Collaborative working - Organ Donation

organdonation.nhs.uk
  • No tags were found...

Collaborative working - Organ Donation

John DarkNewcastle UniversityFreeman Hospital1st National Donation Congress


John DarkNewcastle UniversityFreeman Hospital1st National Donation Congress


ADULT HEART TRANSPLANT RECIPIENTS:Cause of Death (Deaths: January 1992 - June 2008)CAUSE OF DEATH0-30 Days(N = 3,531)31 Days1 Year(N = 3,513)>1 Year3 Years(N = 2,716)>3 Years5 Years(N = 2,356)>5 Years10 Years(N = 5,335 )>10 Years(N = 3,677)CARDIAC ALLOGRAFTVASCULOPATHY62 (1.8%) 163 (4.6%) 383 (14.1%) 369 (15.7%) 767 (14.4%) 520 (14.1%)ACUTE REJECTION 227 (6.4%) 427 (12.2%) 274 (10.1%) 104 (4.4%) 88 (1.6%) 33 (0.9%)LYMPHOMA 1 (0.0%) 66 (1.9%) 93 (3.4%) 103 (4.4%) 246 (4.6%) 145 (3.9%)MALIGNANCY, OTHER 4 (0.1%) 78 (2.2%) 301 (11.1%) 440 (18.7%) 999 (18.7%) 690 (18.8%)CMV 4 (0.1%) 43 (1.2%) 17 (0.6%) 4 (0.2%) 6 (0.1%) 1 (0.0%)INFECTION, NON-CMV 458 (13.0%) 1,066 (30.3%) 343 (12.6%) 229 (9.7%) 570 (10.7%) 361 (9.8%)GRAFT FAILURE 1,452 (41.1%) 626 (17.8%) 636 (23.4%) 473 (20.1%) 965 (18.1%) 609 (16.6%)TECHNICAL 253 (7.2%) 38 (1.1%) 19 (0.7%) 17 (0.7%) 41 (0.8%) 33 (0.9%)OTHER 209 (5.9%) 303 (8.6%) 272 (10.0%) 220 (9.3%) 531 (10.0%) 364 (9.9%)MULTIPLE ORGANFAILURE451 (12.8%) 386 (11.0%) 135 (5.0%) 122 (5.2%) 369 (6.9%) 293 (8.0%)RENAL FAILURE 23 (0.7%) 34 (1.0%) 43 (1.6%) 86 (3.7%) 309 (5.8%) 308 (8.4%)PULMONARY 150 (4.2%) 137 (3.9%) 105 (3.9%) 112 (4.8%) 218 (4.1%) 165 (4.5%)CEREBROVASCULAR 237 (6.7%) 146 (4.2%) 95 (3.5%) 77 (3.3%) 226 (4.2%) 155 (4.2%)ISHLT 1st National 2009 Donation Congress


