Impact of Recruitment Maneuvers to Cover Adverse Effects of Donor Transfer.

OBJECTIVES: Our aim was to investigate the negative effects of transferring brain-dead donors to the intensive care unit on the ratio of PaO2 to inspired oxygen fraction and the benefits of recruitment maneuvers on its reversal. MATERIALS AND METHODS: In this randomized trial, we assigned 30 brain-dead donors to an intervention group and a control group. After transfer to the intensive care unit, donors in the intervention group received a lung recruitment maneuver according to protocol for 1 hour, whereas the control group did not receive this intervention. Arterial blood gas was drawn before transfer, immediately aftertransfer, and 3 hours after transfer. RESULTS: Before transfer to immediately after transfer, the PaO2-to-inspired oxygen fraction ratio decreased from 281.30 ± 100.33 to 225.03 ± 95.72 mm Hg (P < .01). At 3 hours aftertransfer,the PaO2-to-inspired oxygen fraction ratio in the intervention and control groups was 280.4 ± 120.4 and 213.4 ± 75.5 mm Hg (P = .017), respectively. The absolute difference in PaO2-to-inspired oxygen fraction ratio from before to 3 hours after transfer was -16.9 ± 44.1 and 51.8 ± 61.4 mm Hg (P < .001), in the intervention and control groups,respectively. Increasing central venous pressure and/or transfer time further potentiated the decrease ofthe PaO2-to-inspired oxygen fraction ratio. CONCLUSIONS: The PaO2-to-inspired oxygen fraction ratio decreased after transfer of brain-dead donors to the intensive care unit. This was partially reversible by standardized recruitment maneuvers.

Liver Procurement from Poisoned Donors: A Survival Study.

OBJECTIVES: Although transplant teams understand the effects of donor characteristics on liver transplant outcomes, few studies have investigated the quality of livers obtained from poisoned donors. The aim of this study was to compare livers procured from poisoned donors with a matched control group. MATERIALS AND METHODS: Liver transplant outcomes from poisoned donors and from donors with trauma-induced death (as the control group) were compared using data of an Organ Procurement Unit from 2000 to 2013. Procured livers were evaluated via histology findings before transplant. Recipient characteristics were assessed in both groups, and immediate and medium-term (up to 5 years after transplant) survival rates were compared with the use of Kaplan-Meier analyses and log-rank tests. RESULTS: Over a 13-year organ donation program, 1485 livers from brain dead patients were donated. Among them, 115 poisoned donors were evaluated for liver grafts; of these, 74 successful liver transplants were performed. In the poisoned donors, the incidence of reversed cardiac arrest was 54.1%. Likewise, acute kidney injury was detected in 14.9% of the patients, and 16.2% needed urgent dialysis either for clearance of the toxic agents or for treatment of acute kidney injury. No significant differences were observed in 1- to 5-year survival rates, and log-rank test also showed a significance level of 0.83. CONCLUSIONS: Proper case selection strategies can be implemented to expand the donor pool, including use of poisoned donors. Hence, poisoning is not a contra-indication for a referral, which could lead to decreased mortality for patients requiring a liver transplant.

Consequences of More Coordinator Engagement to Take Consent for Organ Donation: Comparisons of New Versus Experienced Staff.

OBJECTIVES: The method of obtaining family consent for organ donation after occurrence of brain death in Iran is an opt-in process. Because of complicated cultural, legal, religious, and familial structures in Iran, it is not simple to take consent for organ donation in brain death situations. The process needs the professional staff to be experienced and have an appropriate personality to obtain consent. MATERIALS AND METHODS: We previous used a limited number of experienced coordinators to take consent. We revised our decision 2 years ago because of lack of trained personnel. From the beginning of 2017, we have started training courses regarding approaching families for donations for all interested coordinators. After participants finished the theoretical and practical training, we allowed them to interview themselves to practice a first evaluation for a suitable potential donor. We have continued this strategy and have gathered feedback from participating coordinators. RESULTS: At the beginning of 2017, 9 coordinators who were previously qualified for handling other steps of organ donation were put into a compact training program to train for family interviews. In 2016, the experienced interviewers had a 88% success rate compared with a success rate of 83% in 2017 for inexperienced interviewers (P = .1). No significant differences were shown. Despite younger ages of donors obtained in 2017, median donated organs per donor decreased from 2.81 to 2.66. The average time interval between first contact with families and establishment of family consent was not significantly different between experienced and inexperienced coordinators (9.2 vs 8.7 h). CONCLUSIONS: Although with the new strategy we experiensed a decrease in the consent rate, we believe this strategy will have long-term beneficial effects for our organization and the decreased rate will be a temporary decline. Interviews showed that this strategy made our coordinators more motivated and responsible for their job. As a result, both volume and quality of organ procurement activities will be increased.

