Organ Donation

Published on 10/03/2015 by admin

Filed under Critical Care Medicine

Last modified 22/04/2025

Print this page

This article have been viewed 1327 times

Chapter 86 Organ Donation

Benjamin T. Suratt, MD , Kapil Patel, MD

1 Who governs the rules and regulations for organ donation?

The Organ Procurement and Transplantation Network (OPTN) is a system for operating and monitoring the unbiased allocation, through established medical criteria, of organs donated for transplantation and maintaining a recipients’ waiting list (including the listing and delisting of recipients).

The United Network for Organ Sharing (UNOS) is a nonprofit organization awarded the contract by the Department of Health and Human Services in 1986 to implement the OPTN.

Organ Procurement Organizations (OPO) serve specific regions in the country for clinical services including working with hospital staff to maintain donor-organ function, working with UNOS to match donor organs with recipients, coordinating organ recovery surgery, and giving compassionate and professional support to donors’ families.

2 Who can be a potential organ donor?

Potential for organ or tissue donation has few absolute contraindications: human immunodeficiency virus infection, active hepatitis B virus infection, active visceral or hematologic neoplasm, or active bacterial infection, with no age limitation. Appropriateness for donation is assessed when the occasion arises. The majority of cases that are considered for organ donation occur within the intensive care unit (ICU). Despite severe organ shortage, no set universal protocol exists for organ donation. It is at the discretion of the intensivist to consider cases for organ donation. If a case is considered, then the next step is to notify the local OPO, which will then gather data and discuss the critical care management with the regional organ donation specialist, usually an intensivist.

The general rule for the possibility for organ donation is that there should be no evidence of end-organ damage (e.g., acute tubular necrosis, myocardial depression, or pneumonia), with the final decision per the accepting transplant center.

3 Which organs can be donated?

Organs: kidney, heart, lung, liver, pancreas, and the intestines. Of note, combined organ transplantations (kidney-pancreas, heart-lung, other transplant) can be performed.

Tissue: corneas, the middle ear, skin, heart valves, bones, veins, cartilage, tendons and ligaments.

4 What is the current standard for organ donation?

Organ donation is possible in patients who are declared brain dead. New brain death guidelines have been published (see Box 86-1). Despite efforts to promote organ donation, an enormous shortage of available organs for transplant continues to exist. As a result, efforts have been undertaken to expand the settings in which organs may become available (i.e., donation after cardiac death (DCD); see later). See Boxes 86-2, 86-3, and 86-4 and Tables 86-1 and 86-2.

Box 86-1 Brain death criteria

Unresponsiveness or coma

Core body temperature (≥ 32° C)

Absence of cerebral motor responses to pain in all extremities

Absence of brainstem reflexes, that is, pupillary, oculocephalic (doll’s eyes), vestibuloocular (cold calorics), corneal, gag, and cough reflexes

Apnea test (see Boxes 86–2, 86–3, and 86–4)

Exclusion of conditions that may confound clinical assessment of brain death, that is, metabolic or endocrine abnormality or drug intoxication

^{Table 86-1} Confirmatory brain death testing

Electroencephalography	No electrical activity for a period of 30 minutes
Cerebral angiography	No intracerebral filling at the level of the carotid bifurcation or circle of Willis Patent external carotid circulation
Transcranial Doppler sonography	No diastolic or reverberating flow Systolic-only or retrograde diastolic flow Small systolic peaks in early systole
Somatosensory evoked potential	Bilateral absence of response to medial nerve stimulation
Cerebral scintigraphy (technetium Tc 99m brain scan)	No uptake of radionuclide in brain parenchyma (hollow skull phenomenon)
Magnetic resonance imaging	Not yet determined

^{Table 86-2} Comparison of donation after brain death and donation after cardiac death

	Donation after brain death	Donation after cardiac death
Cause of illness (e.g., anoxic, trauma, stroke)	Severe irreversible brain injury Does meet criteria of brain death	Severe irreversible brain injury Does not meet criteria of brain death
Organ procurement process	Physician (non–transplant team) declares brain death	Family elects withdrawal of life support
	Referral to OPO	Referral to OPO
	Await OR time for organ procurement	Withdrawal of life support in the OR or ICU
	Transplant team retrieves organs	Physician (non–transplant team) declares cardiac death
	Heart, lungs, kidneys, liver, pancreas, and/or intestines are transplantable	Transplant team waits 5 minutes after cardiac death is declared before procuring organs
		Transplant team retrieves organs
		Kidney, pancreas, and liver are generally transplantable

OR, Operating room.

Modified from Organ Donation After Cardiac Death. Madison, Wis., University of Wisconsin Organ Procurement Organization, 2009.

Box 86-2 Prerequisites for performing the apnea test

Core body temperature ≥ 36.5° C

Systolic blood pressure ≥ 90 mm Hg (may use intravenous fluids or dopamine to achieve)

Eucapnia (PaCO₂ approximately 40 mm Hg) if possible

Normoxemia (PaO₂ ≥ 200 mm Hg) if possible (typically 10 minutes at an FiO₂ of 1.0 will achieve)

FiO_2, Fraction of inspired oxygen.

