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1.
Yang H‐Y, Lin C‐Y, Tsai Y‐T, Lee C‐Y, Tsai C‐S. Experience of heart transplantation from hemodynamically unstable brain‐dead donors with extracorporeal support. Abstract: The shortage of organ donors remains a major problem for transplantation worldwide. Potential donors after brain death may become hemodynamically unstable, despite maximal medical management, which ultimately leads to failure of organ procurement. We reviewed the medical records of five brain‐dead potential donors who presented with hemodynamic instability despite maximal medical management that were supported by extracorporeal circulation membrane oxygenation (ECMO). The outcomes of heart recipients were reviewed. The five donors under extracorporeal support finished a declaration of brain death without cardiac arrest. Donor organs, including three hearts, nine kidneys, and four livers, were harvested from the five donors under ECMO support. All three heart recipients recovered uneventfully after one yr of follow‐up. Our experience indicates that potential donors may experience central‐failure‐related hemodynamic instability after brain death, despite maximal medical support, which leads to a fatal result. Beyond medical management, prompt and early extracorporeal support for salvaging brain‐dead potential donors from cardiac death seems to be a practical strategy to increase the donor pool and preserve donor organs.  相似文献   

2.
Hemodynamic instability is generally considered as a contraindication to liver splitting, in particular when using an in situ technique. We describe the cases of two young donors with brain death in whom refractory cardiac arrest and hemodynamic instability were supported by veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO), allowing uneventful in situ splitting. Two adult and two pediatric liver recipients were successfully transplanted with immediate graft function. Favorable outcomes were also observed for the other transplanted organs, including one heart, two lungs, and four kidneys. Refractory cardiac arrest and hemodynamic instability corrected by VA‐ECMO should not be considered as a contraindication to in situ liver splitting.  相似文献   

3.
The disproportion between the supply and demand of transplant organs could be alleviated by improving the quality of clinical management of deceased potential donors. As a large number of donor losses by cardiac arrest occur due to hemodynamic instability, without instituting all essential maintenance measures, it is likely that the application of simplified potential donor maintenance protocols will help to decrease potential donor losses and increase the supply of organs for transplantation. The Ventilation, Infusion and Pumping (VIP) strategy is a mnemonic method that brings together key aspects of the restoration of oxygen delivery to tissues during hemodynamic instability: adequate mechanical Ventilation, volume Infusion and evaluation of heart Pump effectiveness. The inclusion of the additional initials, “P” and “S,” refers to Pharmacological treatment and Specificities involved in the etiology of shock. The use of simplified care standards can assist in adhering to essential potential donor management measures. Therefore, using a simplified method as the adapted VIP approach can contribute to improving management standards of potential organ donors and increasing the supply of organs for transplantation.  相似文献   

4.
器官移植是治疗终末期疾病的有效手段之一,但供者来源不足桎梏了器官移植的发展。体外膜肺氧合(ECMO)可以改善器官低氧状态及低灌注情况,缩短热缺血时间,在器官紧急获取或血流动力学不稳定等情况下,有效维护供者器官功能,使供者器官得到充分利用,造福更多亟需器官移植的患者。本文总结了ECMO在供者维护中的应用进展,为其在器官移植中的应用提出建议。  相似文献   

5.

Background

Extracorporeal membrane oxygenation (ECMO) must be applied in early stages to perfuse organs before donation in order to expand the donor pool. The aim of this study was to examine the benefits of ECMO for potential organ donors with multiple complications.

Materials and methods

This retrospective review describes patients with ECMO support who were on the verge of brain death and therefore potential subjects for organ donation.

Results

Six organ donors with severe neurological damage under ECMO support completed the procedures, namely, two women and four men of ages 19 to 58 years (mean, 32 years). Three donors completed the brain-death determination procedure, one failed the procedure, and two experienced cardiac asystole prior to the procedure and were unable to be declared dead even after resuscitation. Nine kidneys and three livers were successfully retrieved from 5/6 donors, leading to 11 successful transplantations: eight kidneys, two livers, and one simultaneous kidney-liver transplantations. The organs functioned well and the recipients made full recoveries.