Reasons for Donor Lungs Unsuitability After Radiographic Selection.

OBJECTIVES: Deceased lung donation requires optimum donor care, with lung viability greatly affected by the progress of the disease leading to brain death. In this study, we searched for causes of lung unsuitability for transplant in both primary and secondary evaluations. MATERIALS AND METHODS: Primary lung evaluations included chest radiography, oxygen challenge test, and donor clinical and history examination. Secondary evaluations for lungs that passed the first step included fiberoptic bronchoscopy and donor-recipient matching. RESULTS: From 2012 to 2017, there were 1020 potential deceased organ donors in our center. Primary evaluations showed that the most prominent reason for lung donation unsuitability was low oxygen challenge result (n = 433, 42.5%). Other reasons were abnormal chest radiograph (n = 378, 38%), history of heavy smoking and inhaled drugs addiction (n = 112, 11%), prolonged intubation (n = 28, 2.7%), and lung disease history (n = 69, 6.7%). There were 104 (10.1%) potential donors to undergo fiberoptic bronchoscopy for further lung evaluation, with 47 (45.2%) selected for final lung donation. Five lungs (4.8%) with bronchoscopic confirmation for suitability were not retrieved due to lack of instruments and resources. Among the 57 (54.8%) rejected potential lung donations, the greatest factor impacting suitability was observation of purulent secretions in bronchoscopy (n = 24, 23%), evidence of aspiration (n = 10, 9.6%), infiltration (n = 7, 6.7%), and tracheitis. CONCLUSIONS: The most common cause of lung rejection after primary evaluation is observation of purulent secretions in tracheobronchial tree. Therefore, implementation of appropriate strategies to prevent respiratory infection in the intensive care unit is needed to expand the lung donor pool.

Failed Organ Donations After Transfer to an Organ Procurement Unit.

OBJECTIVES: In Iran, each medical university can have one organ procurement unit for its own hospital. If the family consents, all patients with brain death must be transferred to the organ procurement unit. When brain death is officially confirmed and the family gives the second consent, the organs are then retrieved in the operating room. MATERIALS AND METHODS: To minimize the number of "failed donations" (and to reduce their related costs), we studied 685 patients with brain death who were transferred to the Masih Daneshvari Organ Procurement Unit (Tehran, Iran) from 2016 to 2018 in terms of their outcomes. Of these, 623 led to (at least one) organ donation, whereas the remaining 62 had different causes for unsuccessful organ retrieval and donation. RESULTS: Two causes (not officially confirmed and family withdrawal) were responsible for 4 failed donations (0.5%). We focused on the remaining 58 cases, which had principally medical grounds for unsuccessful organ retrieval and donation. These were further subcategorized into 3 groups: expired, unacceptable laboratory results, and exclusion in the operating room. We compared these groups versus the successful donation group in terms of average age, male-to-female ratio, average body mass index, pace of brain death occurrence, and days of hospitalization. Results showed that age, body mass index, and cause of brain death are important predictive factors in differentiating successful and failed donations, whereas sex and days of hospitalization are not so decisive. CONCLUSIONS: Special precautions must be considered before transfer of brain dead donors who are overweight, are of older age, and have nonhemorrhagic causes of brain death. Stricter criteria are needed to control psychologic and financial burdens of failed transfers of deceased donors to the organ procurement unit.

Demographic Differences Between Two 7-Year Periods of Organ Donation in Iran: A Single-Center Experience.

