Our Brain Death and Organ Donation Experience: Over 12 Years

Our Brain Death and Organ Donation Experience: Over 12 Years Bülent Atik, Gökhan Kılınç*, Abdullah Ömer Atsal, Fuat Çöken, and Volkan Yarar Atatürk City Hospital, Department of Anesthesiology and Reanimation, Balikesir, Turkey ABSTRACT Purpose. Nowadays, as the number of patients waiting for organ transplant is increasing, it is important to diagnose brain death in intensive care units and to provide good donor care. We aimed to share our experience of donor care with the diagnosis of brain death in our clinic. Material and method. One hundred and fifty-one patients diagnosed in our clinic with brain death between June 2006 to 2018 were studied retrospectively. Findings. The mean age of the 151 patients was 46.6 (1e89) years. Fifty-seven (37.7%) of the 151 patients’ families accepted donation. Ten out of 57 patients could not be organ donors for medical reasons. Eighty-four kidneys, 7 hearts, and 40 livers were transplanted to the patients. When the diagnosis at admission to the intensive care unit was examined, it was found that the most common diagnosis was intracranial hemorrhage (36.8%), followed by head trauma (21.05%), drowning in water (3.5%), and firearm injury (3.5%). The apnea test was applied to all cases, but 17 patients could not complete the apnea test. In order to support the diagnosis of brain death, in 63% of patients (n ¼ 95) radiological methods were performed. Cranial computed tomography angiography was performed as a radiological method. All cases were found to have received at least 1 inotropic support. We used dopamine in 41 patients, noradrenaline in 36 patients, dobutamine in 8 patients, and adrenaline in 3 patients. During the 12 months when the organ transplant coordinator was not on duty, there were no organ donors. It is important to maintain an organ and tissue transplant coordinator and an intensive care unit team for organ donation. Conclusion. In order to increase the cadaver donor pool, it is necessary to increase the number of brain death diagnoses and decrease the rate of family rejection. Therefore, patients with poor neurologic prognosis should be carefully monitored for brain death. Successful family discussions by an experienced and trained organ transplant coordinator should try to increase donation rates by emphasizing the importance of organ donation and the fact that brain death is a real death. O RGAN transplants are performed from live donors or cadavers. Cadavers are the most important resource for organ supply. Advances in transplantation and the The heart, pancreas, lung, small intestine, and cornea are only available from cadavers. Delays in early recognition of potential donors and brain death, and inadequate donor increasing number of patients waiting for transplantation make the transplantation of organs from cadavers very important [1]. Since donor resources are very limited, organ *Address correspondence to Gökhan Kılınç, Atatürk City transplants from cadavers are practiced in Turkey. On Hospital, Department of Anesthesiology and Reanimation, Gaz- November 3, 1975, the first kidney transplantation with a iosmanpaşa Mahallesi, 209 Sok No:26, 10100 Altieylül/Balikesir, donor kidney, was performed in Turkey, and on December Turkey. Tel: (þ90) 266 460 40 00; Fax: (þ90) 266 460 40 45. 8, 1988, the first liver transplant from a donor occurred. E-mail: [email protected] ª 2019 Elsevier Inc. All rights reserved. 0041-1345/19 230 Park Avenue, New York, NY 10169 https://doi.org/10.1016/j.transproceed.2019.01.148 Transplantation Proceedings, 51, 2183e2185 (2019) 2183 2184 ATIK, KıLıNÇ, ATSAL ET AL Table 1. Demographic and Clinical Treatment Data for the Donors Sex Inotrop Y Meanage M F Dopamine Dobutamine Noradrenaline Adrenaline 2006 – - - - - - - 2007 - - - - - - - 2008 3 1 - 1 - - - 2009 32.5 1 1 2 - - - 2010 - - - - - - - 2011 29 - 3 3 - 1 - 2012 54 7 1 8 1 - 1 2013 54.4 4 1 3 - 5 - 2014 27.5 2 5 2 - 2 - 2015 71.6 1 2 2 - 1 - 2016 40.8 5 2 5 2 6 - 2017 44 9 6 6 4 14 1 2018 53.8 6 5 9 1 7 2 Total 46.6 36 26 41 8 36 4 care are significant causes of donor source problems. Brain FINDINGS death is the irreversible loss of all activities of the brain, The demographic and clinical treatment data for the donors is brain stem, and cerebellum [2]. We use these criteria for shown in Table 1. The mean age of the 151 cases whose re- brain death: no response to stimuli, no spontaneous cords were examined was 46.6 (1e89). Fifty-seven (37.7%) of breathing or movement, absence of brain stem and spinal the 151 cases accepted family donations. Ten of 57 cases were reflexes, lack of drug use that suppresses the central ner- not included for medical reasons. From 47 cases, 84 kidneys, 7 vous system, absence of hypothermia (<32.2 C), and no hearts, and 40 livers were removed for transplantation. When change in test results after 24 hours (assessments of brain the diagnoses at admission to the intensive care unit were stem reflexes and the apnea test). A confirmatory