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The incidence of potential missed organ donors in intensive care units and emergency rooms: a retrospective cohort

Demetrios J. Kutsogiannis| Sonal Asthana| Derek R. Townsend| Gurmeet Singh| Constantine J. Karvellas
Original
Volume 39, Issue 8 / August , 2013

Pages 1452 - 1459

Abstract

Purpose

There is a shortage of organ donors in Canada. The number of potential organ donors that are not referred to organ procurement organizations in Canada is unknown.

Methods

We conducted a retrospective cohort study of all deaths in ICUs and emergency rooms not referred to the Human Organ Procurement and Exchange Program in four hospitals between 1 January 2008 and 31 December 2010. The primary outcome was the number of normal and expanded criteria heart-beating donors and circulatory death (DCD) donors.

Results

Of 2,931 deaths, 64 patients were identified as having a high probability for progression to heart-beating donation (Glasgow Coma Score of 3 and three or more absent brainstem reflexes) and 130 patients were assessed for possible DCD donation. The number of potential abdominal and lung heart-beating donors ranged from 3.2 to 7.5 and 0.5 to 2.7 per million population. The number of potential DCD abdominal and lung donors ranged from 3.9 to 6.5 and 2.7 to 4.3 per million population. Potential heart-beating abdominal (p = 0.04) and lung (p = 0.06) donors increased after legislation mandating donation discussion. Non-pupillary brainstem reflexes were documented in fewer than 60 % of records. Life-sustaining treatment was withdrawn in 19 of 46 (41.3 %) cardiac arrest patients not requiring high doses of vasoactive drugs within 24 h.

Conclusion

The number of heart-beating or DCD organ donors represented by missed referrals may represent up to 7.5 donors per million population. Improved documentation of brainstem reflexes and encouraging referral of patients suffering cardiac arrest to ICU specialists may improve donor numbers.