OBJECTIVES: Donor characteristics can directly affect transplant outcomes. In this study, we examined donor patterns in an organ procurement unit, which covered one-third of the population in Tehran, Iran over the past 12 years (2005 to 2018). MATERIALS AND METHODS: Demographic data of donors, including sex, age, cause of death, blood group, outcome of donation, number of organs per donor, and comorbidities (including diabetes mellitus and hypertension), were assessed. RESULTS: Our analyses included 1848 deceased donors from 2005 to 2018; of these, 649 were female donors (35.11%), and mean age was 37.11 years old. During the study period, donor age significantly increased. The number of pediatric donors under 15 years old decreased from 11.11% to 7.44%, whereas the number of donors under 5 years old significantly increased during the later period. Cause of death shifted to cerebral hemorrhage rather than trauma. We observed a significant increase in donors with diabetes mellitus and hypertension. In the early study period, 16% of the donors had these comorbidities; however, in the later period, 31% of the donors had at least 1 risk factor, including diabetes mellitus or hypertension. Number of organs per donor was steady over the study period. CONCLUSION: Because donors with brain death are the only source for heart, lung, and liver transplants, it is necessary to determine weak points to reduce lost transplant opportunities.

Liver Donation From Marginal Donors: To Donate or Not to Donate?

OBJECTIVES: Livers from deceased donors compose nearly 30% of all organ transplants, and about 700 liver transplants are carried out per year. Marginal livers (extended-criteria donors), however, are not usually accepted by recipient teams, and there is only one center for these procedures in Iran. The final decision is made according to criteria that are much more conservative than other globally accepted ones. MATERIALS AND METHODS: To find significant differences and construct an algorithm to predict the future of marginal livers (before transfer of donors to our organ procurement unit), successfully donated and unsuccessfully donated livers divided into 2 age groups were compared in terms of age, sex, body mass index, liver function tests, significant medical disorders, and preretrieval liver sonography report. RESULTS: In the first age group (50-59 years old), there were 88 successful donors and 27 unsuccessful cases (due to 3 reasons: positive virology tests, death before retrieval, and ruled out by surgeons in the operating room). In the second age group (? 60 years old), there were 45 successful donors and 11 unsuccessful cases. The results showed that there were no differences between successful and unsuccessful cases regarding age and liver sonography results; however, sex, body mass index, liver function tests, and previous medical disorder were different between groups. Donors in both age groups were mostly male (60% and 73%); however, surprisingly, most unsuccessful cases were female (56.6% and 57%). Donors had generally lower body mass index (2 numerical difference), better liver function tests, and less risk factors (heart disease, diabetes mellitus, fatty liver, and chronic alcohol consumption). CONCLUSIONS: Before transfer of marginal liver donors to the organ procurement unit for further evaluation and organ retrieval, one must consider that age is just a number and the presence of other comorbidities can have more decisive roles on liver quality.

Role of Methylprednisolone in the Management of Hemodynamically Unstable Brain-Dead Cases.

OBJECTIVES: Optimal care of potential donors can lead to successful transplantation. Hemodynamic instability is a common complication in deceased potential donors. The most common underlying causes are hormonal and electrolyte disturbances as well as a hyperinflammatory state, which is rooted in activation of the cytokine cascade. In this study, our aim was to evaluate the efficacy of methylprednisolone injection, an agent introduced for inflammation suppression to achieve more stability in cases of hemodynamic disturbances. MATERIALS AND METHODS: This study covered the period from April 2016 to June 2017 and included 45 randomly selected hemodynamically unstable brain-dead cases (mean arterial pressure < 60 mm Hg). For these cases, primary management included trying to achieve stability; however, after many hours, we experienced hemodynamic instability again. Because of no other correctable methods, we decided to use methylprednisolone injection. The potential deceased donors received a total of 1 g methylprednisolone in two 500-mg divided doses after transfer to the organ procurement unit. RESULTS: Of 45 patients, 26 were male (58%), and the mean age of patients was 33 years. The most common causes of brain death were trauma (33%) and cerebrovascular accident (22%). Systolic and diastolic blood pressures increased significantly after methylprednisolone use. We observed no significant dif ferences in pulse rate. In addition, methylprednisolone could correct pH from 7.33 ± 0.11 to 7.38 ± 0.12 (P = .007). CONCLUSIONS: Use of methylprednisolone in hemodynamically unstable deceased donors could allow better management of these cases. Because there are various factors such as infusion of vasopressor drugs or fluid therapy that could affect the hemodynamic status of these cases, future studies with larger sample sizes are recommended to control these confounding factors.

Virology Tests in Brain-Dead Donors: Let the Bills Run Up?