Conclusions

ECMO allows for the maintenance of abdominal organ tissue perfusion without warm ischemia before organ procurement, providing sufficient time for safe organ donation procedures and reducing the risk of unpredictable cardiac arrest that could result in the donor death and graft loss.  相似文献   

6.
A retrospective review of 114 solid organ donors over a 6-year period (1982-1987) was undertaken to identify problems in organ donor management and determine outcome of donated organs. Admission GCS was less than or equal to 4 in 84% of the donors. Complications included hypotension (81%), multiple transfusion requirements (63%), diabetes insipidus (53%), DIC (28%), arrhythmias (27%), cardiac arrest requiring CPR (25%), pulmonary edema (19%), hypoxia (11%), acidosis (11%), seizures (10%), and positive bacterial cultures (10%). Only 18% of organs were procured within 3 hours of brain death; 23% were procured more than 6 hours later. Six patients excluded from this study suffered cardiovascular collapse before their organs could be retrieved. From 114 organ donors, consent was obtained to procure 224 kidneys, 77 livers, 62 hearts, 35 pancreata, and ten heart-lung units. All 224 donated kidneys were procured and 202 were ultimately transplanted. Of 77 donated livers, 32 were procured; 31 transplanted. Of 62 donated hearts, 38 were procured; 29 transplanted and nine used for valves. Ten heart-lung units were donated; six were procured and transplanted. Of 35 donated pancreata, 11 were procured; only five were transplanted. Reasons for failure of donated organs to be procured or transplanted included abnormal organ characteristics, lack of compatible recipients, unavailability of surgical teams, organ injury during procurement, intraoperative arrest, and anatomic limitations precluding multiple organ procurement. This study identifies characteristics of organ donors and common organ-threatening complications. Rapid and continuing resuscitation of clinically brain dead trauma victims is mandatory.(ABSTRACT TRUNCATED AT 250 WORDS)  相似文献   

7.

Objective

Herein we have reported our experience concerning the usefulness of extracorporeal membrane oxygenation (ECMO) in heart transplant patients.

Patients and Methods

Between July 2002 and March 2007, 11 heart transplant patients, namely, 8 men and 3 women of overall mean age of 49.4 ± 13.9 years (range, 19-62 years) with primary graft failure underwent ECMO implantation. Two patients had pulmonary hypertension; 3 had been transplanted with hearts from marginal donors. At the time of implantation, all were in severe cardiogenic shock despite maximal inotropic support. In 6 patients, the ECMO was implanted centrally in the operating room when there was failure of weaning of cardiopulmonary bypass. Among the 5 remaining patients, ECMO was implanted peripherally in the intensive care unit, during the first 60 hours, including 3 cases of hemodynamic instability and 1 of irreversible cardiac graft arrest. The last patient was implanted on day 30 after transplantation because of acute rejection.

Results

Mean pump outflow was 2.7 ± 0.4 L/min/m2. One patient died on circulatory support due to a cerebral hemorrhage. Ten patients were weaned from ECMO after a mean duration of 9.1 ± 6.9 days (range, 1-18 days). All of them were successfully discharged. No retransplantation occurred.

Conclusion

Rapid operating room or bedside placement of ECMO allowed stabilization of hemodynamics with potential myocardial recovery in patients with cardiac graft failure.  相似文献   

8.
Donation-after cardiac death (DCD) donor organs have potential to significantly alleviate the shortage of transplantable lungs. However, only limited data so far describes DCD lung transplantation (LTx) techniques and results. This study aims to describe the Alfred Hospital's early and intermediate outcomes following DCD donor LTx. Following careful experimentation and consultation DCD guidelines were created to utilize Maastricht category III lung donors from either the ICU or operating room(OR), with a warm ischemic time(WIT) of <60 min. Between May 2006 and December 2007, 22 referred DCD donors led to 11 attempted retrievals after withdrawal, resulting in 8 actual bilateral LTx (2 donors did not arrest in prescribed period and 1 donor had nonacceptable lungs). ICU WIT = 38.4 min (range 20–54, OR WIT = 12.7 min (11–15), p < 0.05. Post-LTx, 1 pulmonary hypertensive patient required ECMO for PGD3. The mean group pO2/FiO2 ratio at 24 hours was 307.7 (240–507) with an ICU stay of 9.5 days (2–21) and ward stay of 21.5 days (11–76). All 8 survive at a mean of 311 days (10–573) with good performance status and lung function. In conclusion, the use of Maastricht category III lungs for human LTx is associated with acceptable early clinical outcomes.  相似文献   

