will not be involved at any point in the medical management of the patient • There will be no direct interaction of the Organ Recovery Team with the primary medical team

  41. CHOA Policy: DCD • Procedure • The patient/legal guardian has made the decision to withdraw life support. This decision is separate from any organ donation discussion or considerations • The End of Life Support Team will discuss the details of organ donation and the DCD process with the family • The location of withdrawal will be at the discretion of the ICU family liaison, the OPO, and OR charge nurse and will be based on family logistics and wishes

  42. CHOA Policy: DCD • Planning, withdrawal of care, declaration of death, and transport to the OR • The place of withdrawal include the ICU bed with immediate access to the OR, or an OR anteroom • The family will be invited and encouraged to stay with the patient during withdrawal through death declaration, but this is not mandated • No organ recovery team members will be present during the withdrawal of treatment or during the dying process

  43. CHOA Policy: DCD • Withdrawal of life support measures • Termination of blood pressure medications • Termination of all IV fluids • Removal of ETT • Heparin bolus as ordered by the OPO • Following withdrawal the primary medical team will be encouraged to maintain patient comfort measures • The attending intensivist will monitor patient for signs of death based on established critical care criteria • Once confirmed the attending will declare death • At 5 minutes following death declaration, the attending will monitor the patient for spontaneous cardiac or respiratory function (auto-resuscitation) for 20 seconds • At that time transfer of the body will occur from the primary medical team to the organ recovery team and OPO

  44. CHOA Organ Donation • 2003-2016 • 54 successful DCD statewide • 10 DCD cases in 2015 • 298 organ donors last year

  45. Organ Transplanted from CHOA DCD Cases

  46. References • BastamiS, Matthes O, Krones T, et al. (2013) Systemic review of attitudes toward donation after cardiac death among healthcare providers and the general public Crit Care Med 41 (3):897-905 • Haplerm SD, Barnes B, Hasz RD, Abt PL (2010) Estimated supply of organ donors after circulatory determination of death: a population based cohort study JAMA 304 (23):2592-4 • Mazor R, Baden H. (2007) Trends in pediatric organ donation after cardiac death Pediatrics 120 (4): e960-6 • Nakagawa TA, Ashwal S, Mathur M et al. (2011)Guidelines for the Determination of Brain Death in Infants and Children: An Update of the 1987 Task Force Recommendations Pediatrics 128(3):e720-740 • Steinbrook, R. (2007) Organ donation after cardiac death. NEJM 367:209-213 • Yoo P, Olthoff K, Abt P. (2011) Donation after cardiac death in pediatric organ donation Curr op organ trans 16(5):483-8

More Related