OBJECTIVES: In the organ donation process, screening for serologic markers for a selection of agents is essential to prevent infection transmission. The screening of donors for specific potential infections can never absolutely exclude the risk of transmission. For reevaluation of serology tests, we analyzed results of tests requested for all brain-dead donors. MATERIALS AND METHODS: Our study included all actual brain-dead donors who were seen from January 2017 to February 2018, received ancillary tests, and had final confirmation of brain death at our organ procurement unit. RESULTS: Most candidates for organ and tissue donation were seronegative for intended agents. We found that 14.4% of the samples were suspicious for infectious and needed further evaluation; 12.2% of donors had positive results corresponding to hepatitis B, and only 1.9% were rejected from donation. Requisiteness to DNA detection for hepatitis B virus infection was mainly related to age over 50 years. CONCLUSIONS: The process of donor screening must systemically assess the donor. At the final stage, essential biomarkers must be investigated. Application of more caution in evaluation of older donors, including more screening tests before transfer to the operating room, remains mandatory.

Causes of Deceased Donors Loss before Organ Retrieval.

BACKGROUND: When potential brain dead donors are in line-up for organ retrieval, their loss would be such a disaster. The aim of this study was to detect the occurrence of different disorders leading to pre-retrieval donor's cardiac arrest and loss in order to prevent this energy and money wasting challenge. MATERIALS AND METHODS: In this observational study, medical records of potential donors from 2001 to 2016 who were lost after transfer to Organ Procurement Unit (OPU) of Masih Daneshvari Hospital and before organ donation were reviewed and weigh of every responsible disorder was tested. Equal number of actual organ donors were randomly selected others for comparison. RESULTS: In 14 years of experience in organ donation, 46 (3.09%) out of 1485 potential donors were lost after their transfer to OPU with the aim of organ donation. Mean age of donors and their gender were not significantly different to actual donors (37.4 ± 17.7 versus 39.2 ± 18.4, P= 0.2). However, proportion of drug toxicity as the cause of brain death was more common in the lost donors (19.5 versus 5.3%, P= 0.001). Thirteen (28.2%) of the cases had a documented history of ischemic heart disease, which was not as common in actual donors. After excluding hypotension and diabetes insipidus, more incident disorders among the lost donors were metabolic acidosis, hypocalcaemia, hyperglycemia, thrombocytopenia, severe anemia and different presentations of coagulopathy. Clinical conditions of 47.8% of cases were flared up by different severities of acute kidney injury and mean ALT levels were significantly higher than actual donors. All the above mentioned disorders were significantly more common in lost donors than actual ones. CONCLUSION: Drug toxicity, history of ischemic heart disease and occurrence of acute kidney injury are associated with more potential donors' loss before organ retrieval.

Impact of a Full-Time Donor Management Protocol on Donors' Liver Biopsy Findings: Progress to Date.

OBJECTIVES: This study investigated a fixed coordinator-directed donor management strategy's impact on donated liver quality, as determined by definitive biopsy results. MATERIALS AND METHODS: We collected donated liver biopsy results from donations both before and after implementing a fixed coordinator-directed donor management strategy. This strategy involved full-time attendance by a donor coordinator and continued resuscitation of brain-dead donors. All donations took place in a single organ procurement unit. We also followed up results of biopsies from the Liver Transplantation Center database of Namazi Hospital in Shiraz, Iran. RESULTS: We compared biopsy findings of 192 livers donated from 2012 to 2013 (group A) with 276 livers donated from 2015 until August 2016 (group B). Data analysis showed that 67 livers (34.9%) in group A were rejected for transplant owing to severe steatosis in 17 (8.9%), moderate/severe fibrosis in 9 (4.7%), moderate/severe necrosis in 28 (14.6%), and 13 (6.8%) rejected for other pathologies. Among group B livers, 59 (21.4%) were not deemed suitable for transplant owing to severe steatosis in 37 (13.5%), moderate/severe fibrosis in 6 (2.1%), and moderate/ severe necrosis in 16 (5.7%). Overall, steatosis was found in 94 livers (49.2%) in group A versus 175 livers (63.3%) in group B (P = .007). Donor age in group A averaged 36.5 years versus 47.9 years in group B (P = .02). Necrosis was found in 33 livers (17.2%) in group A and 22 livers (7.9%) in group B (P = .008). One-month survival rates were 95.3% and 96.3% for groups A and B (P = .08). CONCLUSIONS: Donated liver disqualification before transplant noticeably decreased despite the shift in demographic patterns from 2012 to 2016. In group A, brain-dead liver donors were younger and more often died from trauma, whereas group B donors had more cerebrovascular accident-induced deaths. This achievement took place alongside increased rates of steatosis and decreased rates of necrosis.