ADULT HEART TRANSPLANT RECIPIENTS:Cause of Death (Deaths: January 1992 - June 2008)CAUSE OF DEATH0-30 Days(N = 3,531)31 Days1 Year(N = 3,513)>1 Year3 Years(N = 2,716)>3 Years5 Years(N = 2,356)>5 Years10 Years(N = 5,335 )>10 Years(N = 3,677)CARDIAC ALLOGRAFTVASCULOPATHY62 (1.8%) 163 (4.6%) 383 (14.1%) 369 (15.7%) 767 (14.4%) 520 (14.1%)ACUTE REJECTION 227 (6.4%) 427 (12.2%) 274 (10.1%) 104 (4.4%) 88 (1.6%) 33 (0.9%)LYMPHOMA 1 (0.0%) 66 (1.9%) 93 (3.4%) 103 (4.4%) 246 (4.6%) 145 (3.9%)MALIGNANCY, OTHER 4 (0.1%) 78 (2.2%) 301 (11.1%) 440 (18.7%) 999 (18.7%) 690 (18.8%)CMV 4 (0.1%) 43 (1.2%) 17 (0.6%) 4 (0.2%) 6 (0.1%) 1 (0.0%)INFECTION, NON-CMV 458 (13.0%) 1,066 (30.3%) 343 (12.6%) 229 (9.7%) 570 (10.7%) 361 (9.8%)GRAFT FAILURE 1,452 (41.1%) 626 (17.8%) 636 (23.4%) 473 (20.1%) 965 (18.1%) 609 (16.6%)TECHNICAL 253 (7.2%) 38 (1.1%) 19 (0.7%) 17 (0.7%) 41 (0.8%) 33 (0.9%)OTHER 209 (5.9%) 303 (8.6%) 272 (10.0%) 220 (9.3%) 531 (10.0%) 364 (9.9%)MULTIPLE ORGANFAILURE451 (12.8%) 386 (11.0%) 135 (5.0%) 122 (5.2%) 369 (6.9%) 293 (8.0%)RENAL FAILURE 23 (0.7%) 34 (1.0%) 43 (1.6%) 86 (3.7%) 309 (5.8%) 308 (8.4%)PULMONARY 150 (4.2%) 137 (3.9%) 105 (3.9%) 112 (4.8%) 218 (4.1%) 165 (4.5%)CEREBROVASCULAR 237 (6.7%) 146 (4.2%) 95 (3.5%) 77 (3.3%) 226 (4.2%) 155 (4.2%)ISHLT 1st National 2009 Donation Congress


Optimisation of Thoracic OrgansFor both Hearts and Lungs good donormanagement is an essential component toproducing more transplantsGood donor management is of benefit to alltransplanted organsMore donors may not translate to moreTransplants1st National Donation Congress


1st National Donation Congress


shift from a cerebral protectivestrategy to a peripheral organprotective strategyDouble role of the lung and heartto protect and to be protected1st National Donation Congress


OPTIMAL CARDIO-PULMONARYMANAGEMENTWHITE FACEorgans for donationto be optimally treatedJanus mythDARK FACEto guaranteeOptimal perfusionOptimal oxygenationOptimal pHto peripheral organs1st National Donation Congress


Optimisation of Thoracic OrgansTHE HEART IS DIFFERENTPRIMARY NON-FUNCTION IS OFTEN FATAL• COMMONEST CAUSE OF EARLY DEATHOTHER DONOR ORGANS DEPENDENT ON THEHEART• “GOOD PERFUSION” MAY HAVE A PRICE• POTENTIAL SOURCE OF CONFLICT1st National Donation Congress


Optimisation of Thoracic OrgansReduced Activity due to:Changing Donor DemographicsInadequate Donor ManagementSicker RecipientsFaltering Enthusiasm1st National Donation Congress


Heart transplants* in the UK between 1995 and 2011(*Excludes heart/lung transplants but includes other multi organ)


Deceased donor lung transplants* in the UK between 1995 and 2011(*Includes heart/lung transplants and other multi organ)


Deceased solid organ donors in the UK, between 1995 and 2011


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Age of deceased donors in the UK, 1 April 2001 - 31 March 2011N= 745 777 770 751 764 793 809 899959 1010


ADULT HEART TRANSPLANTS (1/1995Risk Factors for 1 Year MortalityDonor Age(1/1995-6/2001)1st National Donation Congress


Optimisation of Thoracic OrgansIncreasing Donor Age• Predictor for poor early and late outcomeIntra-Cranial Haemorrhage• Hypertension• LVH• Coronary DiseaseConflicts in Donor Management1st National Donation Congress


Optimisation of Thoracic OrgansNoradrenaline >0.1 mcg/Kg/Min• (>0.07 in Cambridge study) isdeleterious to recipient outcome• ATP Depletion• Amplified by ischaemia/reperfusion• Receptor downregulation1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic OrgansThe Heart DonorPre-existing existing diseaseMyocardial Dysfunction• Consequent on both brain-death insult andsubsequent inflammatory upregulation• Differential effects on each ventricle• Potentially worsened by managementPeripheral Vasodilatation1st National Donation Congress


