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Guidelines for

Organ Donation

National Organ Procurement Service Beaumont Hospital Dublin 9 Revised September 2011


2 GUIDELINES FOR ORGAN DONATION

Introduction The guidelines will hopefully enhance existing

The National Organ Procurement Centre for the Republic of Ireland is co-ordinated through Beaumont Hospital. The Co-ordinators provide a 24 hour on-call service to all hospitals around the country and are available at all times to facilitate the organ donation process. At present, the number of people awaiting transplantation greatly exceeds the number of organs available for transplant. This trend continues as the waiting lists continue to increase.

Deceased Donors vs Transplant vs Waiting List Patients in Ireland 1998 – 2010 (Organ Procurement Centre)

practice in identifying potential donors. It is very important that potential donors are identified and that every family is offered the opportunity to consider organ donation. These guidelines aim to provide information and support for healthcare professionals to ensure that families are approached about organ donation in a sensitive manner and at an appropriate time by skilled and experienced personnel. The guidelines will hopefully enhance existing practice in identifying potential donors and optimising the management of the organ donor to ensure organs remain viable for transplant.

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GUIDELINES FOR ORGAN DONATION 3

Contact details The Organ Procurement Centre at Beaumont Hospital provides a 24-hour on-call service.

THERE IS A CO-ORDINATOR ON-CALL AT ALL TIMES. If you have any queries regarding organ donation you can call the Co-ordinator on-call, via Beaumont Hospital switchboard:

01-8093000. Switchboard (24hrs)

01-8093000 Office: Mon-Fri 07:30-1900

01-8093119/2848 01-8528399


4 GUIDELINES FOR ORGAN DONATION

Potential donor referral guidelines

Potential donor checklist can be helpful as information becomes available.

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Identify potential donor. Check suitability by contacting the Co-ordinator on-call through Beaumont Hospital switch on 01-8093000.

First set of Brain Stem Tests are completed.

Family agree to organ donation.

Contact Co-ordinators on call.

Bloods can be sent to Beaumont Hospital for tissue-typing and virology. (Specimen packs should be available on Unit).

Potential donor checklist can be helpful as information becomes available. (Also should be available on Unit).

A copy of the potential donor blood group to be faxed to the Co-ordinator on 01-7974870.

Second set of Brain Stem Tests are completed.

Ensure contact is made with coroner after second set of tests, if applicable.

Family wish to proceed to organ donation - Co-ordinator informed.

Co-ordinator to refer donor offer to multi-organ transplant centres.

Retrieval time organised by the Co-ordinator.

Family met by Co-ordinator and written consent obtained, if not already done.


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GUIDELINES FOR ORGAN DONATION 5

Identifying a Potential Donor Triggers to

ORGAN DONATION

Donation Pathway Donor detection

For Brain Stem Testing

Identification of all patients who may be potential donors Potential Donor

Donor Referral Referral of all potential donors to Organ Procurement Office (OPO) Known Cause of Coma

Glasgow Coma 3

Family care and Communication Sensitive communication and support for families of potential donors

Donor Maintenance Full Ventilation (No spontaneous respirations)

Pupils Fixed Dilated

Clinical management of potential donors

Organ Donation Optimal retrieval protocols


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Donor criteria All cases should be referred to the Organ Procurement Office (OPO) for discussion. The Co-ordinator in turn will refer on, to the individual centres, re suitability of each organ for transplant.

Organ Donor Criteria NO ABSOLUTE AGE LIMIT 1.

The patient has suffered irreversible brain damage and meets pre-conditions for Brain Stem Testing

2.

Brain stem death confirmed (“Diagnosis of brain death and medical management of organ donor” – Intensive Care Society of Ireland)

Contra-indications 1.

Current untreated Sepsis

2.

Malignancy (except biopsy proven primary brain tumour)

3.

Risk related positive virology

4.

Known IV drug abuse

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GUIDELINES FOR ORGAN DONATION 7

Organ Specific Criteria HEART ◆

< 60 years

No previous history of acquired or congenital heart disease

Acceptable Inotropic support

Normal ECG

Each case reviewed on an individual basis

LUNGS ◆

< 65 years

Clear chest radiograph

Accurate smoking history

No history of primary respiratory disease

No prior cardiopulmonary surgery

Acceptable inotropic support

Each case reviewed on an individual basis


8 GUIDELINES FOR ORGAN DONATION

KIDNEYS ◆

< 75 years

No relevant medical history

Each case is reviewed on an individual basis

PANCREAS ◆

< 55 years

No relevant medical history, e.g. diabetes, pancreatitis

LIVER ◆

< 70 years

No relevant medical history

Each case is reviewed on an individual basis

TISSUE DONATION Tissue Bank currently in St. James’s Hospital HEART VALVES < 65 years ◆ ◆