9.
BACKGROUND: Historically, organ recovery rates in donors with cardiac arrest (CA) have been low, presumably from hemodynamic instability. We hypothesized that donor resuscitation has improved hemodynamic stability and organ recovery in CA donors, and that CA triggers ischemic preconditioning (IP) in liver grafts. METHODS: A total of 131 donor pairs with and without CA were matched in age, gender, and year of recovery. Hemodynamic stability was determined by vasopressor use. Abdominal and thoracic organs recovered and livers transplanted were compared between the groups. Liver graft function, injury, and IP benefit were examined by comparing liver chemistries after transplantation and postperfusion biopsies between recipients of grafts from both groups (n=40 each). RESULTS:Hemodynamic stability was similar in both groups, but recovery of thoracic organs was significantly lower in CA versus non-CA donors (35 vs. 53%, P<0.01). On the other hand, recovery rates of three or more abdominal organs from CA donors approached those of non-CA donors (77 vs. 87%, not significant). Although significantly fewer livers were transplanted from CA donors (69 vs. 85%, P<0.01), posttransplantation graft function and injury parameters were similar between the two groups, and CA did not appear to trigger IP. CONCLUSION: Compared with historical data, cardiovascular stability and abdominal organ recovery rates have improved considerably in CA donors. Liver grafts from CA donors function similarly to grafts from non-CA donors with no IP from CA. Our data support the increased use of livers and other organs from donors with CA.  相似文献   

10.
《Transplantation proceedings》2019,51(7):2202-2204
IntroductionThe rate of organ donations from deceased donors in Turkey is among the lowest in the world. We analyzed the reasons why some potential donors whose families had given consent did not become actual solid organ donors.MethodsWe retrospectively reviewed the organ donation, retrieval, and transplantation registries of 102 potential donors from the Ministry of Health Organ and Tissue Transplant Coordination Centre of Istanbul Region from the year 2015.ResultsCardiac arrest occurred in 8 of the potential donors while waiting for organ procurement or during surgery. The organ specific suitability ratio was 83% for kidneys, 82% for livers, 72% for hearts, and 75% for lungs. Of these suitable organs, the transplantation rates were as follows: kidneys 88%, livers 70%, hearts 30%, and lungs 13%. Medical reasons (donor unsuitable) (14%–24%) and poor organ function (2%–24%) were the reasons most organs were not accepted for transplant. These reasons included diabetes insipidus, electrolyte imbalance caused by neuro-humoral changes, inotrope/vasopressor requirement for hemodynamic instability, hypoperfusion, and myocardial dysfunction after brain death.ConclusionThe mismatch between organ donation and demand is a major problem worldwide. In addition to low organ donation rates, late diagnosis of potential donors or inappropriate management of the pathophysiological consequences of brain death reduce the number of transplantable organs even more in our country. In order to overcome these setbacks, we need education programs to improve quality and decrease donor losses in an intensive care unit goal-directed protocol for the management of potential donors.  相似文献   

11.
BACKGROUND: In Argentina, the rate of cadaveric organ donation per million inhabitants has recently increased to 10.5 (it was previously <7). PURPOSE: To overcome this challenge, the National Institute for Organ Donation and Transplantation (INCUCAI) created a proactive donor detection plan performed by intensive care unit (ICU) physicians (hospital transplantation coordinators) from 90 selected hospitals across the country. METHODS: A prospective, observational study of patients in severe coma status was conducted from September 2003 to December 2005. We enrolled hospitalized patients who displayed a Glasgow Coma Scale (GCS) of 7 or less and who were admitted to ICUs. Data included demographics, etiology of coma, cardiac arrest, brain death, discharge or derivation, and positive/negative donation. RESULTS: Among 9841 enrolled patients, we excluded 498 who were discharged to another hospital or had unknown outcomes, leaving 9343 for analysis including 64% males and 36% females of overall mean age 50 +/- 19 years (adults) and 5 +/- 4 years (children). Herein, we have highlighted the high risk of death during the first 2 days in the ICU of patients with GCS 7 or less. Gunshot to the head-injured patients and those with hemorrhagic strokes were less likely to survive. In this study, cardiac arrest events and organ donors (OD) GCS 7 or less ratios emerged as quality control markers of ICU care, unraveling problems of potential donor maintenance or inadequate policies. CONCLUSIONS: The GCS 7 or less surveillance program seemed to be a valuable tool for identifying organ donors and potentially treatable events, such as the high rate of cardiac arrest observed in this study.  相似文献   

