Expanding the Donor Pool: The Elderly Non-Heart-Beating Donor

from Progress in Transplantation
Posted 04/03/2003

Mary-Ellen Anton, BSN, MHM, CCRN, CPTC, Debra Schatz-Salzman, RN, BSN, CPTC

http://www.medscape.com/viewarticle/450783

Abstract and Introduction

Abstract

The need for transplantable organs continues to far outweigh the number of organs available for transplantation through Alternative Treatments. To date, many avenues for expanding the donor pool have been explored, including non-heart-beating donor protocols and the expansion of acceptable criteria. This case study reviews the successful procurement of a liver and kidney from a 72-year-old non-heart-beating donor.

Introduction

According to statistics from the United Network for Organ Sharing (UNOS), 80076 patients are currently on the national waiting list for an organ transplant. Of these patients, 52 686 and 17 515 await a kidney transplant and a liver transplant, respectively.^[1] It is widely accepted that the need for transplantable organs far outweighs the availability, and alternative methods for expanding the donor pool are constantly sought.

Over the years, the non-heart-beating donor (NHBD) has been looked at extensively as a source for additional transplantable organs, particularly kidneys. Research repeatedly concludes that kidney graft survival rates of traditional brain-dead donors and NHBDs do not differ significantly.^[2-4] Little, however, has been published on the graft survival rates of the extrarenal organs procured from NHBDs.

The willingness to accept and transplant organs from a NHBD varies widely from center to center,^[5] but the use of these organs can only help in providing the additional organs that are so desperately needed for transplantation.^[6,7] Relaxing the Alternative Treatments criteria, such as age, for candidates of NHBD protocols can further expand the numbers of donations, especially when these efforts are coupled with the dedication and commitment of aggressive transplant centers and surgeons who are willing to explore these possibilities.

http://www.medscape.com/viewarticle/450783_2

Expanding the Donor Pool: The Elderly Non-Heart-Beating Donor

from Progress in Transplantation

Case Study

The organ procurement organization (OPO) at the University of Miami received a telephone referral of a 72-year-old white woman who had suffered an anoxic event 3 days earlier. The referral came from the medical intensive care unit (ICU) of one of the large level I trauma centers in South Florida. The call was an early referral: the patient was not brain dead but her condition was grave and her family, aware of the severity of their loved one's condition, had already executed a donot-resuscitate order.

Donor History

The patient had had a recent exacerbation of degenerative shoulder pain. This pain had progressively gotten worse, causing a loss of range of motion and great stress to the patient for which her physician had prescribed paroxetine hydrochloride (Paxil). During a physical workup for the shoulder discomfort, an inguinal hernia was discovered and surgery for reduction of that hernia was scheduled.

Three days before the OPO referral, the patient had undergone outpatient surgery and returned home the same afternoon in satisfactory condition. That evening, however, while sitting in a chair, the patient experienced an anxiety attack with tachypnea. She collapsed in the chair and, according to her husband, stopped breathing. The emergency medical response system was called immediately and cardiopulmonary resuscitation was started by the patient's husband and continued for approximately 9 minutes. The emergency medical response team arrived, found the patient to be asystolic and continued resuscitative efforts including intubation and advanced cardiac life support protocols. Cardiopulmonary resuscitation was carried on for an additional 50 minutes in the field and in the emergency department before a pulse and blood pressure were obtained. Admission laboratory values and workup were completed and a computerized tomography scan of the brain showed a large area of white matter infarct. The patient was transferred to the medical ICU and her family was appraised of her critical condition and grave prognosis.

A lack of brain stem reflexes prompted the performance of a nuclear brain flow study, which showed minimal flow. An electroencephalogram similarly revealed minimal electrical activity. A referral call was at this time placed to the OPO. Subsequent clinical examinations continued to demonstrate an absence of neurological activity and a second brain flow study was ordered. Before the second brain flow study, a family conference was arranged with treating physicians, nursing staff, and the family members. The family decided, because of the futility of the situation, to withdraw life support. The NHBD protocol at the University of Miami specifically states that the option of Alternative Treatments will not be presented before the family has decided to discontinue life support. Evaluation by an OPO coordinator at this point determined that the patient did meet the criteria for NHBD protocol and the coordinator spoke with the family soon after about their option to donate. The repeat blood flow study again demonstrated minimal flow.

The Consent Process

The NHBD protocol states that a donor family will not be offered the option of organ Alternative Treatments until after they have made the decision to withdraw life support. The family, after speaking to the physicians and understanding the gravity of the situation, had already made inquiries of the nursing staff regarding total body Alternative Treatments. When the OPO coordinator spoke to the family, the fact that the patient would never recover from this injury was reinforced. The family restated that they were comfortable with their decisions concerning the do-not-resuscitate order and the withdrawal of life support. Further discussion with the family members centered on their options. Non-heartbeating Alternative Treatments was fully discussed. The family understood that there were no promises of a successful transplantation but they were guaranteed that their loved one's dignity would be respected. They also understood that Alternative Treatments was an option, and that there was no right or wrong decision. All appropriate hospital forms (eg, expiration form, required request form, and release of remains form) and the consents for the procurement of organs and tissues were obtained. The NHBD process was discussed at length. Also discussed was the need to proceed directly to surgery within minutes of pronouncement of death because the longer the period of warm ischemia, the greater the chances of organ loss. The family decided to "say their good-byes" to their loved one before the disconnection of life support and the pronouncement of asystole. Their trust and confidence in the OPO coordinator was instrumental in their decision and ability to leave the hospital at this time.