Specific consent for heart valves

No history of valve disease

SKIN < 70 years ◆ ◆

Only if a specific request has been received from the Burns Unit, St. James’s Hospital

ILIAC VESSELS Retrieved and stored in St. Vincent’s Hospital at the time of liver donation

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GUIDELINES FOR ORGAN DONATION 9

Role of the Donor Transplant Co-ordinator The Co-ordinator is involved in the

The National Co-ordinators in Beaumont Hospital provide a 24 hour on-call to hospitals throughout Ireland, to deal with all enquiries regarding organ donation and provide a service to other transplant centres. This includes co-ordinating various retrieval teams involved with the procurement of organs and tissues.

DONOR REFERRALS 2000 - 2010

process from the initial enquiry right through to the donor in theatre. Ultimately our aim is to achieve this expediently with the least inconvenience to both the family and donor hospital. This is achieved by maintaining close contact and co-operation with the donor family, donor hospital and the retrieval teams. The Co-ordinator is involved in the process from the initial enquiry right through to the donor in theatre. Post the donation the co-ordinator will communicate with the donor family and all the staff involved in the care of the donor regarding the outcome of donation.


10 GUIDELINES FOR ORGAN DONATION

Approaching the topic of Organ Donation Every family should be given the option to consider organ donation. Studies have shown that asking about organ donation does not lessen the grief nor should it enhance it. Grief occurs because a loved one has died. It is important to talk to a patient’s family to ensure that those who wish to donate are not denied the chance to do so.

When to ask? The best time to raise the subject of organ donation can be between the two sets of brain stem tests. The family should be told what the tests involve, why they are being done, and given the prognosis. They should then be allowed time to come to terms with their situation before the question of organ donation is raised.

Who can ask? It could be any health professional within the intensive care unit who feels comfortable to do so and has a positive approach. It can be a nurse or doctor who has been caring for the patient and who has built up a rapport with the family. Allow the family time to discuss it privately and make their decision.

The family’s decision In the end, the decision rests with a patient’s closest relative. We are guided by their wishes. However, health professionals have an important role to play. Surveys show that 70% of people say they are willing to be donors. To do so, their relatives need to be asked.


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GUIDELINES FOR ORGAN DONATION 11

Lack of Objection/Consent CORONER Relevant cases that are reported to the Coroner (under the Coroners Act 1962) should be referred in order to determine whether organ donation can proceed.

FAMILY Written consent for organ donation is obtained from the next of kin of every donor at the time of donation. Only organs that are specifically consented for are taken for transplantation. The Department of Health and Children have recommended that information surrounding social and sexual health have to be ascertained in order for transplantation to proceed safely. It may be appropriate for this discussion to include other key people such as extended family and friends. It is important to provide the family with the information leaflet on organ donation. Whilst recognising that this is a difficult time for families and knowing that these questions can seem insensitive, or even cause offense, the transplanting teams are responsible for minimising the risk of transmittable viral infections to transplant recipients. It is routine to carry out full virology screening on all potential donors. An in-depth social and medical history needs to be obtained. The family will be assured that they may change their minds about organ donation at any time.


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Sequence of events Donation can help the family to

The next-of-kin will be aware of the severity of the situation. Following the first set of brain stem death tests the consultant will discuss the results with the next-of-kin and explain to the family that a second set of tests will be performed, following which a diagnosis of brain death is made.

cope as they see the donation of

It may be appropriate in some cases to introduce the potential for organ donation at this time. Some families may have already asked about organ donation themselves.

their loved ones organs

The relatives are informed of the outcome following the second set of tests and advised that this is recorded as the time of death.

as a positive aspect of their tragedy.

If it is a coroner’s case the coroner needs to be informed and his approval sought prior to the family being formally approached about donation.

The family can then be formally approached about organ donation and consent obtained if they are agreeable.

Information for donor families on Organ Donation and Transplantation (available in 12 different languages through Transplant Co-ordinators Office).

It may be helpful to ask the family if the patient held an organ donor card, or if there had ever been any discussion about organ donation and whether the patient had made their wishes known. Donation can help the family to cope as they see the donation of their loved ones organs as a positive aspect of their tragedy.

