Changing Demographics in Death After Devastating Brain Injury

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1 Changing Demographics in Death After Devastating Brain Injury Andreas H. Kramer MD MSc FRCPC Departments of Critical Care Medicine & Clinical Neurosciences Foothills Medical Center, University of Calgary Medical Director, Southern Alberta Organ & Tissue Donation Program Disclosures: None

2 Outline Demographics of deceased organ donation in Canada have changed over time Implications: Donor organ function Organs procured / transplanted per donor Graft function Highlights importance of excellent critical care management of organ donors

3 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Deceased Donor Transplants In Canada (2017) 0% Kidney Liver Lung Heart Pancreas NDD DCD Canadian Organ Replacement Registry

4 Donors per million population Deceased Donation In Canada NDD DCD Total Source: CORR

5 2017: 21.9 dpmp 25% DCD CBS System Progress Report 2017

6 Severe Brain Injury Pathway To NDD Organ Donation Prehospital & ED Resuscitation Survivable injury? Transition to comfort care NDD unlikely Urgent Neurosurgery? Admission to ICU NDD unlikely

7 Pathway To NDD Organ Donation Admission to ICU Recognition / Diagnosis of NDD Approach / Consent For Donation Care Of Organ Donor Organ Recovery & Transplantation

8 Leading Practices

9 Catastrophic Brain Injury Prehospital & ED Resuscitation Survivable injury? Transition to comfort care Pathway To NDD Organ Donation NDD unlikely Urgent Neurosurgery? Admission to ICU National efforts to increase organ donation rates Recognition / Diagnosis of NDD Consent For Donation Care Of Organ Donor Organ Recovery

10 Severe brain injury (Prevention) Prehospital & ED Resuscitation Transition to comfort care Pathway To NDD Organ Donation Survivable injury? Urgent Neurosurgery? Admission to ICU Recognition / Diagnosis of NDD Improvements in health care may reduce NDD rates! Consent For Donation Care Of Organ Donor Organ Recovery

11 140 Traumatic Brain Injury Hospital Admissions Per 100,000 Population In Canada Age 0-19 Age Age Age 60+ CIHI 2006

12 Fu et al, J Trauma 2015

13 Injuries From MVCs in Alberta 60 Injuries Per 10,000 population Source: Traffic Alberta 2017

14 CMAJ 2013

15 CMAJ 2013

16 Developments In TBI Increased adherence to BTF Guidelines Development of TBI protocol Increased use of CSF drainage Increased use of multi-modal neurological monitoring Novel therapies aimed at attenuating cerebral edema (e.g. hypertonic saline) Decompressive craniectomy in selected patients with herniation syndromes / refractory ICP

17 Severe TBI after ATV accident Day #4 in ICU: Increased ICP and fixed pupils

18 Day # 5 CT Scan Post-op day #3: following commands Excellent outcome after 3 months

2009-2014, 51 consecutive TBI patients that underwent decompressive craniectomy 53% with > 1 non-reactive pupil Median midline shift 9 mm 37% with completely absent basal

19 , 51 consecutive TBI patients that underwent decompressive craniectomy 53% with > 1 non-reactive pupil Median midline shift 9 mm 37% with completely absent basal cisterns Outcomes: 21 died (40%)... but no cases of NDD 8 severely disabled (16%) 10 moderately disabled (20%) 12 mildly or not disabled (24%) Good Outcome Neurocrit Care 2016

20 More Bystander CPR Chan et al, Circulation 2014

21 More Automated External Defibrillators 70% 60% 50% 40% 30% 20% 10% 0% No Automated External Defibrillator Prehospital ROSC Automated External Defibrillator Admitted to Hospital Pollack et al, Circulation 2018

22 Long Duration CPR Median duration CPR with non-shockable rhythm: 16.4 minutes (IQR ) Grunau et al, Resuscitation 2016

23 Out of hospital cardiac arrest Prehospital & ED Resuscitation Survivable injury? Transition to comfort care Pathway To NDD Organ Donation NDD unlikely Admission to ICU Recognition / Diagnosis of NDD More bystander CPR Better CPR Longer CPR? Automated defibrillators Consent For Donation Care Of Organ Donor Organ Recovery

24 Systematic review of 26 studies (16 with conventional CPR, 10 with extracorporeal CPR) 23,338 patients, 76% mortality Progression to NDD: 5% with conventional CPR (range 0-16%) 22% with ECPR (range 6-42%) Intensive Care Med 2016

25 Intensive Care Med 2016

26 * * Kramer et al, CMAJ Open 2017

27 Kramer et al, CMAJ Open 2017

28 Cause of Death in Consented Potential DCD Donors in Alberta & B.C. ( ) Cause of Death Alberta B.C. Hypoxic-ischemic Brain Injury 40% 50% Traumatic Brain injury 31% 17% Intracerebral Hemorrhage 11% 8% Subarachnoid Hemorrhage 9% 8% Ischemic stroke 5% 10% Other 4% 9%

