Summary
Between 2013 and 2019, there was an increase in the consent rate for organ donation in the UK from 61% to 67%, but this remains lower than many European countries. Data on all family ...approaches (16,896) for donation in UK intensive care units or emergency departments between April 2014 and March 2019 were extracted from the referral records and the national potential donor audit held by NHS Blood and Transplant. Complete data were available for 15,465 approaches. Consent for donation after brain death was significantly higher than for donation after circulatory death, 70% (4260/6060) vs. 60% (5645/9405), (OR 1.58, 95%CI 1.47–1.69). Patient ethnicity, religious beliefs, sex and socio‐economic status, and knowledge of a patient's donation decision were strongly associated with consent (p < 0.001). These factors should be addressed by medium‐ to long‐term strategies to increase community interventions, encouraging family discussions regarding donation decisions and increasing registration on the organ donor register. The most readily modifiable factor was the involvement of an organ donation specialist nurse at all stages leading up to the approach and the approach itself. If no organ donation specialist nurse was present, the consent rates were significantly lower for donation after brain death (OR 0.31, 95%CI 0.23–0.42) and donation after cardiac death (OR 0.26, 95%CI 0.22–0.31) compared with if a collaborative approach was employed. Other modifiable factors that significantly improved consent rates included less than six relatives present during the formal approach; the time from intensive care unit admission to the approach (less for donation after brain death, more for donation after cardiac death); family not witnessing neurological death tests; and the relationship of the primary consenter to the patient. These modifiable factors should be taken into consideration when planning the best bespoke approach to an individual family to discuss the option of organ donation as an end‐of‐life care choice for the patient.
This multidisciplinary consensus statement was produced following a recommendation by the Faculty of Intensive Care Medicine to develop a UK guideline for ancillary investigation, when one is ...required, to support the diagnosis of death using neurological criteria. A multidisciplinary panel reviewed the literature and UK practice in the diagnosis of death using neurological criteria and recommended cerebral CT angiography as the ancillary investigation of choice when death cannot be confirmed by clinical criteria alone. Cerebral CT angiography has been shown to have 100% specificity in supporting a diagnosis of death using neurological criteria and is an investigation available in all acute hospitals in the UK. A standardised technique for performing the investigation is described alongside a reporting template. The panel were unable to make recommendations for ancillary testing in children or patients receiving extracorporeal membrane oxygenation.
Summary
The COVID‐19 pandemic had a major impact on UK deceased organ donation and transplantation activity. We used national audit data from NHS Blood and Transplant to explore in detail the effects ...of the pandemic in comparison with 12 months pre‐pandemic, and to consider the impact of the mitigating strategies and challenges placed on ICU by ‘waves’ of patients with COVID‐19. Between 11 March 2020 and 10 March 2021, referrals to NHS Blood and Transplant of potential organ donors were initially inversely related to the number of people with COVID‐19 undergoing mechanical ventilation in intensive care (incident rate ratio (95%CI) per 1000 patients 0.93 (0.88–0.99), p = 0.018), although this pattern reversed during the second wave (additional incident rate ratio (95%CI) 1.12 (1.05–1.19), p < 0.001). Adjusted numbers of donors (incident rate ratio (95%CI) 0.71 (0.61–0.81), p < 0.001) and organs retrieved (incident rate ratio (95%CI) 0.89 (0.82–0.97), p = 0.007) were inversely dependent on COVID‐19 workload, though weekly numbers of transplants were unrelated (incident rate ratio (95%CI) 0.95 (0.86–1.04), p = 0.235). Non‐COVID‐19 mortality fell from 15,007 to 14,087 during the first wave (rate ratio (95%CI) 0.94 (0.92–0.96), p < 0.001) but climbed from 18,907 to 19,372 during the second wave (rate ratio (95%CI) 1.02 (1.00–1.05), p = 0.018). There were fewer in‐hospital deaths from cardiac arrest and intracranial catastrophes throughout (rate ratio (95%CI) 0.83 (0.81–0.86), p < 0.001 and rate ratio (95%CI) 0.88 (0.85–0.91), p < 0.001, respectively). There were overall fewer eligible donors (n = 4282) when compared with pre‐pandemic levels (n = 6038); OR (95%CI) 0.58 (0.51–0.66), p < 0.001. The total number of donations during the year fell from 1620 to 1140 (rate ratio (95%CI) 0.70 (0.65–0.76), p < 0.001), but the proportion of eligible donors who proceeded to donation (27%) was unchanged (OR (95%CI) 0.99 (0.91–1.08), p = 0.821). The reduction in donations and transplantation during the pandemic was multifactorial, but these data highlight the impact in the UK of a fall in eligible donors and an inverse relationship of referrals to COVID‐19 workload. Despite the challenges faced, the foundations underpinning the UK deceased organ donation programme remained strong.
