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Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
Francesco Procaccio Italy  -  Monday 28 -  ICU and Organ Donation
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Francesco Procaccio Italy - Monday 28 - ICU and Organ Donation

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  • 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. 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. 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. Italian Regions – 2010 vs 2011 * preliminary data August 31, 2011 Declared BD p.m.p. 20 p.m.p. 80 p.m.p.
  • 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. Indicators : Potential of donation Brain Death declarations PROC 2 = ------------------ % Deaths with Acute Cerebral Lesions in ICU Benchmarking 50-65 %
  • 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. 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>
  • 11. Utilized DBD Donors Age years Median Mean
  • 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
  • 13. Deaths with ACL in ICU Age vs BD declaration vs Donors BD declared AGE DONORS
  • 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
  • 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
  • 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>
  • 17. ICU DDC The ICU Donation Champions & the Deceased Donor Coordination Tx Hospital
  • 18. 2010
  • 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
  • 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.
  • 21. Do enhance ICU’s SKills & Motivation Research Recognition in organ donation

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