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Corresponding author: Marcella L. Donkin, RN, CPNP, CCRN, St. Louis Children’s Hospital at Washington University Medical Center, One Children’s Place, 7E25, St. Louis, MO 63110 (e-mail: mld6826{at}bjc.org).
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Abstract |
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• Objective To examine current rates of recovery of organs from children for transplantation at free-standing pediatric hospitals versus all other hospitals.
• Methods Data from the hospitals served by Mid-America Transplant Services from January 2000 to July 2003 were reviewed. Organ recovery rates from freestanding children’s hospitals were compared with the rates from other types of institutions. Patients were included if their organs were considered medically suitable at the time of referral for donation.
• Results Overall, 66% (210/318) of the potential organs were recovered. The type of institution in which the potential donor was managed did not influence the proportion of organs recovered: 67% (96/144) at freestanding children’s hospitals versus 66% (114/174) at all other hospitals. A greater proportion of livers were recovered at other donor institutions than at children’s hospitals (100% vs 85%, P
.01).
• Conclusion The organ recovery rate from potential pediatric donors is low. In general, this rate does not appear to be affected by the type of managing pediatric institution except for liver recovery, which favors institutions that are not freestanding children’s hospitals. The low rate of recovery suggests that although suitable donors are identified, appropriate referrals are made, and families provide consent for donation, major obstacles remain to the successful recovery of organs.
We sought to examine current organ recovery rates in children at a variety of managing institutions. We hypothesized that the ability to recover organs from potential child donors is influenced by the type of institution in which the donor is managed: freestand-ing children’s hospitals versus other hospitals. We also hypothesized that the effect would be more pronounced in younger children.
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Methods |
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All potential donors less than 18 years old were evaluated. Patients were included if their organs were considered medically suitable by MTS at the time of referral for donation. Patients were excluded if the organs were not recovered because of factors considered outside of institutional influence. These factors included the lack of consent as a whole or per individual organ, refusal by the medical examiner, and failure to place organs with an appropriate recipient on the basis of age, size, or blood type. For the purposes of this investigation, the total number of organs that could potentially be recovered from each donor was 6: heart, lungs (2), liver, and kidneys (2).
| More than 2000 children under the age of 18 are waiting for donor organs.
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MTS does not have specific guidelines for management of child donors. Each potential organ donor is managed by an organ procurement coordinator from MTS. The coordinators are all registered nurses without specific pediatric experience. When assistance is needed with management of child donors, coordinators consult one of their medical directors or the critical care team on site. The medical directors have pediatric, but not critical care, expertise.
Organ donors were managed via standard MTS practice. Procedures were not altered during the study period. Regular suctioning and chest physiotherapy were performed. Tidal volume was set at 10 to 15 mL/kg and positive end-expiratory pressure was set at 5 cm H2O. Ventilator management was adjusted to normalize the acid-base status on the basis of arterial blood gas measurements. A nasogastric tube was inserted and set to low intermittent suction. Body temperature was maintained at or near 37°C by using forced-air convection warmers or cooling blankets as needed. Intravenous arginine vasopressin was administered if urine output was greater than 500 mL/h for 2 consecutive hours. All routine medications except antibiotics and inotropic agents were discontinued. If not already in use, dopamine was administered to achieve age-appropriate blood pressure. Intravenous fluids were infused to maintain normal central venous pressure. Cefazolin and methylprednisolone were administered in the operating room just before organ recovery.
Statistical analysis was performed by using SPSS version 10.0.5 (SPSS Inc, Chicago, Ill). Differences in organ recovery rates were compared by using a 
2 test and the Fisher exact test. Significance was determined as a P value of .05 or less.
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Results |
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The 53 patients were divided into 4 groups by age: less than 1 year, 1 to 5 years, 6 to 10 years, and 11 to 17 years. Overall, 8 potential donors were less than 1 year old. Although individual organs were recovered in the group less than 1 year old and are analyzed later, all donors in that group had at least 1 organ that met exclusion criteria. In the group 1 to 5 years old, 72% (13/18) of the potential organs were recovered from 3 donors. This proportion decreased to 63% (34/54) among the 9 potential donors who were 6 to 10 years old. Finally, 66% (163/246) of potential organs were recovered from 41 donors in the group who were 11 to 17 years old.
The type of donor institution did not influence recovery when age groups were analyzed. In children’s hospitals, 83% (10/12) of the potential organs in the group 1 to 5 years old were recovered versus 50% (3/6) in other hospitals. In the group 6 to 10 years old, 64% (27/42) of organs were recovered at children’s hospitals versus 58% (7/12) in other hospitals. The recovery proportions were minimally different in the group 11 to 17 years old: 66% (59/90) for children’s hospitals versus 67% (104/156) for other hospitals.
| The type of institution, pediatric versus other, did not affect organ recovery rate.
