By

Dr Omar Hj Sulaiman

National Transplant Resource Centre (NTRC) HKL/HSA

Increasing Donor Pool in Malaysia:

What ICU can offer?

Cold Spring Harb Perspect Med. 2013 Jun;

3(6): a014985.

doi: 10.1101/cshperspect.a014985

PMCID: PMC3662355

Why Is Organ Transplantation Clinically

Important?

Josep M. Grinyó

Solid organ transplantations save lives in

patients affected by terminal organ failures

and improve quality of life. Organ

transplantations have gradually ameliorated in

the last two decades and usually provide

excellent results in children and young adults,

and are increasingly challenged by the growing

proportion of elderly transplant patients with

comorbidities

Organ & Tissue Donation in Malaysia

0

10

20

30

40

50

60

70

80

2010 2011 2012 2013 2014 2015 2016 2017

Donation rate p.m.p

No. of donor

Organ Supply versus Organ Demand

(2017)

End stage organ failure

21,612

Organ Transplanted (Cadaveric)

35

How to overcome the demand…..??

Organ

Donation

Cadaveric

Brain Death

(BD)

Cardiac Death (DCD)

Living

Part of liver/kidney

The organ donation & transplant

process

• Education

• Media Public

Awareness

• Identification

• Family Discussion & Consent

Donation

• Retrieval

• Transplant & Post Transplant Care

Procurement

&

Transplant

ICU

…….supplier

ICU

Intensive

&

Continuous Mx

Cardiac Death

(DCD)

Brain

Death

(DBD)

What ICU can offer?????

• Triage

• End of Life Care

Admission

• Drs & Nurses

• Brain Death

• Organ Donation

Awareness • Donation After

Cardiac Death

• DCD

End of Life Care

What ICU can offer…….1st. Offer

ICU Management Protocol No 1

Admission, Discharge Criteria & Triage

Reversible medical condition

Reasonable prospect of substantial recovery

C. Neurological

Severe head trauma

Brain dead/potential

Pt who’s are generally NOT appropriate for

ICU admission

1. Irreversible brain damage

2. Brain dead non-organ donor

660 668

0.002

Identification & early

referral to ICU if suspected brain dead

Elective non-therapeutic ventilation

(ENTV)

“ End of Life Care”

Elective-Non-Therapeutic Ventilation (ENTV)

1990 ~ Royal Devon & Exeter Hospital in UK ~ protocol ~ increased donor rate of 14.6 donors pmp

~ ethical issue

2003 ~ approval of the Care Ethics Committee, Gregorio Maranon Hospital Madrid (pioneer) with proper protocol

2003 - 2005 : 30% of all organ donors

2013 ~ USA and most European Countries ~ 20-30%

“Organ Donation and Elective Ventilation : A Necessary Strategy”

Doleres Escurado et. Al

Biomedical Research International ;2017

Ethical issues

Is it appropriate to admit a potential

donor from ED into the last ICU bed? Dr Jonathan Thompson , Consultant Intensivist, UH of Leicester NHS Trust

8th May 2014

• Can treatment be prolonged in order to give retrieval team time to get to the donating hospital?

Non-Heart Beating

Donation

• Is it right to admit someone to ICU, knowing that they will die, just to get their organs?

Transfer from Emergency

Department

• Is it fair to stabilize someone’s condition , simply to be dx DCD

Donor

Stabilization

What ICU can offer……2nd. Offer

Brain Death

Non-Heart Beating

(DCD)

“End of Life Care”

American Journal of Transplantation

The Influence of End‐of‐Life Care on Organ Donor Potential

M. Witjes A. Kotsopoulos I.H.F. Herold L. Otterspoor K.S. Simons J. van Vliet M. de Blauw B.

Festen J.J.A. Eijkenboom N.E. Jansen J.G. van der Hoeven W.F. Abdo

First published: 29 March 2017

Many patients with acute devastating brain injury die outside intensive care units and could go

unrecognized as potential organ donors. We conducted a prospective observational study in

seven hospitals in the Netherlands to define the number of unrecognized potential organ donors

outside intensive care units, and to identify the effect that end‐of‐life care has on organ

donor potential. Records of all patients who died between January 2013 and March 2014 were

reviewed. Patients were included if they died within 72 h after hospital admission outside the

intensive care unit due to devastating brain injury, and fulfilled the criteria for organ donation.