Optimisation of Thoracic OrgansThe Heart DonorPre-existing existing diseaseMyocardial Dysfunction• Consequent on both brain-death insult andsubsequent inflammatory upregulation• Differential effects on each ventricle• Potentially worsened by managementPeripheral VasodilatationThis Cannot be disentangled bymeasuring blood pressure alone1st National Donation Congress


Optimisation of Thoracic OrgansConflicting and changing influences ofmyocardial dysfunction and vasculartone can only be resolved bymeasuring both flow and pressure1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic OrgansDonor ManagementInvasive Monitoring, Flowdirected manipulation,vasopressin rather thannoradrenalineMay transform substantialnumbers of “marginal” heartsShould be instituted at an earlystage1st National Donation Congress


Optimisation of Thoracic OrgansDonor ManagementInvasive Monitoring, Flowdirected manipulation,vasopressin rather thannoradrenalineMay transform substantialnumbers of “marginal” heartsShould be instituted at an earlystage• Not just with the retrieval team1st National Donation Congress


Optimisation of Thoracic OrgansDonor ManagementInvasive Monitoring, Flowdirected manipulation,vasopressin rather thannoradrenalineMay transform substantialnumbers of “marginal” heartsShould be instituted at an earlystage• Not just with the retrieval team1st National Donation CongressBenefits all organs


Beneficial Donor ManagementRecipient36 Year old Male, DCMInotrope Dependent180cm, 80 Kg, Group OChronic upper abdominal sinus excludedVAD1st National Donation Congress


Beneficial Donor ManagementDonor24 year old male, 180 cm, 84 Kg, OHanging victim, asystolic when found20 minute paramedic resus, prolongeddowntime1st National Donation Congress


Beneficial Donor ManagementDonor24 year old male, 180 cm, 84 Kg, OHanging victim, asystolic when found20 minute paramedic resus, prolongeddowntimeBP 100/70, HR 123, CVP 21• Noradrenaline “44 ampoules in 50 at13 ml/min”(0.25 mcg/Kg/min)1st National Donation Congress


PA CatheterBeneficial Donor Management19.00CVP 4PACWP 2MAP 82HR 123SVR 1385CI 2.120.20CVP 8PACWP 7MAP 79HR 113SVR 573CI 4.71st National Donation Congress


Beneficial Donor ManagementPA Catheter placed by retrieval team19.00CVP 4PACWP 2MAP 82HR 123SVR 1385CI 2.120.20CVP 8PACWP 7MAP 79HR 113SVR 573CI 4.7Norad Off1st National Donation Congress


Trends in reasons for non-acceptance of DBD donor heartsN 233 286 233 249 260 251 281Percentage (%)100%90%80%70%60%50%40%30%20%10%0%1513 13 15 1421195 5945944811 7 12 1421513 1515 15202924 20232727453738 393030242004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011Poor function Organ unsuitable - clinical Donor unsuitable- non medicalDonor unsuitable - medical Donor age Other1st National Donation Congress


100%Use of Swan-Ganz catheterisation for DBD hearts notaccepted due to poor functionN 57 85 86 113 99 99 8480%4960%100 100758867 6540%20%0%492133 35112 4 12004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/20111st National Donation CongressSwan-Ganz inserterd Swan-Ganz use not reported Swan-Ganz not inserted


Availability of ECHO for DBD hearts not accepted due to poorfunction100%N 57 85 86 113 99 99 8480%27 274430 3160%100 100 4516410 1240%20%28585260 570%2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 2009/2010 2010/2011ECHO performed ECHO use not reported ECHO not performed1st National Donation Congress


Optimisation of Thoracic OrgansFlow Directed ManagementSome advantages of PACatheter• Accurate CVP• LV Preload1st National Donation Congress


Thoracic Transplant Centres in the UK


Optimisation of Thoracic OrgansFlow Directed ManagementSome advantages of PACatheterCardiac Retrieval Teams haverelevant skills, time andavailability1st National Donation Congress


Optimisation of Thoracic OrgansFlow Directed ManagementSome advantages of PACatheterCardiac Retrieval Teams haverelevant skills, time andavailabilityIncreasingly will come to donorhospital at early stage1st National Donation Congress