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Because individual organs may have met exclusion criteria, a second analysis was performed for each recoverable organ: heart, lungs (2), liver, and kidneys (2). A total of 64% (42/66) of all hearts were recovered from potential child donors. Although a higher percentage of hearts was recovered from donors managed in children’s hospitals than in other hospitals (69% [25/36] vs 57% [17/30]), the difference was not significant. All 5 hearts recovered from children less than 1 year old were from children’s hospitals. All potential donor hearts in children less than 5 years old who were managed in children’s hospitals were recovered (n = 4) compared with only 50% (1/2) of those managed at other hospitals. In groups of children more than 6 years old, the percentages are similar when pediatric and other institutions are compared (Table 2).
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A greater proportion of livers were recovered at other donor hospitals than at children’s hospitals: 100% (36/36) versus 85% (33/39; P .01). This difference was mainly due to recovery in the older age group (11–17 years old; Table 2). A total of 92% of all kidneys were donated; these percentages were nearly identical between the 2 types of institutions: 94% (58/62) in children’s hospitals versus 90% (65/72) in other hospitals.
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Discussion |
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Although overall recovery rates were poor among potential child donors, the rates were not significantly affected by age or donor institution. We had thought that the experience of the donor institution with managing critically ill children would affect recovery rates. Furthermore, we had anticipated that this effect would be more pronounced in the younger age groups, on the basis of the availability of pediatric expertise and resources available at freestanding children’s hospitals. Our data suggest that this access does not significantly affect management and subsequent recovery.
| Even though potential donors were identified and consent was obtained, only 66% of the organs were recovered successfully.
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Our data do not allow examination of specific causal relationships for recovery rates. However, because brain death causes severe cardiovascular, hormonal, and metabolic changes, early diagnosis is crucial in terms of maintaining organ function.6 The widespread physiological changes that occur after brain death lead to a high incidence of complications that jeopardize vital organ function. Prompt treatment to preserve organ function increases the chances of successful organ transplantation. Strategies for the management of organ donors exist whereby the rapid physiological decline that occurs after brain death can be stabilized by active donor resuscitation so that the functional integrity of potentially transplantable organs is maintained.3,7,8
A recent study3 confirmed that the application of a standardized protocol for donor management results in significant increases in the number of organs procured without any reduction in the quality of transplanted organs. This finding may be applicable to children as well. Although aggressive strategies for donor management in adults have been linked to increased numbers of recovered organs,9 few data exist relative to donor management in children. We thought that the access to the specific resources presumably available at freestanding children’s hospitals might influence management strategies. Our data do not support that conclusion.
Although our data reveal suboptimal recovery rates, it is unclear whether modifications to current practice can affect this rate. As stated, specific care protocols for child donors could be developed and implemented. Furthermore, opportunities may occur to examine both the constituency and the role of the donor management team.
After brain death is declared and consent for donation has been obtained, the attention of the organ procurement coordinator turns to evaluating and maintaining donor organ function to optimize organ recovery. The coordinators are also simultaneously responsible for communicating with recipient institutions to secure placement of the organs. Currently, coordinators have a lack of experience with children.
Additionally, consultation requests by the organ procurement organization result in physicians who may have experience with pediatric medicine but not with critical care medicine. The influence of implementing strategies such as adding pediatric critical care nurses and physicians to the management team and following strict pediatric care protocols on the outcome of organs has yet to be examined. Wheeldon et al10 suggested that the inclusion of a trained physician on the donor team was a crucial change in their practice and improved recovery rates.
Our study is limited by its retrospective nature. We were unable to control for severity of donor illness, mechanism of donor injury, or referral patterns; any future prospective studies should include these considerations. Additionally, we were unable to control for degree of input from hospital staff during the management period; in many instances, this information is undocumented. However, we anticipate that staff within a children’s hospital would influence results from these institutions in a beneficial way. Furthermore, we were unable to examine exactly what the resource differences were among institutions. Finally, our study population is a regional sample. Assessment of the reproducibility of these results on a national scale is a future area of investigation.
Our study highlights active efforts in this area of practice. In April 2003, the Department of Health and Human Services commissioned the Organ Donation Breakthrough Collaborative, which is designed to determine best recovery practices among US hospitals and to implement the practices into standards of care. Further efforts by this collaborative will be directed at improving the recovery process while supporting donors’ families and staff involved with the donors.
The Department of Health and Human Services also has initiated funding opportunities to enhance research efforts geared toward organ recovery and, in October 2005, launched the Organ Transplantation Collaborative. This program was developed to find ways to improve the number of organs recovered per donor. Recovery efforts should not be aimed solely at increasing consent rates. Improved recovery may be affected by enhancing the donor management. Child-specific strategies may play a role in this effort and warrant further study.
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