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146 I N D I C AT O R N º 9 5
Indicator EVALUATION OF POTENTIAL ORGAN DONORS AFTER CIRCULATORY DEATH (DCD) WITH LIMITING LIFE SUPPORT
Dimension Appropriateness
Justification
In recent years, donation after circulatory death (DCD) has expanded the pool of organs available for transplants. Considering donation from patients expected to die (according to cardiorespiratory criteria) after limitations on life support (LLS) is good practice in end-of-life care for critical patients.
Formula
total nº of patients dying of cardiac arrest after LLS (withdrawal) evaluated for DCD --- x 100
total nº of patients dying of cardiac arrest after LLS (withdrawal) Explanation of
terms
Evaluation for potential DCD: patients with LLS in whom the possibility of DCD is assessed according to protocol, including evaluation of viability criteria and clinical contraindications, possibility of dying of cardiac arrest in the time period that allows organ extraction for transplantation.
Population
All patients with LLS dying of cardiac arrest in the ICU during the period reviewed.
Exclusion criteria: patients with prior instructions refusing donation; LLS only to withhold new treatments.
Type Process
Source of data Clinical documentation. Death certificate reports. Transplant coordination records.
Standard 95 %
Commentaries
References:
Bodí MA, Pont T, Sandiumenge A, Oliver E, Gener J, Badía M, Mestre J, Muñoz E, Esquirol X, Llauradó M, Twose J, Quintana S. Brain death organ donation potential and life support therapy limitation in neurocritical patients. Med Intensiva. 2015 Aug-Sep;39(6):337- 44
Lesieur O, Leloup M, Gonzalez F, Mamzer MF; EPILAT Study Group. Eligibility for organ donation following end-of-life decisions: a study performed in 43 French intensive care units. Intensive Care Med. 2014 Sep;40(9):1323-31. doi: 10.1007/s00134-014-3409-2
Donación en asistolia en España: Situación actual y recomendaciones. National Consensus Document 2012. En: http://www.ont.es/infesp/Paginas/Documentaciion.aspx
Royal Decree 1723/2012, (28 December), regulating obtainment, clinical use, and territorial coordination of human organs for transplantation and establishing quality and safety requirements. https://www.boe.es/boe/dias/2012/12/29/pdfs/ BOE- A-2012-15715.pdf
Frutos MA, Guerrero F, Daga D, Cabello M, Lebrón M, Quesada García G, et al. [Kidney transplantation with grafts from type III Maastricht death cardiac donors]. Nefrología 2012;32:760-6
Quality Criteria and Quality Indicators in Organ Donation http://www.odequs.eu/pdf/ODEQUS_Quality_Criteria-Indicators.pdf
147 I N D I C AT O R N º 9 6
Indicator MONITORING POTENTIAL ORGAN DONORS Dimension Appropriateness
Justification
Potential donors should be maintained to achieve the greatest possible number of organs and to optimize their viability. This requires an ICU “maintenance protocol” for multiple organ donors. The significant and frequent alterations in hemodynamics, metabolism, and temperature regulation in these patients can threaten the viability of the organs to be transplanted.
Formula
total nº of brain-dead potential donors monitored appropriately
--- x 100 total nº of brain-dead potential donors
Explanation of terms
Brain death: clinical situation in which the function of both the cerebral hemispheres and the brainstem has ceased completely and irreversibly.
Potential donor: patients diagnosed with brain death without absolute contraindications for donation.
Appropriate monitoring: Minimal requirements:
Invasive arterial blood pressure
Central venous pressure/possibility of transpulmonary monitoring in cardiopulmonary donors and early and periodic ultrasonography n heart donors
Heart rate Central temperature Diuresis
Blood gases
Hemogram and coagulation
Biochemical parameters: electrolytes, glucose, systematic liver and renal function tests, and urinary sediment
Population All brain-dead potential donors discharged from the ICU during the period reviewed.
Type Process
Source of data Clinical documentation. Clinical information system Standard 100%
Commentaries
References:
Seller Pérez G, Herrera-Gutiérrez ME, Lebrón-Gallardo M, Quesada-García G. [General planning for the maintenance of the organ donor] Med Intensiva. 2009 Jun-Jul;33(5):235- 42
Hinojosa R, Herruzo A, Escoresca Ortega AM, Jiménez PI. [Evaluation and maintenance of heart donors]. Med Intensiva. 2009 Nov;33(8):377-84
Del Río F, Escudero D, De La Calle B, Vidal FG, Paredes MV, Núñez JR. [Evaluation and maintenance of the lung donor]. Med Intensiva. 2009 Jan-Feb;33(1):40-9
Salim A, Martin M, Brown C, Rhee P, Demetriades D, Belzberg H. The effect of a protocol of aggressive donor management: Implications for the national organ donor shortage. J Trauma. 2006 Aug;61(2):429-33
Salim A, Velmahos GC, Brown C, Belzberg H, Demetriades D. Aggressive organ donor management significantly increases the number of organs available for transplantation. J Trauma. 2005 May; 58(5):991-4
Wood KE, Becker BN, McCartney JG, D’Alessandro AM, Coursin DB. Care of the potential organ donor. N Engl J Med. 2004 Dec 23;351(26):2730-9
148 I N D I C AT O R N º 9 7
Indicator DIAGNOSING BRAIN DEATH Dimension Effectiveness
Justification
A high percentage of the organs transplanted in Spain come from brain-dead donors, so broad, correct clinical information about diagnosing this condition is fundamental for donation.
In Spain, about 15% of patients who die in ICUs are in this condition; in ICUs in neurosurgery reference centers, the percentage can be as high as 30%.
Formula
total nº of cases of brain death diagnosed
--- x 100 total nº of deaths in the ICU
Explanation of terms
Brain death: clinical situation in which the function of both the cerebral hemispheres and the brainstem has ceased completely and irreversibly.
The diagnosis requires clinical neurologic examination or instrumental diagnostic tests listed in the regulations in force: Royal Decree 1723/2012, (28 December). Brain death should be recorded in the clinical history.
Population All deaths in the ICU in the period reviewed
Type Outcome
Source of data Clinical documentation and Transplant Coordination records.
Standard 5%-30%
< 5% represents a low level of diagnosis
Commentaries
References:
Real Royal Decree 1723/2012, (28 December) regulating and establishing the quality and safety requirements for the obtainment, clinical use, and territorial coordination of human organs for transplantation. https://www.boe.es/boe/dias/2012/12/29/pdfs/ BOE-A-2012- 15715.pdf
Escudero D, Matesanz R, Soratti CA, Flores JI; on behalf of the Iberoamerican Donation and Transplant Network/Council. [General considerations on brain death and recommendations on the clinical decisions after its diagnosis.] Med Intensiva. 2009 Dec;33(9):450-4
Escudero D. [Brain death diagnosis] Med Intensiva. 2009 May;33(4):185-95
Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001; 344: 1215-21
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