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Maximisation of heart and lung donation in a neurosurgical intensive care unit
Critical Care volume 11, Article number: P503 (2007)
The number of heart-beating donors in The Netherlands is decreasing. This decrease is only partially compensated for by an increase of nonheart-beating donations, resulting in an increasing shortage of donor organs, especially of donor hearts and lungs. In 2005 compared with 2004 the number of patients waiting for a donor heart increased from 38 to 50 (32%). In lung donation the increase was 37% (from 79 to 108). One approach to reduce this shortage is to maximize the number of organs per donor by optimisation of donor treatment in the ICU.
We investigated the possibilities for improvement of donor management in our ICU by a retrospective study in 37 heartbeating organ donors hospitalised in our ICU from 1993 to 2005. There was no protocol for the treatment of organ donors in our institution.
The heart was donated in 18 of 37 patients (49%). Lung donation was possible in only eight of 37 donors (22%). Most hearts and lungs were rejected for transplantation for valid reasons. In some patients there was room for improvement: in two of the three cases where hemodynamic instability impeded heart and lung donation (one dying from subarachnoidal bleeding and one from ischemic cerebral infarction), hemodynamic instability was closely associated with the moment of cerebral death. In three further patients heart donation was not carried out because of wall movement abnormality or electrocardiogram abnormalities. None of them had previous cardiac disease. All three had disturbances in cardiac rhythm closely related to the occurrence of cerebral death. Two of these three patients also developed neurogenic pulmonary edema. We speculate that in all five patients the instability leading to the decision not to perform heart and lung donation was caused by excessive sympathic stimulation at the time of cerebral death leading to impaired myocardial function and neurogenic pulmonary edema. These disturbances may be reversible within a few hours. Inotropic therapy, judicious fluid administration guided by close hemodynamic monitoring together with a trial of treatment with triple hormonal therapy (corticosteroid, vasopressin and thyroid hormone) might have improved cardiac and pulmonary function, rendering heart and lung donation possible.
On the basis of this retrospective study we conclude that donor management in our ICU can be improved. A management protocol with special attention for treatment of disturbance in cardiac and pulmonary function caused by sympathic overstimulation might considerably increase the amount of hearts and lungs donated, contributing to a decrease in organ shortage.
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Aerdts, S., Hofstra, J. Maximisation of heart and lung donation in a neurosurgical intensive care unit. Crit Care 11 (Suppl 2), P503 (2007). https://doi.org/10.1186/cc5663