Physicians of included patients were interviewed using a standardized questionnaire regarding

logistics and medical decisions related to end‐of‐life care. Of the 5170 patients screened, we found 72

additional potential organ donors outside intensive care units. Initiation of end‐of‐life care in acute

settings and lack of knowledge and experience in organ donation practices outside intensive care units

can result in under‐recognition of potential donors equivalent to 11–34% of the total pool of organ

donors. Collaboration with the intensive care unit and adjusting the end‐of‐life path in these patients

is required to increase the likelihood of organ donation

Critical Care Med 2014;40 2595-2560 Families : “Something good has come

from our loss”

Intensivists & ICU Nurses : “Helping a patient become an organ donor would

improve End of Life Care”

Is consideration of Organ Donation

practice in End of Life Care?

The Maastrict Categories of DCD DonorsCategory Description Where ?

I Dead on arrival(Uncontrolled)

Spain , France , Italy

IIUnsuccessful resuscitation

(Uncontrolled) Spain , France, Italy

III Awaiting cardiac arrest(Controlled)

“End of Life Care”

Japan, Belgium, United Kingdom, Netherlands,

Australia, USA, New Zealand

IVCardiac arrest while brain

dead(Uncontrolled)

VCardiac arrest in a hospital inpatient

(Uncontrolled)

VI Euthanasia(Controlled)

Netherlands

What is Donation After Cardiac Death

(DCD)?

Guidelines/Protocol

OTA

“Australia National Protocol for DCD 2010”

“End of Life Care”

Or

Withdrawal Therapy

(Total)

Death :

Immobility

Apnoea

Absence of skin perfusion & circulation

Not fulfill Brain Death Criteria

“..if death does not occur within 60/90 minutes…

…DCD process ceases & EOL care continues….

What ICU can offer...3rd. offer

Organ Donation

Intensivists ICU

Nurses

Intensive Care Medicine & Organ

Donation Dr Manuel Alonso (Spain)

• 85% of all transplant coordinators are intensivists

• Directly responsible or identifying potential donors & donor maintenance

Dr Ian Ball Kingston (Canada)

• Head of Organ Donation Program in Kingston GH Toronto

• 2008 as pioneer in Canada for DCD ~ increase donation rate 30%

• 2014 ~ research on Organ Donation & End of Life Care

Dr Raghavan Murugan (USA)

• ICU Director & Head of Critical Care Medicine UPMC

• Initiate DCD & Communication Skill in Breaking Bad News

• Intensivist -Led Mx of Brain-Dead Donors: Intensivist as Transplant Coordinator Is a Must……

……in Malaysia, Intensivists as

Transplant Coordinator….

Dr Azmin

Huda Dr Premala

Indian J Crit Care Med. 2016 Oct; 20(10): 593–596.

Organ donation after brain death in India: A trained intensivist is the key to success

Vijayanand Palaniswamy, Suganya Sadhasivam,1 Cibi Selvakumaran,2 Priyadharsan Jayabal,2 and S.

R. Ananth3

Abstract

Organ donation after brain death in India is gaining momentum but only in a few states. Tamil Nadu

is leading in the country in this regard. Certain cities have performed well compared to Chennai's

results. A single tertiary hospital performed 28 donations in a 17 months period with a

team of an intensivist and a transplant coordinator. An intensivist needs training and

interest in this noble cause. There is no formal training program in this noble cause for doctors in

India. A structured formal training needs to be introduced and made mandatory for the doctors in

intensive care to make this donation process a successful program.