12.
INTRODUCTION: Although the use of non-heart beating donors (NHBD) could bridge the widening gap between organ demand and supply, its application to liver transplantation is limited due to warm ischemia (WI), biliary tree injury, and inadequate organ assessment. Warm blood reperfusion using extracorporeal membrane oxygenation (ECMO) can be a suitable option to reduce WI in organs from NHBD, allowing one to determine hepatic flow characteristics and bile production and facilitating assessment of organ viability. METHODS: This work evaluates the use of warm blood veno-arterial ECMO reperfusion in NHBD swine. Systemic and hepatic hemodynamics, bile, urine, and mixed venous blood were measured. After baseline data collection, 10 kU heparin was given intravenously followed by 1 g KCl to elicit cardiac arrest (CA). ECMO was started after 30 or 60 minutes of CA and kept running for 120 minutes. RESULTS: One-way repeated measures analysis of variance (ANOVA) with Tukey test analysis was used within a group. Two-way ANOVA was used between groups. ECMO can restore venous SO2 and pH in both groups; the values were close to baseline in the 30-minute CA group. Also, in this group, bile production was > 65% from baseline early during reperfusion and its value was lower in the longer CA group < 55% (P < .001). Aspartate aminotransferase (AST) was doubled at the end of ECMO support in the 60-minute CA group (P < .05). CONCLUSION: In this preheparinized NHBD swine model, ECMO support restores liver perfusion, oxygenation, and bile production after 60 minutes of CA. Quantification and analysis of bile production could be a determinant of liver function during ECMO resuscitation, and it may be a predictor of graft viability before transplantation.  相似文献   

13.
《Transplantation proceedings》2023,55(4):1021-1026
BackgroundThe use of grafts from donors after cardiac death (DCD) would greatly contribute to the expansion of the donor organ pool. This study aims to determine the benefits of extracorporeal membrane oxygenation (ECMO) and hypothermic oxygenated machine perfusion (HOPE) in a large animal model of DCD liver.MethodsAfter cardiac arrest, the abdominal aorta and the inferior vena cava were cannulated and connected to an ECMO circuit. Porcine livers were perfused in situ with ECMO at 22°C for 60 minutes after 45 minutes of cardiac death. Then, the livers were perfused for 4 hours by cold storage (CS) or HOPE. In group 1, non-in situ ECMO and grafts were preserved by HOPE. In group 2, in situ ECMO and grafts were preserved by HOPE. In group 3, in situ ECMO and grafts were preserved by CS. After preservation, all grafts were evaluated using an isolated reperfusion model (IRM) with autologous blood for 2 hours.ResultsDuring HOPE, aspartate aminotransferase (AST) levels and hepatic arterial pressure in group 2 tended to be lower than in group 1. Hematoxylin–eosin staining findings after HOPE showed more massive sinusoidal congestion and hepatocyte cytoplasmic vacuolization in group 1 than in group 2. The AST and LDH levels in group 2 at the start-up of IRM tended to be lower than in group 1.ConclusionsThe combined use of in situ subnormothermic ECMO and HOPE is essential for the functional recovery of DCD liver grafts.  相似文献   

