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Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
Rui  Maio   Portugal - Monday 28 - ICU and Organ Donation
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Rui Maio Portugal - Monday 28 - ICU and Organ Donation

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  • Let ’ s now look at some ancient history. In the Neolithic period – around 5000 BC, mean human life expectancy was only around 20. Although some individuals certainly lived into their 40s and even 50s infant, child and young adult mortality was very high – such that the mean age at death was only 20. It even declined a little during the Bronze Age around 2000 BC – farmers were exposed to animal-borne diseases and probably had inferior nutrition to Neolithic hunter-gatherers. By the time of the ancient Greek and Roman empires, mean life expectancy had risen to 28, but it is salutary to reflect on the implications of the fact that the average Roman woman had to have 4.4 babies to maintain a constant population of Roman citizens. There was only a slight improvement during the Middle Ages and even into late Victorian times mean life expectancy was still under 40 years. However, there have been spectacular changes in life expectancy in the last century, most of them pre-dating the technological advances in medicine in the late 20 th century.
  • The aging of the population and the trends toward overeating and a more sedentary lifestyle (which lead to a dramatic increase in obeSinglety) are leading to an increase in the incidence and prevalence of type 2 diabetes. [Passa, p.S5] Reference 1. Passa P. Diabetes trends in Europe. Diabetes Metab Res Rev. 2002;18:S3-S8. Passa, p.S5
  • :
  • We conclude that the mortality rate is high in neurocritical patients and around 21% die in brain death . LTE is applied in 25% of neurocritical cases. The majority of families accept doctors recommendation regarding LTE . Donation information is received in 81% of brain death and 16% of other deaths
  • But what do they get instead ? What fraction of all deaths take place in the ICU ? In NZ it is 5%, Malcolm tells me that it is 10% in NSW and US data vary widely by state between 10 and 25%. Dying is increasingly being managed as a negotiated business transaction between legally designated surrogates and health-care service providers. Although this modus operandi is American, it is surely metastasising across the Pacific, more rapidly I think into Australia than New Zealand.
  • Transcript