29 Catastrophic Brain Injury Prehospital & ED Resuscitation Survivable injury? Transition to comfort care Pathway To NDD Organ Donation NDD unlikely Urgent Neurosurgery? Admission to ICU DCD before progression to NDD Decreased progression to NDD NDD unlikely Consent For Donation Care Of Organ Donor Organ Recovery

30 1.9 dpmp 3.6 dpmp 11.8 dpmp 13.4 dpmp 13.3 dpmp CMAJ 2017

31 Catastrophic Brain Injury Prehospital & ED Resuscitation Transition to comfort care Pathway To NDD Organ Donation Survivable injury? Urgent Neurosurgery? Admission to ICU Eligible for DCD? Recognition / Diagnosis of NDD NDD unlikely Consent For Donation Care Of Organ Donor Organ Recovery

32 Deceased Organ Donation in Calgary (YTD) NDD DCD to NDD DCD

33 Outline Demographics of deceased organ donation in Canada have changed over time Implications: Donor organ function Organs procured / transplanted per donor Graft function / recipient outcomes

34 Creatinine (mmol/l) ALT (units/l) ABI TBI Stroke 0 ABI TBI Stroke PaO2:FIO Troponin T (ng/ml) ABI TBI Stroke 0 ABI TBI Stroke Kramer et al, CMAJ Open 2017

Organs Transplanted Per Donor 5 4.5 4 3.5 3 2.5 2 1.5 1 0.

35 Organs Transplanted Per Donor No Cardiac Arrest Cardiac Arrest 0-30 Minutes Cardiac Arrest Minutes Cardiac Arrest > 60 Minutes Kramer et al, CMAJ Open 2017

36 Canadian Organ Replacement Registry ( ) Cause Of Death Traumatic Brain Injury Anoxic Brain Injury Proportion of NDD Donors Where Organ Was Recovered Kidney Liver Lung Heart 94% 86% 37% 36% 84% 83% 26% 25% Stroke 86% 83% 32% 21% Other 84% 80% 38% 26%

37 Kramer et al, CMAJ Open 2017

38 Canadian Organ Replacement Registry (2017) Cause Of Death Organs procured per donor Total Kidney Liver Lung Pancreas Total NDD DCD

39 60% Recipient Outcomes: Delayed Graft Function 50% 40% 30% 20% 10% 0% TBI CVA Cardiac Arrest 0-30 Minutes Cardiac Arrest Minutes Cardiac Arrest > 60 Minutes Dialysis "Functional" DGF Kramer et al, CMAJ Open 2017

40 Recipient Outcomes: Delayed Graft Function TBI CVA Cardiac Arrest 0-30 Minutes Discharge Cr (Median) Cardiac Arrest Minutes One Year Cr (Median) Cardiac Arrest > 60 Minutes

41 DGF Following DCD in Alberta ( ; n=65) Cerebrovascular Disease (n=16): 88% Hypoxic Ischemic Encephalopathy (n=27): 63% Traumatic Brain Injury (n=18): 44% Other (n=4): 50% P=0.05 for difference in DGF between diagnostic categories Unpublished Data

- 77 liver transplants from cardiac arrest donors - 807 liver

42 - 77 liver transplants from cardiac arrest donors liver transplants from non cardiac arrest donors Liver Transplant 2015

43 AJRCCM 2013

44 Conclusions Demographics of deceased organ donation in Canada have changed HIBI is emerging as the predominant cause of death in deceased organ donors (both NDD and DCD) DCD accounts for growing proportion of deceased donation activity

45 Conclusions Implications of changing demographics: More severe organ dysfunction in donors Fewer organs per donor are procured More DGF (kidneys) Outcomes are favorable with transplants from wellselected donors with HIBI Future research should be aimed at: Optimizing care of organ donors Maximizing number organs procured per donor Refining criteria for acceptance / rejection of marginal organs

46 Updated guidelines in 2019!

47 Leprince et al, Eur J Cardiothorac Surg 2016 Cotter et al, J Cardio Thorac Anesth 2018

48 Summary / Questions? Demographics of deceased organ donation in Canada have changed over time Implications: Donor organ function Organs procured / transplanted per donor Graft function / recipient outcomes Highlights importance of excellent critical care management of organ donors

Deceased Organ Donation Requires Timely Not Early Referral To An Organ Donation Organization

Deceased Organ Donation Requires Timely Not Early Referral To An Organ Donation Organization Andreas H. Kramer MD MSc FRCPC Clinical Associate Professor Departments of Critical Care Medicine & Clinical