14.
Pertussis is a leading cause of death from community infections in infant. Life-threatening clinical presentations of pertussis can associate multiple organ system failure with respiratory distress. The question of the optimal management of these severe forms of pertussis, in order to reduce the high mortality rate, is raised by the clinicians caring for such patients. We report the case of a 1 month infant who was admitted to the pediatric intensive care unit (PICU) for a severe pertussis. He presented with an acute respiratory distress syndrome, a severe pulmonary hypertension was treated initially with mechanical ventilation and nitric oxide. At day 4 (D4), a cardiogenic shock occurred and, despite epinephrine and norepinephrine infusion, fluid expansion, the hemodynamic condition worsened with two episodes of cardiac arrest. The child was then successfully resuscitated, and, facing the extreme hemodynamic instability, extracorporeal membrane oxygenation (ECMO) was considered. ECMO allowed epinephrine and norepinephrine to be progressively discontinued, and protective mechanical ventilation. ECMO withdrawal was possible at D9, with milrinone as the sole inotropic agent. Weaning from mechanical ventilation was possible on D15 and the total length of stay in PICU was 20 days. While the analysis of the literature, through limited experiences on the use of ECMO in children with severe pertussis does not allow concluding definitively on the utility of ECMO in this situation, the contribution of ECMO in the favourable outcome for our patient was considerable. This is an argument, to our opinion, for considering ECMO in the management of those very instable patients.  相似文献   

15.
BACKGROUND: Our organ procurement organization recently developed an aggressive donation after cardiac death program. Thoracic organs are rarely recovered from non-heart-beating donors. Therefore, there is concern that donation after cardiac death may affect the recovery of thoracic organs from donors not allowed to progress to brain death. OBJECTIVE: To evaluate the potential impact of donation after cardiac death on the recovery of thoracic organs. METHODS: On the assumption that prolongation of care on all cases would result in a diagnosis of brain death. By retrospective chart review, all donations after cardiac death were evaluated for thoracic organ potential using the same standards that were used to evaluate brain-dead donors. RESULTS: During the study period there were 34 of 44 (77%) non-heart-beating donors qualified to donate abdominal organs only. Ten of 44 non-heart-beating donors (24%) qualified to potentially donate thoracic organs; the families of 4 of 10 of these donors insisted on the immediate withdrawal of life support, leaving only 6 donors with thoracic organ potential. All 6 of these donors qualified as potential heart donors and 3 as potential lung donors. CONCLUSIONS: A total of 97 organs were recovered and successfully transplanted from 44 non-heart-beating donors. If all the donors who qualified to donate thoracic organs progressed to brain death and if their thoracic organs were transplantable, then 6 additional hearts and 3 pairs of lungs may have been recovered. These data demonstrate that an aggressive donation after cardiac death program contributes significantly to the organ donor pool, with a minimal impact on potential thoracic organ recovery.  相似文献   

16.
心脏死亡器官捐献获取流程探讨   总被引:1,自引:0,他引:1  
目的总结并进一步探讨心脏死亡器官捐献(DCD)获取流程的初步经验。方法回顾性分析2009年7月至2012年1月期间广州军区总医院28例DCD者的临床资料、供体入选标准及器官获取流程。结果 28例DCD供体均成功实施了器官捐献,其中MaastrichtⅢ类3例(10.7%),MaastrichtⅣ类1例(3.6%),脑-心双死亡捐献(DBCD)供体24例(85.7%)。3例MaastrichtⅢ类供体实施了标准DCD器官获取流程(简称DCD流程),1例MaastrichtⅣ类供体采用DBCD器官获取流程(简称DBCD流程)非体外膜肺氧合(ECMO)模式,24例DBCD采用了DBCD流程ECMO模式。供体器官热缺血时间:DBCD为0 min,MaastrichtⅣ类为18 min,MaastrichtⅢ类平均25 min(22~28 min)。本组共获取了28个肝脏、40个肾脏、2个心脏,分别成功用于肝移植、肾移植和心脏移植。结论我国DCD器官获取可分为DCD流程和DBCD流程,后者又分为ECMO模式和非ECMO模式。ECMO模式可避免器官热缺血损伤且没有伦理学争议,对我国公民DCD器官有着十分重要的作用。  相似文献   