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GUIDELINES FOR ORGAN DONATION 13

Sequence of events The Co-ordinator will be available to talk to the family and will organise the subsequent retrieval. The Co-ordinator usually meets with the family to obtain consent if required, and is available to come to the donor hospital to make the initial approach, following the confirmation of brain stem death. The role of the Co-ordinator is to facilitate the wishes of the donor and the donor family in carrying out their wishes and those of their loved one and to support the staff caring for the donor and family.

The family should be kept informed at all stages of the donation process. They may not wish to stay in the hospital but all families must have adequate time and privacy to say their goodbyes to their loved one.

Theatre time depends on local circumstances, the family wishes and theatre availability and may be delayed for local emergency operations. The donor is transferred to theatre with ventilatory and haemodynamic support maintained.

The surgery is performed by transplant surgeons and can take up to five hours for a multi-organ donation.

Utmost dignity and respect of the donor is maintained by all members of the transplant team throughout the whole donor process.

The family will be informed of the outcome of the transplant operations by the Co-ordinator who will write to them within a month of donation.

When the operation is complete the donor is cared for by the Co-ordinator and theatre team.


14 GUIDELINES FOR ORGAN DONATION

Donor Management Once Brain Stem Death has been confirmed, there is a shift in care from preserving cerebral perfusion to maintaining the organs for transplantation. Brain stem death leads to derangement of normal homeostatic mechanisms. For medical management of the organ donor, please refer to the Intensive Care Society of Ireland’s (ICSI) Guidelines and Diagnosis of Brain Death and Medical Management of the Organ Donor 2010, available from their website. www.icmed.com

Standard requirements for all potential organ donors ◆ ◆ ◆

Blood group (copy faxed – 01-7974870) Weight and height Details of past medical/social and current condition (see medical questionnaire for organ and tissue donation)

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U&E, CBC, LFTs, Protein, Albumin, Coag, Amylase, Glucose

Bloods taken and sent to Beaumont Hospital for virology and tissue typing 10mls clotted X 2, 10mls citrated X 4 and 7.5mls in EDTA tube (blood bottles available on the unit).

Specific requirements for cardiac team ◆ ◆

Chest X-ray, ECG on day of donation

Echo if available

Improve systemic vascular resistance by administering: Methylprednisolone 15mg/kg (slow iv bolus) T3 (Tridothyronine) 20mls water or normal saline Pitressin (argine-vasopressin) – 2iu in 50mls 5% Dex- 5mls/hr

Blood gases: On present ventilator settings On 100% Fi02 peep 5cm H20 for 10 minutes

The Cardio Thoracic centres may request additional tests prior to identification and acceptance of an organ for a potential recipient.

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GUIDELINES FOR ORGAN DONATION 15

Organ Donor Retrieval ◆ The retrieval of organs from a donor takes place, under aseptic conditions, in the operating theatre of the hospital in which the donor has died. The dignity of the donor is maintained at all times by every member of the retrieving team at every stage of the operation.

◆ Theatre availability is arranged by the Co-ordinator and the theatre staff in the donor hospital.

◆ The operating room is set-up as for a major surgical procedure with diathermy, two suction machines and extra drip stands for perfusion. The scrub nurse sets up a basic laparotomy set.

◆ The retrieval teams bring their own specialised perfusion and retrieval instruments, cooled perfusion fluid, perfusion technician and sometimes their own scrub nurse.

◆ Additional sterile trolleys will be required for perfusion, depending on how many organs are being retrieved. There may be up to four transplant surgical teams from different centres, i.e. heart/lung, liver, kidney/pancreas.

◆ The ventilated donor is transported from the Intensive Care Unit by the Anaesthetist accompanied by the Intensive Care Nurse who hands the patient over to the Theatre Nurse.

◆ The identity of the patient and consent for the procedure is checked by the ITU and Theatre Nurse.

◆ The transplant teams check consent, blood group and brain stem test records.

The sequence for the donor operation should be discussed with the Co-ordinator who is always available during the donor operation.


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Multi-Organ Retrieval Instruments Major General Set ◆ ◆ ◆ ◆ ◆ ◆

Bowl sets x 3 Retrieval Set (team to bring) Perfusion Set (team to bring) Square Tray Mallet Sternal Retractor

Sutures ◆ ◆ ◆ ◆ ◆ ◆

4/0 Silk Ties 0 Silk Ties 2/0 Vicryl Suture 2/0 Silk Ties 3/0 Vicryl Suture 2 Nylon Suture

Blades ◆ ◆

Size 20 x 2 Blade removers x 2

Extras ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆

Suction tubing x 2 Discarda pad Dacron tapes x 2 45 x 45 swab Cysto sets x 2 Jelco cannula 14g William Harvey cannula (Co-ordinator to bring) Yankauer tip x 2 Tip cleaner Vessel loops x 8 Bone wax 3m bags IV giving set

