ORGAN DONATION AND TRANSPLANTATION

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ORGAN DONATION AND TRANSPLANTATION
LIZ WAITE TRANSPLANT CO-ORDINATOR ROYAL
INFIRMARY EDINBURGH
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Who can be an Organ/ Tissue Donor?

• Brain Stem dead patient on mechanical ventilation

• Non-Heart beating donation

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Human Tissue (Scotland) Act 2006

• The wishes expressed by the deceased in life are
  paramount as to what they would like to happen to
  their organs and tissues after death. This is
  called authorisation under the 2006 Act.
• The Act allows both adults and children aged over
  12 to express their wishes about donation.
• The clinicians caring for the patient and/or
  donor transplant coordinator have a
  responsibility to determine what the wishes of
  the deceased are.

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HB Donations
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NHB Donations
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1000 Deaths pa. 3 a day
Procurator Fiscal Workshop Airth Castle 3rd March
2008
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SGHD Campaigns
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International Donor Rates (2006)
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Organ Donation Task Force
Recommendation 14 The Department of Health and
the Ministry of Justice should develop formal
guidelines for coroners concerning organ donation
Copies on DH Website www.dh.gov.uk/publications
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Definitions of Death

• Irreversible loss of capacity for consciousness
  plus irreversible loss of capacity to breathe
• Cardiorespiratory death
• Brainstem death

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Diagnosis of Brainstem Death

• Preconditions
• Patient in apnoeic coma (GCS 3 on ventilator
  with no obvious respiratory drive)
• Irremediable structural brain damage
• Exclude Reversible Causes of Coma
• Drugs
• Hypothermia
• Metabolic disturbance
• Systematic Clinical Examination
• Test cranial nerves
• Apnoea test
• Repeat tests to confirm diagnosis

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The multi-organ donor

• Heart
• Lungs
• Liver
• Kidneys
• Pancreas
• Small bowel

• Corneas
• Tendons
• Heart valves
• Bone
• Skin

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The Donation Process

• Identifying the potential donor
• Refer to relevant Co-ordinator
• Approaching the family
• Co-ordinator gains authorisation risk
• assessment
• Procurator Fiscal
• Allocation of organs/tissue
• Organ retrieval
• Last offices carried out

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Donor Screening

• Direct access to next of kin
• Medical records
• General Practitioner
• Blood screening
• Authorisation
• Donor screening forms

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When Transplant Team Ready for Organ Retrieval-

• Deceased transferred to theatre on ventilator,
  with heart still beating
• No sedation
• May paralyse with neuromuscular blocking agents
  because of spinal reflex movements
• Ventilation continued until aorta cross-clamped
  by surgeon

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Non-Heart Beating Donation

• The surgical recovery of organs after the
  pronouncement of death, based on
  cardio-respiratory arrest.
• Brook Nicholson (2003)

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Criteria

• Candidates for non-heart beating donation are
  limited to patients in which
• Illness or injury has caused an unrecoverable,
  neurological devastation and/or other
  irreversible organ failure leading to the
  conclusion that death or irreversible coma is
  inevitable.
• The family are in agreement to withdraw
  mechanical support.

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NHBD Programme

• Programme started January 2005 at WGH
• March 2007 programme started at RIE
• May 2007 - Borders General refer 1st donor
• Aug 2007 Victoria/Kirkcaldy refer 1st donor
• Oct 2007 Ninewells Hospital refer 1st donor
• January 2008 all regional hospitals on board as
  NHB Donation

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Breakdown of referrals 45
Actual Donors
Clinical History
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34
Actual Donors
Non-Proceed Donors
Family Refusal
Clinical History
Non-Proceeding Donors
Family Refusal
13
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Organs donated from 14 donors
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Kidneys
5
Liver
3
Lungs
0
5
10
15
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Ischaemic Time (NHBD).

• Warm ischaemic time
• 50mmHg sys asystole
• Optimum less than 45 mins.
• Cold ischaemic time.
• Asystole transplantation.
• Optimum less than10 hours.

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NHBD Timeline

• Early referral to co-ordinator (Notify Liver
  Co-ord)
• Decision to withdraw.
• Donation authorised (up to or gt 1hr)
• Blood group (30mins)
• Virology Testing ( 1hr)
• Bloods (clinical chemistry) (1hr)
• Tissue typing (3.5hrs) not needed to proceed to
  theatre.
• Core Donor DATA (2hrs)
• Organ offering (approx 3hrs)
• Theatre organisation (1hr)

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NHBD Timeline

• Treatment withdrawn( death lt3hrs)
• Death certified.
• Organ preservation and donation.

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Controlled NHBD

• Preliminary family discussion
• Planned withdrawal of treatment
• ICU/EM
• Authorisation
• Assessment

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The Royal Infirmary of Edinburgh

• Scottish Liver Transplant Unit
• East of Scotland Kidney Transplant Unit
• Scottish Pancreas and Kidney Transplant Programme

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References

• Brook NR Nicholson ML (2003) Kidney
  transplantation from non-heart beating donors.
  The SurgeonJournal of the Royal Colleges of
  Surgeons of Edinburgh Ireland 1(6) 311-322
• DAlessandro AM, Hoffman RM, Belzer FO (1995)
  Non-heart Beating Donors One Response to the
  organ shortage Transplantation Reviews 9(4)
  168-175
• Lewis DD, Valerius W Sommerville MA (1998)
  Non-heart-beating donors a case study in
  procurement Journal of Transplant Co-ordination
  8(4) 218-220
• Edwards JM, Hasz RD Robertson VM (1999) Non
  heart beating donation Process and review
  Transplantation 10(2) 293-300

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Questions