Role of More Active Identification of Brain-Dead Cases in Increasing Organ Donation.

OBJECTIVES: Organ donor shortage is a worldwide problem, resulting in 10% to 30% mortality rates for patients on wait lists for organ transplant. For brain-dead patients in Iran, it is mandatory for intensive care unit patients with Glasgow Coma Scale below 5/15 to be reported to an organ procurement unit. However, this process has not been functioning effectively. Here, we present the effects of changing the strategies on detecting brain-dead cases on the organ donor pool. MATERIALS AND METHODS: From March 2015 to March 2016, we changed our strategy in active detection of brain-dead cases. Since March 2015, our newly established protocol for active detection of brain-dead cases includes the following changes: (1) instead of calling high-volume intensive care units 3 times per week, we switched to calling every day in the morning; (2) instead of calling low-volume intensive care units 1 time per week, we switched to calling 3 times per week; (3) we included intensive care units (cardiac and general), neurosurgery, and emergency departments, as well as nursing supervisor offices, in our call and visit lists; and (4) we increased visits to wards by our trained staff as inspectors. RESULTS: From March 2015 to March 2016, the number of reported suspected brain-dead cases has increased from 224 to 460 per year, with proven brain death increasing from 180 to 306 cases. The actual number of donors has also increased, from 116 to 165 donations (53% increase) over 1 year. CONCLUSIONS: More proactive strategies have had significant effects on brain-dead detection, resulting in significantly increased donor pools and organ donations. In countries with low cooperation of hospital staff, more proactive engagement in detecting brain-dead cases is a good solution to prevent loss of potential organ donors, with a final result of decreasing wait list mortality.

Pathology Results at Autopsy in Brain-Dead Patients with Brain Tumors.

OBJECTIVES: Brain tumors are the most challenging causes of brain deaths due to the lack of pathology results in many cases. It is not uncommon to find a brain tumor in a brain-dead patient with no pathology results or neuroradiology reports available; this would exclude the deceased from organ donation. The mortality that occurs while patients are on transplant wait lists motivated us to find a solution to prevent losing brain-dead patients as potential donors. We present our experiences in autopsy examinations of brain tumors and the results of frozen-section pathology. MATERIALS AND METHODS: We performed autopsy examinations of 8 brain-dead patients who were suspected of having highly malignant brain tumors and in whom there were no pathology or radiology reports available. The autopsy process began at the conclusion of organ retrieval. First, we performed a complete brain dissection; the tumor was then removed with its adjacent brain tissue and sent for examination by an expert pathologist. Organ transplant was deferred until the pathology examination was completed. RESULTS: Organ transplant was cancelled if the frozen sections revealed a high-grade tumor. For all other results, the transplant was performed. If a medulloblastoma was confirmed, only the heart was transplanted. The duration of the delay for pathologic examination was 30 to 45 minutes. A total of 21 organs were donated that would otherwise have been rejected. CONCLUSIONS: It is worth performing an autopsy and frozen-section pathology examination to prevent losing potential organs from donors with brain tumors who are suspected of having a high-grade neoplasm but have no pathology or neuroradiology reports. This process is simple and has the potential to save lives.

A piece of broken metal from intubation stylet retained in tracheobronchial tree: a case report.

Intubation stylets are still being used in many medical centers for difficult intubations. Although very rare, it may break inside the trachea during endotracheal intubation despite routine pre-assessments by anesthesiologists and may surprisingly move deep into the tracheobronchial tree. In this case report, we describe a rare complication after stylet or guide-wire intubation in a patient in whom, a broken piece of metal guide remained in his tracheobronchial tree for 3 days. A 62 year-old man was admitted to our hospital with the chief complaint of functional class 3 dyspnea. The patient was a known case of chronic obstructive pulmonary disease (COPD) from 3 years ago with a history of heavy smoking (40 p/y) and oral opioid usage. We report a case with an unrecognized broken piece of stylet in his trachea and left main bronchus, which was later detected by CT scan and extracted before causing pressure rise symptoms in the airway. Despite precise evaluation before use, signs of breakage in the stylet may be missed and consequently, it may break inside the trachea and result in serious complications. It is strongly recommended that the anesthesiologists pay attention to the sounds and movements of the instruments. This article also briefly reviews the most serious reported complications due to stylet breakage.