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
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
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
Donors per million population Deceased Donation In Canada 25 20 15 10 5 0 NDD DCD Total Source: CORR
2017: 21.9 dpmp 25% DCD CBS System Progress Report 2017
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
Pathway To NDD Organ Donation Admission to ICU Recognition / Diagnosis of NDD Approach / Consent For Donation Care Of Organ Donor Organ Recovery & Transplantation
Leading Practices
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
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
140 Traumatic Brain Injury Hospital Admissions Per 100,000 Population In Canada 120 100 80 60 40 20 0 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 Age 0-19 Age 20-39 Age 40-59 Age 60+ CIHI 2006
Fu et al, J Trauma 2015
Injuries From MVCs in Alberta 60 Injuries Per 10,000 population 50 40 30 20 10 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Source: Traffic Alberta 2017
CMAJ 2013
CMAJ 2013
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
Severe TBI after ATV accident Day #4 in ICU: Increased ICP and fixed pupils
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 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
More Bystander CPR Chan et al, Circulation 2014
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
Long Duration CPR Median duration CPR with non-shockable rhythm: 16.4 minutes (IQR 10.3-23.3) Grunau et al, Resuscitation 2016
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
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
Intensive Care Med 2016
* * Kramer et al, CMAJ Open 2017
Kramer et al, CMAJ Open 2017
Cause of Death in Consented Potential DCD Donors in Alberta & B.C. (2015-2017) 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%
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
1.9 dpmp 3.6 dpmp 11.8 dpmp 13.4 dpmp 13.3 dpmp CMAJ 2017
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
Deceased Organ Donation in Calgary 40 35 30 25 20 15 10 5 0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 (YTD) NDD DCD to NDD DCD
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
600 3000 Creatinine (mmol/l) 400 200 ALT (units/l) 2000 1000 0 ABI TBI Stroke 0 ABI TBI Stroke 600 10 PaO2:FIO2 400 200 Troponin T (ng/ml) 8 6 4 2 0 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 0.5 0 No Cardiac Arrest Cardiac Arrest 0-30 Minutes Cardiac Arrest 31-60 Minutes Cardiac Arrest > 60 Minutes Kramer et al, CMAJ Open 2017
Canadian Organ Replacement Registry (2000-2013) 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%
Kramer et al, CMAJ Open 2017
Canadian Organ Replacement Registry (2017) Cause Of Death Organs procured per donor Total Kidney Liver Lung Pancreas Total NDD 1.64 0.80 0.50 0.28 3.61 DCD 1.73 0.43 0.31 0.10 2.58
60% Recipient Outcomes: Delayed Graft Function 50% 40% 30% 20% 10% 0% TBI CVA Cardiac Arrest 0-30 Minutes Cardiac Arrest 31-60 Minutes Cardiac Arrest > 60 Minutes Dialysis "Functional" DGF Kramer et al, CMAJ Open 2017
Recipient Outcomes: Delayed Graft Function 250 200 150 100 50 0 TBI CVA Cardiac Arrest 0-30 Minutes Discharge Cr (Median) Cardiac Arrest 31-60 Minutes One Year Cr (Median) Cardiac Arrest > 60 Minutes
DGF Following DCD in Alberta (2009-2017; 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 transplants from non cardiac arrest donors Liver Transplant 2015
AJRCCM 2013
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
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
Updated guidelines in 2019!
Leprince et al, Eur J Cardiothorac Surg 2016 Cotter et al, J Cardio Thorac Anesth 2018
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