Indian J Urol. 2016 Jul-Sep; 32(3): 178–185.

The development and current status of Intensive Care Unit management of prospective

organ donors

Margaret Kathleen Menzel Ellis, Mitchell Brett Sally,1 and Darren Malinoski

Introduction:

Despite continuous advances in transplant medicine, there is a persistent worldwide shortage of organs

available for donation. There is a growing body of research that supports that optimal management of

deceased organ donors in Intensive Care Unit can substantially increase the availability of organs for

transplant and improve outcomes in transplant recipients.

Results:

In addition to overall adherence to catastrophic brain injury guidelines, optimization of physiologic

state in accordance with established donor management goals (DMGs), and establishment of

system-wide processes for ensuring early referral to organ procurement organizations (OPOs),

several specific critical care management strategies have been associated with improved rates

and outcomes of renal transplantation from deceased donors. These include vasoactive medication

selection, maintenance of euvolemia, avoidance of hydroxyethyl starch, glycemic

control, targeted temperature management, and blood transfusions if indicated.

Conclusions:

Management of deceased organ donors should focus first on maintaining adequate perfusion to all

organ systems through adherence to standard critical care guidelines, early referral to OPOs,

and family support. Furthermore, several specific DMGs and strategies have been recently shown to

improve both the rates and outcomes of organ transplantation.

American Journal of Transplantation

Intensivist‐Led Management of Brain‐Dead Donors Is

Associated with an Increase in Organ Recovery for

Transplantation

K. Singbartl R. Murugan A. M. Kaynar D. W. Crippen S. A. Tisherman

K. Shutterly S. A. Stuart R. Simmons J. M. Darby

First published: 30 March 2011

June 11, 2018

EJRC Article Review

Improving organ donation in ICU:

What can make a difference?

•The Spanish experience , with 40 donors and more than 100 transplant procedures per

million inhabitants in 2015, their success comes from a specific organisational approach,

which includes promoting the identification and early referral of possible organ

donors before they even enter the intensive care unit; considering elective non-

therapeutic intensive care and incorporating the routine option of organ donation

into end-of-life care. Each of the three strategies in this approach require ICU teams to

question their habits and to integrate organ donation into all stages of their

practice.

• Oczkowski and his team (3), identified 15 documents from which 12 recent and active

related to organ donation in the ICU, including 6 protocols, two policies, two order sets

and two unclassified documents. Four major themes emerged: 1) the organ donation

process in ICU, 2) quality of care and collaboration, 3) patient and family-centred care,

and 4) the role of the institution. There was no identified target for “success” in organ

donation. Collaboration and quality of care, as well as patient and family supports and

engagement, were particularly highlighted, revealing that the need to protect and offer

support to potentially vulnerable families was seriously taken into account.

12 months after ODST in UPMC 2009

Characteristic Without

Intensivist

With Intensivist

(as Transplant

Coordinator)

% of change

No. of donors 46 57 23.9

No. of organ

transplanted

84

138

64.3

Organs recovered

per donor

1.83

2.42

32.2

Standard criteria 2.67 3.55 33

Extended Criteria 1.18 1.76 49.1

Heart/Lung

Transplant

15 32 113.3

Kidney Transplant 44 72 63.6

Liver Transplant 24 32 33.3

Donation after

cardiac death

(DCD)

1.45

1.64

13.1

Organ Donation

A Dream of the Past

A Challenge for the Future

A Reality of the Present

Spanish Model

Spanish Model

SEMICYUC Recruit 50

intensivists per year

Organize Specific Organ Donation

Workshop

Team Network

Active & Direct participation

“Spanish Model”

What we have done……..

Increasing Donor Pool in Malaysia:

What ICU can offer?

ENTV

“End of Life Care”

Organ Donation

“A Gift of Life”

Transplant

Coordinator

Points to ponder….

As intensivist…

New frontiers :

DCD

ENTV

Gratitude to the donors & their

families

“Consolidate the commitment to

organ donation” “A Gift Of Life”