Keywords

References

  1. Oz MC, Kherani AR, Rowe A, Roels L, Crandall C, Tomatis L, Young JB (2003) How to improve organ donation: results of the ISHLT/FACT poll. J Heart Lung Transpl 22:389–410
    • View reference on publisher's website
  2. Canadian Institute for Health Information (2010) E-statistics report on transplant, waiting list and donor statistics (2010) http://www.cihi.ca/CIHI-ext-portal/internet/en/document/types+of+care/specialized+services/organ+replacements/report_stats2010. Accessed 1 May 2013
  3. Abadie A, Gay S (2006) The impact of presumed consent legislation on cadaveric organ donation: a cross-country study. J Health Econ 25:599–620
    • View reference on PubMed
    • View reference on publisher's website
  4. The ACRE Trail Collaborators (2009) Effect of “collaborative requesting” on consent rate for organ donation: randomised controlled trial (ACRE trial). BMJ 339:b3911. doi:10.1136/bmj.b3911
    • View reference on publisher's website
  5. Simpkin AL, Robertson LC, Barber VS, Young JD (2009) Modifiable factors influencing relatives’ decision to offer organ donation: systematic review. BMJ 338:b991
    • View reference on PubMed
    • View reference on publisher's website
  6. Salim A, Malinoski D, Schulman D, Desai C, Navarro S, Ley EJ (2010) The combination of an online organ and tissue registry with a public education campaign can increase the number of organs available for transplantation. J Trauma 69:451–454
    • View reference on PubMed
    • View reference on publisher's website
  7. Tu JV, Nardi L, Fang J, Liu J, Khalid L, Johansen H, Team CCOR (2009) National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke, 1994–2004. CMAJ 180:E118–E125
    • View reference on PubMed
  8. Kompanje EJ, Bakker J, Slieker FJ, Ijzermans JN, Maas AI (2006) Organ donations and unused potential donations in traumatic brain injury, subarachnoid haemorrhage and intracerebral haemorrhage. Intensive Care Med 32:217–222
  9. Opdam HI, Silvester W (2004) Identifying the potential organ donor: an audit of hospital deaths. Intensive Care Med 30:1390–1397
  10. Province of Alberta (2009) Human tissue and organ donatio act. Alberta Queen’s Printer, Edmonton, Alberta. http://www.qp.alberta.ca/documents/acts/h14p5.pdf. Accessed 1 May 2013
  11. de Groot YJ, Jansen NE, Bakker J, Kuiper MA, Aerdts S, Maas AI, Wijdicks EF, van Leiden HA, Hoitsma AJ, Kremer BH, Kompanje EJ (2010) Imminent brain death: point of departure for potential heart-beating organ donor recognition. Intensive Care Med 36:1488–1494
  12. de Groot YJ, Wijdicks EF, van der Jagt M, Bakker J, Lingsma HF, Ijzermans JN, Kompanje EJ (2011) Donor conversion rates depend on the assessment tools used in the evaluation of potential organ donors. Intensive Care Med 37:665–670
  13. Ojo AO (2005) Expanded criteria donors: process and outcomes. Semin Dial 18:463–468
    • View reference on PubMed
    • View reference on publisher's website
  14. Feng S, Goodrich NP, Bragg-Gresham JL, Dykstra DM, Punch JD, DebRoy MA, Greenstein SM, Merion RM (2006) Characteristics associated with liver graft failure: the concept of a donor risk index. Am J Transpl 6:783–790
    • View reference on publisher's website
  15. Rull R, Vidal O, Momblan D, González FX, López-Boado MA, Fuster J, Grande L, Bruguera M, Cabrer K, García-Valdecasas JC (2003) Evaluation of potential liver donors: limits imposed by donor variables in liver transplantation. Liver Transplant 9:389–393
    • View reference on publisher's website
  16. Botha P (2009) Extended donor criteria in lung transplantation. Curr Opin Organ Transplant 14:206–210
    • View reference on PubMed
    • View reference on publisher's website
  17. Yeung JC, Cypel M, Waddell TK, van Raemdonck D, Keshavjee S (2009) Update on donor assessment, resuscitation, and acceptance criteria, including novel techniques–non-heart-beating donor lung retrieval and ex vivo donor lung perfusion. Thorac Surg Clin 19:261–274
    • View reference on PubMed
    • View reference on publisher's website
  18. Oto T (2008) Lung transplantation from donation after cardiac death (non-heart-beating) donors. Gen Thorac Cardiovasc Surg 56:533–538
    • View reference on PubMed
    • View reference on publisher's website
  19. Snell GI, Levvey BJ, Oto T, McEgan R, Pilcher D, Davies A, Marasco S, Rosenfeldt F (2008) Early lung transplantation success utilizing controlled donation after cardiac death donors. Am J Transplant 8:1282–1289
    • View reference on PubMed
    • View reference on publisher's website
  20. Yee AH, Rabinstein AA, Thapa P, Mandrekar J, Wijdicks EF (2010) Factors influencing time to death after withdrawal of life support in neurocritical patients. Neurology 74:1380–1385
    • View reference on PubMed
    • View reference on publisher's website
  21. Rabinstein AA, Yee AH, Mandrekar J, Fugate JE, de Groot YJ, Kompanje EJ, Shutter LA, Freeman WD, Rubin MA, Wijdicks EF (2012) Prediction of potential for organ donation after cardiac death in patients in neurocritical state: a prospective observational study. Lancet Neurol 11:414–419
    • View reference on PubMed
    • View reference on publisher's website
  22. de Groot YJ, Lingsma HF, Bakker J, Gommers DA, Steyerberg E, Kompanje EJ (2012) External validation of a prognostic model predicting time of death after withdrawal of life support in neurocritical patients. Crit Care Med 40:233–238
    • View reference on PubMed
    • View reference on publisher's website
  23. Rosner B (1995) Fundamentals of biostatistics. Wadsworth, Belmont
  24. Shemie SD, Doig C, Dickens B, Byrne P, Wheelock B, Rocker G, Baker A, Seland TP, Guest C, Cass D, Jefferson R, Young K, Teitelbaum J, Pediatric Reference Group, Neonatal Reference Group (2006) Severe brain injury to neurological determination of death: canadian forum recommendations. CMAJ 174:S1–S13
    • View reference on PubMed
  25. Morgan SE, Stephenson MT, Harrison TR, Afifi WA, Long SD (2008) Facts versus ‘feelings’. How rational is the decision to become an organ donor? J Health Psychol 13:644–658
    • View reference on PubMed
    • View reference on publisher's website
  26. Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H (2012) Year in review in intensive care medicine 2011: i. Nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals. Intensive Care Med 38:192–209
  27. Kohn R, Rubenfeld G, Levy M, Ubel P, Halpern S (2011) Rule of rescue or the good of the many? An analysis of physicians’ and nurses’ preferences for allocating ICU beds. Intensive Care Med 37:1210–1217
  28. Weng L, Joynt G, Lee A, Du B, Leung P, Peng J, Gomersall C, Hu X, Yap H (2011) Attitudes towards ethical problems in critical care medicine: the Chinese perspective. Intensive Care Med 37:655–664
  29. Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G, Group LoCSIatCCCT (2003) Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 349:1123–1132
    • View reference on PubMed
    • View reference on publisher's website
  30. Turgeon AF, Lauzier F, Simard JF, Scales DC, Burns KE, Moore L, Zygun DA, Bernard F, Meade MO, Dung TC, Ratnapalan M, Todd S, Harlock J, Fergusson DA (2011) Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ 183:1581–1588
  31. Becker KJ, Baxter AB, Cohen WA, Bybee HM, Tirschwell DL, Newell DW, Winn HR, Longstreth WT Jr (2001) Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology 56:766–772
    • View reference on PubMed
    • View reference on publisher's website
  32. Hemphill JC 3rd, Newman J, Zhao S, Johnston SC (2004) Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke 35:1130–1134
    • View reference on PubMed
    • View reference on publisher's website
  33. Zahuranec DB, Brown DL, Lisabeth LD, Gonzales NR, Longwell PJ, Smith MA, Garcia NM, Morgenstern LB (2007) Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology 68:1651–1657
    • View reference on PubMed
    • View reference on publisher's website
  34. Barber K, Falvey S, Hamilton C, Collett D, Rudge C (2006) Potential for organ donation in the United Kingdom: audit of intensive care records. BMJ 332:1124–1127
    • View reference on PubMed
    • View reference on publisher's website

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