Page 1591 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1110 PART 10: The Surgical Patient

refusal. Families need time to acknowledge the death before they are duration of “downtime” (cardiopulmonary arrest) and cardiopulmonary
approached about donation. Consent rates have been shown to increase resuscitation, vital signs, drugs administered, and obvious signs of chest
from 18% to 60% if there was a delay between death and the request for and abdominal trauma are noted. If an old chart or the patient’s primary
donation. Ensuring that this delay occurs is referred to as “decoupling” physician is available, a pertinent medical history is obtained.
of the request. The timing of the request has been evaluated in numerous Completing a battery of laboratory tests in a timely manner will
studies, and all the researchers have reached the same conclusion: that expedite organ placement and decrease the time required for donor
decoupling the request leads to improved donation rates. However, management. A blood sample is also obtained from the donor, to per-
despite vigorous attempts by the organ donation and the health care form bacteriologic and serological screening for infectious disease. This
community to educate critical care staff, about the importance of decou- serological sample is usually sent to a central laboratory that performs
pling the request, a significant number of requests are still “coupled.” 16,28 such testing on a 24-hour basis; however, once the sample arrives at
Unfortunately, current medical school curricula generally lack train- the laboratory, it usually takes about 6 hours for the results to be deter-
ing on how to break bad news and inform of death. It is important that mined. Usually, the donation coordinator is aware of the serological
the word “dead” should be pronounced and not avoided. At the brain results as the offers for organ-specific recovery are made.
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death declaration, the main task of the intensive care unit staff is not The organ procurement coordinator reviews a comprehensive medi-
that of obtaining consent for organ removal, but rather counseling and cal and social history with the appropriate family members or significant
helping the family to cope with the grieving process. Minimizing the others. Donors are screened for a number of factors, including but not
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family’s distress is the focus of care and is an essential prerequisite for a limited to, any history or treatment of heart disease, hypertension, chest
subsequent organ donation request. pain, or diabetes; use of tobacco, drugs, and alcohol; and high-risk
Unrestricted visits to the potential donor should not only be permit- behaviors for transmission of human immunodeficiency and hepatitis
ted, but actively encouraged. All the family’s questions about brain death viruses. Pertinent family history is reviewed also. The organ procurement
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must be answered unhurriedly by the staff, and the right words should coordinator does a complete physical examination of the donor, paying
be used in front of a warm cadaver with a heart that is still beating. For close attention to any finding that may influence organ integrity. The
example, it is better to use terms which strengthen the certainty of the transplant surgeons determine the suitability of the donor with respect
death, such as “no, he does not breathe, but the ventilator forces the air to the transplantable organs.
into the lungs,” or “yes, the heart is still pumping the blood, and it will
do so for some hours more because it is artificially stimulated and this ■ SCREENING FOR INFECTIOUS AGENTS
is why the skin is warm.” No mention about organ donation should be Serological screening for HIV, human T lymphotropic virus (HTLV),
raised before the concept of brain death is comprehended and the death hepatitis B virus (HBV), hepatitis C virus (HCV), and cytomegalovirus
is accepted by the family. The staff should refer to the dead patient using (CMV) is routinely performed along with screening for Treponema
the past tense; as soon as family members begin to talk of him or her antigen (syphilis) and for Toxoplasma. The presence of an active viral
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using “was,” the acceptance of death becomes clear. The physician who is infection in the form of encephalitis or meningitis, varicella-zoster virus
in charge of the intensive care unit should only discuss brain death with infection, or HIV infection is an absolute contraindication to organ
the family. The discussion relating to organ donation should be intro- donation because of the hazard that each of these clinical situations pose
duced by the transplant coordinator so that there is a clear distinction to the allograft recipient.
between the two functions (ie, treatment of the patient and preparation Isolated hepatitis B surface antibody positivity usually implies
for donation). The request should be made by the transplant coordinator previous vaccination. Hepatitis B surface antigen (HBsAg) positivity
in a positive way. It should be proposed as an option that the hospital reflects the presence of viral DNA in the blood that is related to
offers the family for helping other patients, rather than an apologetic or current hepatitis B infection or a remote infection that has not cleared.
indifferent businesslike gesture. Those who have difficulty in requesting These donors have contagious hepatitis B and will transmit the disease
consent should delegate the task to more confident staff. The family to the recipients unless the recipient has neutralizing antibodies due to
must never be forced into making a hasty decision, and it is always advis- previous exposure or vaccination. Patients who have acute hepatitis
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able to let them take their time and discuss the matter among themselves infection develop antibodies to the core antigen early in the course of the
and with other members of the family before asking again. Often an disease. Donors who are core antibody–positive should be considered
initial refusal turns into a convinced consent over the course of two or infectious because they may be convalescing from acute infection. If
three meetings. While a firm refusal must be respected, hesitation can both surface and core antibodies are positive, the patient has recov-
easily lead to authorization if the subject of the urgent need of organs for ered from hepatitis B and demonstrates immunity. Nevertheless, liver
many patients, as a lifesaving procedure or a dialysis-relieving therapy, recipients from these donors are at significant risk for the development
is raised tactfully. The consent process for organ and tissue donation of acute hepatitis B infection, as opposed to the recipients of the other
should not only be considered a necessity, but also a family’s right and organs. Organs from these core-positive donors are generally reserved
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as a quality measure of an intensive care unit’s performance. for patients with a documented response to the hepatitis B vaccine. 32,33
Obtaining consent for organ donation from families is enhanced by: All hepatitis C antibody–positive donors should be considered
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• Allowing time for families to accept death infectious. The hazard of HCV transmission from a previously infected
• Having someone who is an expert in donation consent approach the organ donor is a concern for all allograft recipients. Approximately 5%
family of all organ donors are positive for antibody to HCV. The presence of
antibody to HCV is indicative of HCV infection, because antibody to
• Approaching the family in a private, quiet area in an unhurried manner HCV appears in peripheral blood within 2 months of HCV exposure.
• Involving nursing and the organ procurement organization staff in Most organ procurement organizations have adopted a policy of screen-
the coordination of the entire consent and donation process ing organ donors for antibody to HCV. IgG antibody to HCV does not
protect against donor organ contamination; however, the risks of trans-
EVALUATION OF A POTENTIAL DONOR mission from HCV-RNA negative, HCV antibody-positive donors have
not yet been fully determined. 32
Once consent for organ donation is given, a thorough evaluation is Although a positive screening result does not necessarily rule out
conducted. The organ procurement coordinator collaborates with the organ donation, a selective strategy of reserving organs from HCV-
critical care nurse to obtain the necessary history and results of diagnos- positive donors for recipients with previous HCV exposure and detect-
tic tests. The donor’s chart is reviewed for prehospital and emergency able antibody to HCV can be applied. Transplantation of a liver or
department entries for details of the events leading to admission. The kidney(s) from a donor positive for antibody to HCV to a recipient

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