Francesco Procaccio Italy - Monday 28 - ICU and Organ Donation


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Francesco Procaccio Italy - Monday 28 - ICU and Organ Donation

  1. 1. Silent Brain Death The problem of donor identification. F Procaccio , L Rizzato, A Ricci, A Nanni Costa Italian Transplant National Centre Rome - Italy ISODP - Buenos Aires 2011
  2. 2. POTENTIAL DBD DONOR A person w hose clinical condition is suspected to fulfill brain death criteria. ELIGIBLE DBD DONOR A medically suitable person who has been declared dead based on neurologic criteria as stipulated by the law of the relevant jurisdiction. Critical pathways for organ donation * POSSIBLE DECEASED ORGAN DONOR A patient with a devastating brain injury or lesion <ul><li>Reasons why a potential donor </li></ul><ul><li>does not become a utilized donor </li></ul><ul><li>System </li></ul><ul><li>Failure to identify/refer a potential or eligible donor </li></ul><ul><li>Brain death diagnosis could not be confirmed </li></ul><ul><li>(e.g. does not fulfill criteria) or completed </li></ul><ul><li>(e.g. lack of technical resources or clinician to make diagnosis or perform confirmatory tests) </li></ul>Donation after BrainDeath ( DBD ) Treating physician to identify/refer a potential donor * The “dead donor rule” must be respected . That is, patients may only become donors after death, and the recovery of organs must not cause a donor’s death . <ul><li>ACTUAL DBD DONOR </li></ul><ul><li>A consented eligible donor: </li></ul><ul><li>In whom an operative incision was made with the intent of organ recovery for the purpose of transplantation. </li></ul><ul><li>and/or </li></ul><ul><li>From whom at least one organ was recovered for the purpose of transplantation. </li></ul>UTILIZED DBD DONOR An actual donor from whom at least one organ was transplanted. Donation after Circulatory Death ( DCD )
  3. 3. Cadaveric Organ Procurement Principles in Italy <ul><li>Dead Donor Rule and Consent </li></ul><ul><li>Death declaration in all Brain Dead Patients independently from possible donation </li></ul><ul><li>Each BD is referred and evaluated as Potential Donor </li></ul><ul><li>No Controlled NHB donors (yet) </li></ul>
  4. 4. Italian Regions – 2010 vs 2011 * preliminary data August 31, 2011 Declared BD p.m.p. 20 p.m.p. 80 p.m.p.
  5. 5. Veneto Region ICUs a confidential prospective study <ul><li>836 Deaths with ACL </li></ul><ul><li>64% Brain Death diagnosis </li></ul><ul><li>31% Legal BD declaration </li></ul>F Procaccio et al. Deaths with acute cerebral lesion in the Veneto Region. Minerva Anestesiol, 2001
  6. 6. Indicators : Potential of donation Brain Death declarations PROC 2 = ------------------ % Deaths with Acute Cerebral Lesions in ICU Benchmarking 50-65 %
  7. 7. <ul><li>Deaths with Cerebral Lesion 21090 </li></ul><ul><li>BD Declarations 8859 PROC 2 = 42% </li></ul><ul><li>(benchmarking 50-65%) </li></ul><ul><li>Missing 1000 “silent” BD per year </li></ul>F Procaccio, L Rizzato, A Ricci, S Venettoni, Nanni Costa Organs&Tissues&Cells, 2008 – Transplant Proc ,2010 Italian Registry of Deaths with Acute Cerebral Lesion in ICU
  8. 8. The “ silent ” Brain Death <ul><li>Inadequate treatment From autonomic “storm” to e arly circulatory arrest </li></ul><ul><li>Omitted diagnosis Brainstem reflexes & apnoea not tested </li></ul><ul><li>Critical diagnosis CBF tests not available or uncertain results </li></ul><ul><li>Omitted legal declaration </li></ul><ul><li>- Personal judgment of unsuitability </li></ul><ul><li>- Personal attitudes “ against ” BD </li></ul><ul><li>- Inadequate experience </li></ul><ul><li>- Organizative pitfalls </li></ul><ul><li>Withdrawal of life support before BD </li></ul><ul><li>- End-of-life ICU policy </li></ul>F Procaccio et al. Transplant Proc, 2010
  9. 10. Hypothesis of key factors for lost (silent) Brain Deaths <ul><li>AGE Pre-selection based on age </li></ul><ul><li>POLICY Deaths with Acute Cerebral Lesion occur out of the ICU </li></ul><ul><li>ICU ATTITUDE In some ICUs BD is omitted or not recognized </li></ul>
  10. 11. Utilized DBD Donors Age years Median Mean
  11. 12. Italian Registry – DACL in ICU Age Actual Donors Deaths with cerebral lesion Brain Deaths The “ silent ” BD vs Age F Procaccio et al. Transplant Proc, 2010
  12. 13. Deaths with ACL in ICU Age vs BD declaration vs Donors BD declared AGE DONORS
  13. 14. Prospective Veneto Region Study Oct 2010 - Jan 2011 – 39 Hospitals/ICUs 523 cases <ul><li>Deaths with ACL in ICU 162 (20 ICUs) </li></ul><ul><li>Median age 71 - Median Timing of death : 5 days </li></ul><ul><li>BD declared 33% </li></ul><ul><li>Deaths with ACL out of ICU 361 (31 Hosp) </li></ul><ul><li>Median age 83 - Median Timing of death : 7 days 50% Ischemic Stroke – 25% < 75 years old </li></ul>DACL: Total 350 p.m.p. - 110 p.m.p. in ICU (73% Neuro ICUs) Procaccio, Munari, Frigo et al. 2011
  14. 15. Deaths with ACL In ICU vs BD Declaration 391 DLCA 128 BDs 33% range 17/22 ( 77 %) 26/50 ( 52 %) 7/50 ( 14 %) Deaths With Acute Cerebral Lesion 4 ICUS around 50 5 ICUs 20-40 7 ICUs 1-10 16 ICUs Region x BD DACL DACL BD ICUs
  15. 16. GOAL 1 : Every death in ICU will lead to a timely decision regarding donation <ul><li>Barriers to Achieving Goals : </li></ul><ul><li>ICU physicians and nurses are not aware of the extent of the need for organs and the crucial role the ICU can play in meeting that need </li></ul><ul><li>ICU physicians and nurses do not see organ donation as part of their responsibility in caring for patients </li></ul><ul><li>ICU physicians are not familiar or comfortable with determining death </li></ul><ul><li>Limited ICU resources </li></ul>ICU Staff <ul><li>Donation as ICU mission </li></ul><ul><li>Awareness of ICU role </li></ul><ul><li>BD diagnosis skills </li></ul>
  16. 17. ICU DDC The ICU Donation Champions & the Deceased Donor Coordination Tx Hospital
  17. 18. 2010
  18. 19. en sciene & en route Aggressive treatment circulation ventilation ICP control Max treatment Organs Brain All they need is flow recovery Brain Death Organ Donor
  19. 20. Transplant Proc, 2010 As neurointensive treatment can improve outcomes and reduce “silent” BDs, more DBD donors exist where patients with acute cerebral lesion are better treated.
  20. 21. Do enhance ICU’s SKills & Motivation Research Recognition in organ donation