Optimisation of Thoracic OrgansFlow Directed ManagementSome advantages of PACatheterCardiac Retrieval Teams haverelevant skills, time andavailabilityIncreasingly will come to donorhospital at early stageOf Benefit to all donated organs1st National Donation Congress


1st National Donation Congress


White face: lungs to be protectedP


dark face: lungs to protect organs1st National Donation Congress


Optimisation of Thoracic OrgansAdjuncts to Cardiac AssessmentPA CatheterEchoCoronary Angiography1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs1st National Donation Congress


Optimisation of Thoracic Organs“Do not be dissuaded by resultsfrom echo – the science doesnot support you”1st National Donation Congress


Optimisation of Thoracic OrgansLeft Ventricular HypertrophyBest assessed by EchoPredictor of poor outcome1st National Donation Congress


Outcome in Cardiac Recipients of Donor Hearts With Increased Left t Ventricular WallThicknessAmerican Journal of TransplantationVolume 7, Issue 10, pages 2388-2395, 31 AUG 2007 DOI: 10.1111/j.1600-6143.2007.01930.x1st National Donation Congresshttp://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2007.01930.x/full#f1


Optimisation of Thoracic OrgansAdjuncts to Cardiac AssessmentPA CatheterEchoCoronary Angiography1st National Donation Congress


Optimisation of Thoracic OrgansCoronary AngiographyWidely practised in USA and EuropeMay obviate fruitless assessmentand retrievalDifferentiates palpable from luminaldisease1st National Donation Congress


Optimisation of Thoracic OrgansCoronary AngiographyWidely practised in USA and EuropeMay obviate fruitless assessmentand retrievalDifferentiates palpable from luminaldisease1st National Donation Congress


FIGURE 1.Impact of Donor-TransmittedAtherosclerosis on Early CardiacAllograft Vasculopathy: NewFindings by Three-DimensionalIntravascular Ultrasound Analysis.Yamasaki, Masao; Sakurai, Ryota;Hirohata, Atsushi; Honda, Yasuhiro;Bonneau, Heidi; Luikart, Helen;Yock, Paul; Fitzgerald, Peter; Yeung,Alan; Valantine, Hannah; Fearon,WilliamTransplantation. 91(12):1406-1411,June 27, 2011.DOI:10.1097/TP.0b013e31821ab91bFIGURE 1. Typical IVUS images ofthe donor-transmittedatherosclerosis with maximumintimal thickness >=0.5 mm (left),and nonatherosclerotic coronaryartery with maximum intimalthickness


1st National Donation Congress


Donor screening angiogram of a 55-year-old graft revealed a 75% proximal LAD stenosis.Grauhan O et al. Eur J Cardiothorac Surg2007;32:634-6381st National Donation Congress© 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rightsreserved.


Coronary angiogram 22 months after transplantation with occluded LAD stent and patentvenous graft to LAD: a 64-year-old donor heart with good left ventricular function but atrialfibrillation; screening angiography showed a significant proximal stenosis in the left anteriordescending coronary artery and a significant lesion in a small circumflex artery with adominant right coronary artery.Grauhan O et al. Eur J Cardiothorac Surg 2007;32:634-6381st National Donation Congress© 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rightsreserved.


Optimisation of Thoracic OrgansCoronary AngiographyWidely practised in USA and EuropeMay obviate fruitless assessment andretrievalDifferentiates palpable from luminaldiseaseUS and EU experience is that it results inmore hearts used for transplantShould become an aim in UK1st National Donation Congress


Optimisation of Thoracic OrgansCoronary AngiographyWidely practised in USA and EuropeMay obviate fruitless assessment andretrievalDifferentiates palpable from luminaldiseaseUS and EU experience is that it results inmore hearts used for transplantShould become an aim in UK1st National Donation Congress


Heart transplants* in the UK between 1995 and 2011(*Excludes heart/lung transplants but includes other multi organ)

More magazines by this user
Similar magazines