17.
Because the supply of cadaveric organ donors is limited and their ICU management is complex, a multidisciplinary, well-coordinated, and institutionally supported approach to management is essential to ensure the maintenance of the current supply and to increase the future supply of organs and tissues that are suitable for transplantation. The potential organ donor is at high risk for instability as a direct consequence of the loss of physiologic homeostatic mechanisms that are dependent on functioning of the central nervous system. The keys to successful ICU management of the potential organ donor include a team approach that is focused on the anticipation of complications, appropriate physiologic monitoring, aggressive life support, with frequent reassessment and titration of therapy.  相似文献   

18.
Abstract:  Caring for a brain dead potential organ donor requires a shift in critical care from the extensive treatment of increased intracranial pressure towards strategies to maintain donor organ function. Suboptimal, unstandardized critical care management of organ donors, however, is one of the main reasons for insufficient organ procurement. The pathophysiological changes following brain death entail a high incidence of complications including hemodynamic instability, endocrine and metabolic disturbances, and disruption of internal homeostasis that jeopardize potentially transplantable organs. Strategies for the management of organ donors exist and consist of the normalization of donor physiology. This has resulted in standardized efforts to improve the critical care delivered to potential organ donors, increasing not only the number, but also the quality of suitable organs and aiming at an optimal outcome for the recipients. In this review, we discuss the pathophysiological changes associated with brain death and present the current guidelines at our department, which are optimized based on available literature.  相似文献   

19.
BACKGROUND: The shortage of transplantable organs has become a national crisis. Despite various attempts to expand the donor pool, the difference between organ supply and organ demand continues to widen. With no foreseeable increase in the number of donors, it is necessary to maximize the utilization of organs from the existing donor pool. METHODS: Records of all patients referred to the regional organ procurement organization for possible organ donation over an 8-year period (1995-2002) were reviewed. A policy of aggressive donor management (ADM) by dedicated physicians was instituted in January 1999 involving intensive care unit admission, pulmonary artery catheterization, aggressive fluid resuscitation, early use of vasopressors, prevention and treatment of complications associated with brain death, and liberal use of thyroid hormone in hemodynamically unstable donors. Data regarding referrals for organ donation, actual organ donors, organs recovered, and donors lost due to cardiovascular collapse before organ donation were compared before (January 1995- December 1998) and after (January 1999- December 2002) ADM. RESULTS: There were 878 patients referred for organ donation during the 8-year period. Of those, 469 (53.4%) were confirmed as potential donors, but only 161 (34.3%) became actual donors. When compared with the period before ADM, the period after ADM showed a 57% increase in total referrals (p < 0.001), 19% increase in potential donors (p = 0.01), 82% increase in actual donors (p < 0.001), 87% decrease in the number of donors lost due to hemodynamic instability (p < 0.001), and a 71% increase in the number of organs recovered (p < 0.001). CONCLUSIONS: A policy of ADM increases the referral pool for organ donation and reduces the number of organ donors lost due to cardiovascular collapse. The net result is a significant increase in the number of organs available for transplantation.  相似文献   

20.
METHODS: We retrospectively analyzed the registry data from one organ procurement organization obtained between January 1 and December 31, 2005. RESULTS: Among the 378 potential deceased donors, 182 (48.2%) were lost, mainly due to clinical conditions (27%) or cardiac arrest (19.3%). Of the remaining 196 (51.8%) potential donors, family consent was obtained in 94 cases (48%). Family refusal was higher for potential donors aged between 18 and 59 years (70%). Of the 94 donors, 72 (77%) had their organs harvested. Cardiac arrest before harvesting (56.5%) and positive viral serology (26%) were the main reasons for further losses. The mean donor age was 40 years and 51% were men. Causes of death were cerebral vascular accidents (55.5%), cranium encephalic traumas (29%), and gun shot wounds (8%). The rate of organ donation was 100% for kidneys and livers, 96% for hearts, 86% for pancreatas, 76% for lungs, and 74% for corneas. After assessment of organ viability, 94% of corneas, 91% of kidneys, and 88% of livers were transplanted, but only 52% of pancreata and 42% of hearts. The most frequent causes of discarded organs were age and concomitant donor infection. CONCLUSION: Areas for potential improvements are: (1) earlier identification and adequate maintenance of potential donors; (2) campaigns for organ donation; and (3) careful evaluation of donated organs and selection of a suitable population to increase utilization of expanded criteria organs.  相似文献   

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