    • 1. Quality indicators in ICU and organ donation Rui Maio MD, PhD, CETC, FEBS ETCO Past-President 2011 Organ Donation Congress Buenos Aires, November 2011
    • 2.
      • Close cooperation between intensivists and TC ’s is the cornerstone of the donation/ transplantation process
      • Progressive changes in the profile and background of the professionals involved in transplant coordination
      • Initially most TC came from surgery and nephrology
      • In recent years – more healthcare professionals (doctors and nurses) with experience and activity in ICU’ s and emergency areas
      Intensivists and Transplant Coordinators
    • 3.
      • All steps of the donation process have to be managed in the ICU :
        • Donor detection
        • Death diagnosis
        • Viability evaluation
        • Approach to the family and support
        • Donor treatment
      • Cooperation between ICU staff and TC’s :
        • Increase the number of donors
        • Increase the number of organ per donor
        • Improve the quality of the organs
      WHY THE INVOLVEMENT OF THE INTENSIVIST IN ORGAN DONATION?
    • 4. WHO recomendation
    • 5. OVER THE NEXT YEARS, WE WILL SEE STRIKING CHANGES IN HEALTH CARE
      • POPULATION IS GETTING OLDER
    • 6. AVERAGE HUMAN LIFE EXPECTANCY (WEIGHTED MEAN AGE AT DEATH) New stone age Bronze age Classical Greece and Rome 2000 Medieval Britain 1880 1920 1940 5000 BC 2000 BC 1000 AD 0 (S. Streat)
    • 7. OVER THE NEXT YEARS, WE WILL ASSIST TO STRIKING CHANGES IN HEALTH CARE
      • POPULATION IS GETTING OLDER
      • POPULATION IS GETTING SICKER
    • 8. TYPE II DIABETES IN EUROPE (Adapted from Passa P. Diabetes Metab Res Rev . 2002;18:S3-S8)
    • 9. OVER THE NEXT YEARS, WE WILL ASSIST TO STRIKING CHANGES IN HEALTH CARE
      • POPULATION IS GETTING OLDER
      • THE POPULATION IS GETTING SICKER
      • HEALTH CARE FACILITIES AND THEIR USE ARE CHANGING
    • 10. ACUTE CARE BEDS (OECD, France)
    • 11. DEATHS IN THE HOSPITAL (OECD, Portugal)
    • 12. 2000 UCI HOSPITAL HOSPITAL MORE DEMAND FOR INTENSIVE CARE SERVICES
    • 13. ARE WE PREPARED TO FACE THESE CHALLENGES?
    • 14.
      • These are critically ill, unstable patients in need of intensive treatment and monitoring that cannot be provided outside of the ICU.
      • Usually, these treatments include ventilator support, continuous vasoactive drug infusions, etc.
      • Priority 1 patients generally have no limits placed on the extent of therapy they are to receive.
      • Examples of these patients may include postoperative or acute respiratory failure patients requiring mechanical ventilatory support, and shock or hemodynamically unstable patients
      ICU ADMISSION PRIORITY 1 (Guidelines for ICU admission, Discharge, and Triage Task Force of the ACCCM/SCCM, 1999)
    • 15.
      • These patients require intensive monitoring and may potentially need immediate intervention .
      • No therapeutic limits are generally stipulated for these patients.
      • Examples include patients with chronic co-morbid conditions who develop acute severe medical or surgical illness.
      ICU ADMISSION PRIORITY 2 (Guidelines for ICU admission, Discharge, and Triage Task Force of the ACCCM/SCCM, 1999)
    • 16.
      • These unstable patients are critically ill but have a reduced likelihood of recovery because of underlying disease or nature of their acute illness.
      • Priority 3 patients may receive intensive treatment to relieve acute illness, however, limits on therapeutic efforts may be set, such as no intubation or cardiopulmonary resuscitation.
      • Examples include patients with metastatic malignancy complicated by infection, cardiac tamponade, or airway obstruction.
      ICU ADMISSION PRIORITY 3 (Guidelines for ICU admission, Discharge, and Triage Task Force of the ACCCM/SCCM, 1999)
    • 17.
      • These are patients who are generally not appropriate for ICU admission.
      • Admission of these patients should be on an individual basis, under unusual circumstances, and at the discretion of the ICU Director. These patients can be placed in the following categories:
        • A. Little or no anticipated benefit from ICU care based on low risk of active intervention that could not safely be administered in a non-ICU setting ( too well to benefit from ICU care ).
        • Examples include patients with peripheral vascular surgery, hemodynamically stable diabetic, ketoacidosis, mild congestive heart failure, conscious drug overdose, etc.
      ICU ADMISSION PRIORITY 4 (Guidelines for ICU admission, Discharge, and Triage Task Force of the ACCCM/SCCM, 1999)
    • 18.
      • B. Patients with terminal and irreversible illness facing imminent death ( too sick to benefit from ICU care ).
      • For example: severe irreversible brain damage, irreversible multiorgan system failure, metastatic cancer unresponsive to chemotherapy and/or radiation therapy (unless the patient is on a specific treatment protocol), patients with decision-making capacity who decline intensive care and/or invasive monitoring and who receive comfort care only, brain-dead non-organ donors, patients in a persistent vegetative state, patients who are permanently unconscious, etc.
      ICU ADMISSION PRIORITY 4 (Guidelines for ICU admission, Discharge, and Triage Task Force of the ACCCM/SCCM, 1999) AND ABOUT PATIENTS WITH BRAIN DEATH DIAGNOSED OR ANTECIPATED?
    • 19. T. Pont , J. Gener, E. Oliver, M. Bodí, M. Badia, J.Mestre, E. Muñoz, X. Esquirol, P. López, N. Masnou, S. Quintana, R. Deulofeu. Working Group of Catalan Transplant Organization. Barcelona. Spain The Impact of Neurocritical Patients ’ Evolution on Organ Donation. A Multicentric Study in Catalonia, Spain. Preliminary Results
    • 20. Objectives
      • To analyse the evolution of patients with Critical Neurological Disease (CND), defined by a Glasgow Coma Score ≤ 8 and in particular to detect possible losses of organ donors.
      • To determine whether all families of potential organ and/or tissue donors have been informed about the opportunity of donation.
      • To Know the number of cases of CND to which Limitation of therapeutic effort (LTE) is applied.
      • To analyse the effects of LTE on organ donation.
    • 21. Results ( October-December 09)
    • 22. Types of Limitation Therapeutic Effort (LTE)
          • N=71
    • 23. Conclusions
      • Patient mortality with GSC≤8 is high (48%).
      • Deceased in BD 21% of Critical Neurological Disease (CND). 60% become organ donors.
      • LTE is applied to 25% of CND. Non-admittance to ICUs is main LTE.
      • Families accept doctors ’ proposals regarding LET (81%).
      • Donation is not sufficiently considered in End-of-Life decisions.
    • 24.  
    • 25.  
    • 26.  
    • 27.  
    • 28. END OF LIFE care includes organ donation
      • How can we increase the interactions between intensive care medicine and organ transplantation organizations?
      • How can we reimburse the ICUs for the work involved in organ harvesting?
      • Finding the best balance between the treatment of a patient as a potential organ donor and a potential survivor.
    • 29. “ ...they still have my body on the ventilator! ” ANY POSSIBLE DECEASED ORGAN DONOR A patient with a devastating brain injury or lesion OR a patient with circulatory failure AND apparently medically suitable for organ donation Potential donor Start donor treatment Contact the Transplant Coordinator Organ donation is a quality indicator in Intensive Care Medicine
    • 30. “ Teamwork is the ability to work together toward a common vision. It is the fuel that allows common people to attain uncommon results.” Andrew Carnegie ICU staff and Donor Coordinators Thank you

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