Perfusion Table for Kidneys ◆ ◆ ◆ ◆ ◆

Perfusion Set Mallet 3m Bags x 4 4/0 Silk Ties Square Tray

Perfusion Table for Pancreas ◆ ◆ ◆ ◆ ◆ ◆ ◆

Perfusion Set Mallet Bethadine Antiseptic Amphotericin Square tray 14g Jelco Cannula TA55 Multi-fire

Perfusion Table for Liver ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆

1 Basin 1 Watson Cheyne 2 Debakey dissecting forceps 3 Intestinal bags 1 6g Jelco cannula 1 Bowl 1 Mallet 1 William Harvey Cannula 1 20ml syringe

Perfusion Table for Heart/Heart Lung ◆ ◆

Sterile Trolley Sterile Bowl


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GUIDELINES FOR ORGAN DONATION 17

Surgical Procedure ◆

A midline incision is performed from the supra sternal notch to the pubic symphysis. A sternotomy is performed using Gigli saw. This allows maximum exposure of the organs within the thoracic and abdominal cavity. After the incision is made, a full laparotomy is performed. Each transplant team inspects the organs for any trauma, occult neoplasm, or intrinsic disease.

The heart and lungs are inspected for suitability. The ureters are isolated and the kidneys are mobilised on their vascular pedical. The liver is mobilised. The aorta is isolated and the main anterior branches i.e. the coeliac axis and the supra mesenteric artery dissected free.

The venous system is also isolated prior to dissection.

The great vessels of the chest are then isolated. The abdominal aorta is cannulated with a William Harvey cannula supplied by the team. The superior mesenteric artery via the portal vein is also cannulated. The aorta is cross clamped in the chest. In situ perfusion is commenced and ventilation is discontinued. The heart is perfused with cardioplegia. The intra-abdominal organs are perfused with U.W. solution (University of Wisconsin).


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The sequence of Organ Removal ◆

The heart/heart lung is removed followed by the liver, the pancreas and then the kidneys are removed en bloc. Specimens of spleen and lymph nodes are removed for tissue typing purposes. Iliac vessels are also removed to necessitate liver transplant surgery.

On removal, each organ is separately perfused on a perfusion table by the team retrieving the organs. They are individually placed in double sterile bags, packed in ice and transported to the different transplant centres as quickly as possible. The kidneys are separated and marked right and left before packing.

A kidney perfusion machine called the Lifeport System is used on occasion for kidney preservation. This optimises the kidneys and reduces delayed graft function. This is also the preferred method of preservation in donors over 55 years or donors with a history of hypertension. The kidneys are biopsied and then placed on continuous perfusion by the transplant surgeon in theatre.

Heart valves may be retrieved if heart is found to be unsuitable for transplant.

After all swabs and instruments are accounted for by the scrub and circulating nurse, the incision is closed with a continuous suture material by the transplant team. The theatre staff and Co-ordinator will care for the body of the donor following organ retrieval. This can be an emotional time particularly as the donors are often very young, and although the theatre staff do not come in contact with the relatives of the donors, they still feel sympathy for their loss.

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GUIDELINES FOR ORGAN DONATION 19

The maximum preservation time for each solid organ is: ◆

HEART

4 hours

LIVER

18 hours

KIDNEYS

36 hours

PANCREAS

LUNGS

HEART VALVES

Switchboard (24hrs)

01-8093000 Office: Mon-Fri 07:30-1900

01-8093119/2848 01-8528399

< 12 hours

6 hours

long-term preservation


It is important to remember that organ transplantation is a very positive outcome from an otherwise tragic situation.

Further information and booklets available The following literature is available from the Transplant Co-ordinators Office, Beaumont Hospital. ◆

Checklist for Diagnosis of Brain Stem Death.

Theatre Set-up.

Drug Reconstitution for Cardiothoracic Recommendations.

Blood Samples required.

Information for Donor Families on Organ Donation and Transplantation

The following websites may be of interest

www.beaumont.ie www.icmed.com www.strangeboat.org www.ika.ie

(available in 12 different languages through Beaumont Hospital website).

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www.coe.int

Consent for Organ Donation. Potential Donor Referral form.

On behalf of everyone involved in Organ Procurement and Transplantation, we would like to thank all the participating hospitals around the country for your ongoing support. Without your continued support, we would not have a transplant programme here in Ireland.

Any queries regarding organ retrieval please do not hesitate to contact the Co-ordinator on-call in Beaumont Hospital on 01-8093000.

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Guidelines for Organ Donation