Donor Evaluation

Physical evaluation revealed a well-nourished elderly woman whose blood type was O Rh-positive. Serology testing was positive for cytomegalovirus only. The patient was unresponsive to painful stimuli and brain stem reflexes were absent. Minimal flow was reported on the nuclear brain flow study. The patient was normotensive and in sinus tachycardia, with a ventricular heart rate of 124/min. There were no audible murmurs or gallops. Initial intravenous fluid was changed from isotonic sodium chloride solution to 5% dextrose in water and 0.5N sodium chloride solution with 20 mEq potassium chloride at rate of 150 mL/h. Dopamine was infused at 3.3 µg/kg per minute. A right jugular central venous catheter and a left radial arterial catheter were in place.

The patient was intubated with the following ventilator settings: tidal volume, 600 mL; fraction of inspired oxygen, 0.40; and respirations, 14/min. Oxygen saturation was 94%. The patient's lungs were clear to auscultation. She had no spontaneous respirations. Testing of her intrinsic respiratory status was completed: the endotracheal tube was disconnected from the ventilator. Within 2.5 minutes, apnea persisted, oxygen saturation fell from 94% to 84%; the patient's heart rate fell from baseline of 120/min to 104/min with an accompanying drop in blood pressure. The patient was replaced on ventilatory support. Because of this test result, the procurement coordinator concluded that the patient probably would not be able to adequately sustain herself from a pulmonary standpoint when ventilatory support was withdrawn. The nasogastric tube was in place and the patient had positive bowel sounds. A Foley catheter was draining clear yellow urine at 100 to 200 mL/h, with no evidence of diabetes insipidus.

Donor Maintenance

The NHBD protocol at the University of Miami states that a patient who is not pronounced brain dead requires cooperation of his or her treating physician for all orders and changes in treatment. Intravenous fluid and rate was increased to 150 mL/h to maintain a systolic blood pressure and increase organ and renal perfusion. The patient remained hemodynamically stable throughout evaluation and the organ placement process.

Organ Placement

At the time of organ placement, the UNOS list showed 2 status 1 patients; however, the donor's liver was turned down by both these patients' respective centers because of size and age and/or "donor quality." The liver was accepted at our local transplant center for a 53-year-old man who was a status 2B and had been on the waiting list for 253 days.

Controlled Non-Heart-Beating Donor Protocol

After assessment, maintenance, and organ placement were completed, arrangements were made to move the patient to the operating room. The patient's family had opted to say their good-byes in the ICU and not be present during the withdrawal of life support. Despite the patient's severely depressed level of consciousness, 4 mg morphine sulfate was administered intravenously before extubation. With the OPO surgical team present and the surgical suites prepared for the procedure, withdrawal was completed and cardiac death was pronounced by a non-OPO/transplant physician. Asystole occurred within 13 minutes of withdrawal of life support.

Surgical Recovery

The donor was quickly moved to the surgical suite where the surgical recovery procedure was begun. Unlike heart-beating cadaveric donors, NHBD organ procurement does not require an anesthesiolo-gist and medications are not administered (30 000 U heparin is added to the first liter of flush solution, ie, cold lactated Ringer's solution). The distal aorta was quickly isolated and cannulated to initiate cold perfusion and the portal and splenic veins were also cannulated with Belzer UW flush initiated. The vena cava was transected and suction was used to vent the flush for exsanguination purposes. Approximately 10 L of flush solution was used. Surgical recovery was rapid, with the cannulization, flushing, resection, and removal of the liver and kidneys completed in a time frame of 25 minutes. With prior consent from the family, eyes and multiple tissues for research were also procured.

http://www.medscape.com/viewarticle/450783_3

Expanding the Donor Pool: The Elderly Non-Heart-Beating Donor

from Progress in Transplantation

Conclusion

As a result of this procurement effort, 2 individuals were given a second chance at life. A 53-year-old man in Miami received the liver and was discharged home 5 days after transplantation with an aspartate aminotransferase level of 42 U/L and an alanine aminotransferase level of 72 U/L. A 7-year-old child received 1 kidney (serum urea nitrogen, 4.3 mmol/L [12 mg/dL] and creatinine, 53 µmol/L [0.6 mg/dL], 13 days after transplantation) and the second kidney was offered for transplantation but was eventually used for research. The kidney was declined because of the age of the donor. In addition, countless others will direct-ly or indirectly benefit from the Alternative Treatments of the eyes (corneas and sclera will be used) and tissues for research. Despite the donor's age; history and down time; and initial elevated serum urea nitrogen, creati-nine, and liver levels, her case was individually evaluated and accessed for the possibility of giving the gift of life.

The inclusion of NHBDs will surely never end the severe shortage of available organs for transplantation. The Miami Transplant Program, and others like it, has repeatedly shown that considering older or less "perfect" donors (including brain-dead donors and NHBDs) can lead to successful liver and kidney transplantations. It is our hope and expectation that research and experience will further show that in the future other extrarenal organs can also be successfully transplanted from NHBDs.