test was examined, it was found that the most common diagnosis was used to assess brain circulation for cases diagnosed with intracranial hemorrhage (36.8%), followed by head trauma brain death, and, if this test was consistent with brain death, (21.05%), drowning in water (3.5%), and firearm injury no additional 24 hours were expected for the second (3.5%) (Fig 1). The apnea test was applied to all cases, but the neurologic examination. test could not be completed in all cases, because 17 patients could not tolerate apnea testing. The most common auxiliary MATERIAL AND METHOD test was computed tomography angiography (63%). All pa- tients received at least 1 inotropic support. Forty-one patients One hundred and fifty-one patients diagnosed with brain received dopamine support, 36 cases received noradrenaline death in our clinic between June 2006 to 2018 were studied support, 8 cases received dobutamine support, and 3 cases retrospectively. Demographic characteristics such as age, received adrenaline support (Table 1). No donor organs were sex, hospitalization and additional tests, family organ issued in 2010, when the organ transplant coordinator was not donation rate, donor rate, number of removed organs, and on duty. inotropic treatments were recorded. DISCUSSION In our study, patients, who were diagnosed with brain death between 2006 to 2018, were examined. A total of 151 cases of brain death were identified and the total number of do- nations was 57 (37.7%). According to the data of 2016 Spain had the highest rate of deceased organ donation among select OEDC countries with 43.8 people per million popu- lation. The rate in Turkey was 7.1 people per million [3]. Religious, cultural, and legal reasons; the lack of adequate infrastructure and resources are the main reasons behind the inability to use this lifesaving and life-improving treat- ment. When the hospitalization of the patients diagnosed with brain death was examined, trauma (21.05%) and intracranial hemorrhage (36.8%) were found to be the Fig 1. Cause of brain death. highest rate in our study as in similar studies [1e4]. In our BRAIN DEATH AND ORGAN DONATION EXPERIENCE 2185 Table 2. Brain Death and Number of Donors Per Year The most important issue with organ donation in Turkey is Brain death Organ Ratio Transplanted the death of patients without the diagnosis of brain death. The (n) donation (n) (%) Donated organs organs reason for not being diagnosed may be the lack of information 2006 2 0 0 0 0 or the hesitancy of physicians to diagnose brain death. In- 2007 8 0 0 0 0 ternational standardization has been achieved for the diag- 2008 11 1 9 2 kidneys 1 liver 2 kidneys nostic criteria of brain death. There is a need for an effective 1 heart 1 liver team to diagnose brain death. Many hospitals aim to advance 2009 17 2 11 4 kidneys 2 4 kidneys the diagnostic process effectively and quickly by means of livers 2 livers specially appointed coordinator. In the study of Kıraklı et al 2 hearts [7], when the families of organ donors were interviewed, 36% 2010 5 0 0 0 0 2011 5 3 60 6 kidneys 3 4 kidneys reported that they looked positive previously, while 64% livers 2 livers attributed this to the influence of the coordinator. Therefore, 3 hearts it is very important that organ transplant coordinators, who 2012 11 8 72 16 kidneys 12 kidneys will receive family approval, are trained and experienced. As 8 livers 7 livers the diagnosis of brain death increases, the number of poten- 8 hearts 1 heart tial organ donors will increase. 2013 13 5 38.4 10 kidneys 8 kidneys 5 livers 3 livers 5 hearts 1 heart CONCLUSION 2014 7 2 28.5 4 kidneys 2 4 kidneys livers 2 livers In order to increase the donor pool from cadavers, the 2 hearts detection of brain death should be increased, and the rate of 2015 12 3 25 6 kidneys 3 4kidneys family rejection should be reduced. Patients with poor livers 3 livers neurologic prognosis should be carefully monitored for brain 3 hearts 1 heart death. Successful family interviews by an experienced and 2016 14 7 50 14 kidneys 8 kidneys trained organ transplant coordinator emphasizes that brain 7 livers 4 livers 7 hearts 1 heart death is a real death, and the importance of organ donation 2017 31 15 48.3 30 kidneys 15 24 kidneys should be emphasized. Recognition and acknowledgment of livers 10 livers brain death should be 1 of the prioritized goals of raising 15 hearts 2 hearts awareness among health care professionals and the public 2018 15 11 73.3 22 kidneys 14 kidneys about the support and funding of organ donors to improve the 11 livers 6 livers number and quality of supporting bodies. 11 hearts 1 heart REFERENCES study, the mean age of cases with brain death was found to be 46.6, similar to other studies [4,5]. [1] Dosemeci L, Yilmaz M, Cengiz M, Dora B, Ramazanoglu A. In two different studies conducted in Turkey, the family Brain death and donor management in the intensive care unit: ex- periences over the last 3 years. 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