Surveillance for donor-derived infections in Australia.

BACKGROUND: Systems for quality and safety assurance in organ donation and transplantation are vital, especially those that seek to minimize donor disease transmission. Australia has developed a national vigilance and surveillance system to identify, review, and analyze actual and potential donor-derived infections and other disease transmissions. METHODS: The system involves notification of incidents to the Australian Organ and Tissue Authority for review by a Vigilance and Surveillance Expert Advisory Committee (VSEAC). The VSEAC grades incidents, O makes recommendations, and issues communications both publicly and to the clinical donation and transplant sector. RESULTS: Annual notifications have increased since the inception of the system in 2012 until 2022. The vast majority relate to procedural aspects including donor assessment, information/data issues, and the recovery, offer, allocation, preservation and transportation of organs. Possible donor-derived disease accounted for 19% of all notifications, and those related to possible donor-derived infection only 12%. The VSEAC, as a result of reviewing these incidents, has made recommendations resulting in revisions to donor screening, organ allocation, packaging and transportation. The review of incidents has led to changes in clinical guidance for increased viral risk donor assessment, testing, and ensuing organ utilization and recipient surveillance. Guidance has also been reviewed for other infectious risks including strongyloides, human T-lymphotropic virus, and HEV. CONCLUSION: The Australian vigilance and surveillance system has enabled national retrospective reporting and evaluation of serious adverse events or reactions to identify trends and inform processes and guidelines, therefore improving the safety of donation and transplantation.

Hormonal Therapy in Organ Donors.

Optimal supportive treatment of brain dead potential organ donors maximizes donation and transplant outcomes. Brain death is associated with activation of inflammatory pathways and loss of autoregulatory brain functions that may include hypothalamic-pituitary dysfunction. As well as general supportive care, specific treatment to counter the common sequelae of brain death such as hypotension, hypothermia, and diabetes insipidus is required. In addition, the provision of specific hormonal therapy (thyroid hormone, vasopressin, and steroids) has been proposed but is controversial due to lack of high level evidence to support its efficacy.

A pilot assessment of the FloTrac cardiac output monitoring system.

OBJECTIVE: To compare measurement of cardiac output (CO) by means of the FloTrac CO monitor with the pulmonary artery catheter (PAC). DESIGN: Prospective observational study. SETTING: Intensive care unit of a tertiary hospital. PATIENTS: Six post-operative cardiac surgery patients with existing arterial cannulas and PACs. INTERVENTIONS: Attachment of the FloTrac CO monitor and transducer to an existing arterial cannula. Simultaneous measurements of CO, indexed to body surface area (cardiac index, CI) by the FloTrac CO monitor and by either a bolus thermodilution or continuous CO PAC. Statistical analysis of observations. MEASUREMENTS AND RESULTS: We performed CO measurements in six patients every 1-4 h after cardiac surgery. Comparison of all measurements showed a limited correlation for CI with the two devices (r (2)=0.1218, bias=0.21, 95% limits of agreement -0.81, 1.23). CI measurements obtained with the intermittent bolus PAC had better correlation with the FloTrac CI values (r (2) = 0.2693, bias=-0.0057, 95% limits of agreement -1.2042, 1.1929) than did those obtained with the continuous CO PAC (r (2)=0.0557, bias=0.2436, 95% limits of agreement -0.7350, 1.2222). When analysed according to heart rhythm, CI values measured during atrial pacing showed the best correlation (r (2)=0.377, bias=-0.0244, 95% limits of agreement -0.5226, 0.5714). CONCLUSIONS: CO measurements obtained using the FloTrac CO monitor show a limited correlation with those acquired using the PAC, relatively wide limits of agreement but no clear bias. Further evaluation is required before this device can be recommended for use in the clinical setting.

Identifying the potential organ donor: an audit of hospital deaths.

OBJECTIVE: To quantify the potential for organ donation in Victoria and identify missed opportunities for organ donation. DESIGN AND SETTING: Prospective medical record audit of all deaths in 12 Victorian hospitals. MEASUREMENTS: Data on deaths, total potential donors, organ donors and outcome of requests for organ donation were collected. Patients in whom brain death was confirmed or likely to occur and in whom organ donation was not requested (unrealised potential donors) were classified by an independent panel. Rates of organ donation and unrealised donors were determined as a proportion of total potential donors and hospital deaths and the maximal potential organ donor rate was estimated. RESULTS: Of 5551 deaths, there were 112 potential donors, with 66 requests for organ donation resulting in 39 consents (consent rate of 59%) and 37 organ donors (33% of total potential donors; 0.7% of hospital deaths). Two consented potential donors did not donate due to failed physiological support (5%). There were 46 medically suitable unrealised potential donors; 3 with confirmed brain death. Approximately half of these patients had treatment withdrawn in the intensive care unit and half in the Emergency Department. The estimated maximal potential donor rate was 30 per million population. CONCLUSIONS: The potential for organ donation in Victoria is relatively low compared with previous estimates in Australia and overseas. An increase in the organ donation rate may be possible through increasing consent and the identification and support of potential donors. This would require substantial changes in clinical practice that have resource and ethical implications.