Summary
We report three deaths following percutaneous dilatational tracheostomy in a series of 1187 procedures undertaken in a single intensive care unit over a 13‐year period. All deaths were due to ...severe haemorrhage. The first patient died during the procedure from uncontrollable haemorrhage from the innominate vein. Delayed haemorrhage in the other two patients was caused by the tracheostomy tube eroding into the aorta in one patient and into the innominate vein in the other. In both these patients, the tracheal stoma was found at postmortem to be sited unexpectedly low. Fatal haemorrhage is a rare complication of percutaneous tracheostomy (0.25% in this series), but is probably under‐reported. While bronchoscopy is now used routinely during percutaneous tracheostomy insertion in most units, we speculate that ultrasound examination of the neck is more likely to identify major vascular structures at risk. However, whilst intuitive, there is little evidence that either bronchoscopy or ultrasound scanning reduces the incidence of complications. Magnetic resonance images of normal subjects are presented to demonstrate the anatomical relations of the trachea to major vascular structures and their variability.
Background In the UK demand for organ transplantation continues to outstrip supply and one strategy aimed at reversing this trend is the introduction of non-heart beating donor (NHBD) schemes. In ...this paper we describe our experience after the introduction of the NHBD scheme at a regional neuroscience intensive care unit (ICU) that also provides general intensive care. Methods We describe the steps taken to establish the scheme and present our results from the time of its implementation in July 2002 until March 2007. Results Of the 100 patients whom we referred to the transplant co-ordinators, 71 were identified as potential NHBDs and of these 29 went on to become actual donors (conversion rate of 40.8%). Fifty-six kidneys were retrieved and 53 successfully transplanted. In addition, two livers were retrieved but subsequently found to be unsuitable for transplantation, while eight pancreas were retrieved and used for islet cell research. The serum creatinine at 1 yr demonstrates that there is no significant difference between transplanted kidney function from NHBDs and heart-beating donors (HBDs). Conclusions We believe that by establishing the NHBD organ donation scheme we are able to fulfil the wishes of more patients who have indicated that they would like to donate their organs while increasing the availability of solid organs for transplantation. With careful preparation, audit, and communication our experience demonstrates that the NHBD scheme can be successfully introduced in an ICU and expanded to other ICUs in a region.
To determine the effect of an intensive care management protocol on the intensive care unit (ICU) and hospital mortality of severely head-injured patients, we designed a longitudinal observational ...study of all patients admitted with a head injury between 1992 and 2000.
A computerized patient database was used to identify all patients with severe head injury admitted to the ICU at Frenchay Hospital, Bristol, UK: a tertiary referral centre for the clinical neurosciences. We compared the ICU and hospital mortality and length of stay in patients before and after implementation of a protocol for their ICU management in 1997.
Implementation of the protocol was associated with a significant reduction in ICU mortality from 19.95% to 13.5% (odds ratio 0.47; 95% CI 0.29–0.75), and in hospital mortality from 24.55% to 20.8% (odds ratio 0.48; 95% CI 0.31–0.74). This was achieved despite a significant increase in the median APACHE II score (14 vs 18) of patients admitted after implementation of the protocol. The median ICU and hospital length of stay remained constant over the study period.
The introduction of an evidence-based protocol to guide the ICU management of patients with severe head injury has been associated with a significant reduction in both ICU and hospital mortality.
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