Box 86-3 Apnea test

1. Patient is disconnected from the ventilator.

2. Oxygen cannula is placed at the level of carina, and 100% oxygen is delivered at a rate of 6 L/min.

3. Patient is observed for respiratory movements (e.g., chest or abdominal excursions).

4. Arterial PaO₂, PaCO₂, and pH are measured after approximately 8 minutes.

5. Patient is reconnected to the ventilator.

Box 86-4 Interpretation of apnea test results

Confirmatory results: No respiratory movements witnessed with resultant arterial PCO₂ ≥ 60 mm Hg (or 20 mm Hg increase in PCO₂ over pretest baseline)

Contradictory results: Any evidence of respiratory movements (regardless of PCO₂ level)

Inconclusive results: No respiratory movements and PCO₂ ≤ 60 mm Hg. Apnea test may be repeated within 10 minutes.

If cardiovascular or pulmonary instability occurs during the test (i.e., systolic blood pressure ≤ 90 mm Hg, dysrhythmia, or arterial oxygen desaturation), arterial blood gas value is immediately obtained, and the patient is reconnected to the ventilator. Alternative confirmatory testing to determine brain death (see Table 86–1) is then performed at the discretion of physician.

5 What is organ DCD?

DCD is considered in patients who have expressed a wish to donate organs and who sustain severe, irreversible brain injury short of meeting criteria for brain death (see earlier), but in whom withdrawal of life support is planned. In this case, organ procurement occurs immediately after death as declared by cardiopulmonary criteria. For organs to be successfully recovered for transplantation, death must occur between 60 and 120 minutes (depending on the institution) of withdrawal of life support. If death does not occur within the preset time frame, the patient is brought back to the ICU and provided comfort care measures without organ procurement.

The most commonly procured organs in DCD are kidney, liver, and pancreas. The time period required between cardiac arrest and the initiation of organ retrieval is 5 minutes. This time frame leaves other organs susceptible to ischemia. Currently very limited data support the procurement of lungs after cardiac death. However, recent data on DCD lung transplantation from the Toronto Lung Transplant Program have demonstrated acceptable outcomes.

6 Is donation after cardiac death ethically appropriate?

A national conference on donation after cardiac death in 2005 concluded that it is “an ethically acceptable practice of end-of-life care, capable of increasing the number of deceased-donor organs available for transplantation.” This national conference affirmed the ethical propriety of DCD as not violating the “dead donor rule.”

7 What is the dead donor rule?

“Organ transplantation has been guided by the overarching ethical requirement known as the ‘dead donor rule,’ which simply states that patients must be declared dead before the removal of any vital organs for transplantation.”

8 What are some of the statistics for organ donation and transplantation?

Every 11 minutes, a patient is added to the transplant waiting list (e.g., lung, kidney, heart).

Every day, approximately 75 patients receive an organ transplant. Yet every day approximately 20 patients die waiting for a transplant.

As of May 4, 2009, the percentage of recipients who were still living 5 years after solid organ transplantation was as follows:

In 2008, 60% of living donors were women. Sixty percent of deceased donors were men.

In 2008, 67% of all deceased donors were white, 16% were black, 14% Hispanic, and 2.5% Asian.

As of November 2010, patients on the national waiting list were 45% white, 29% black, 18% Hispanic, and 6% Asian.

In 2007 (the most recent data), nearly 2.5 million people died in the United States. Yet only 8085 of these people donated their organs.

OPTN data show a progressive increase in the rate of organ recovery from DCD donors (844 DCD donors in 2008 compared with 268 in 2003).

Currently, more than 86 million people in the United States have indicated a wish to become a donor. Although impressive at first, this still will not be nearly enough to address the growing demand (see Fig. 86-1).

Figure 86-1 Over the past two decades, the gap between the number of patients waiting for a transplant and the number receiving a transplant has continued to widen. The substantial difference between the number of donors and the number of patients waiting for a transplant is one factor that contributes to waiting time from listing to transplantation. *Data include deceased and living donors.

(From the University of Wisconsin Organ Procurement Organization: organdonor.gov/aboutStatsFacts.asp.)

Key Points Organ donation

1. All patients with impending brain death or withdrawal of care should be screened for the possibility of organ donation.

2. To diagnose brain death all confounding factors must be excluded.

3. DCD is an ethically acceptable manner in which terminally ill patients can be considered for organ donation.

4. The gap between those patients awaiting transplants and those donating organs is widening exponentially—the vast majority of those on the transplant list will die waiting.

Association of Organ Procurement Organizations: aopo.org

Organ Procurement and Transplantation Network: optn.transplant.hrsa.gov

United Network for Organ Sharing: unos.org

U.S. Government Information on Organ and Tissue Donation and Transplantation: organdonor.gov

1 Bernat J.L., D’Alessandro A.M., Port F.K., et al. Report of a national conference on donation after cardiac death. Am J Transplant. 2006;6:281–291.

2 Cypel M., Sato M., Yildirim E., et al. Initial experience with lung donation after cardiocirculatory death in Canada. J Heart Lung Transplant. 2009;28:753–758.

3 Truog R.D., Miller F.G. The dead donor rule and organ transplantation. N Engl J Med. 2008;359:674–675.

4 Wijdicks E.F., Varelas P.N., Gronseth G.S., et al. Evidence-based guideline update: determining brain death in adults. Neurology. 2010;74:1911–1918.

Related

Critical Care Secrets 5e