Regional variation of organ

donors

in Swedish ICUs may indicate

missed opportunities for donationThomas Nolin*, Sten Walther*, Caroline Mårdh*, Göran Karlström* & Charlotte

Möller**

* The Swedish Intensive care Registry, SIR **The Swedish Council for Organ and Tissue Donation

http://www.icuregswe.org

The Swedish Intensive care Registry - SIR

SSAI Congress, Bergen 15-17 June, 2011Poster presentation

16 June 2011 Swedish Intensive care Registry, SIR 2

Background

The Swedish Council for Organ and Tissue Donation (Donationsrådet):– Objective: 22 donors per million people (DPMP) by 2014– Focus on withholding/withdrawing medical treatment in ICU

The National Board of Health and Welfare (Socialstyrelsen):– Proposal for new regulations on life-sustaining treatment

Potential conflict of interest in end-of-life decisions and organ procurement?

16 June 2011 Swedish Intensive care Registry, SIR 3

Starting point - Definition

Potential deceased organ donor– Intensive care patient with

– Mechanical ventilation and

– Brain death diagnosis (completed) and

– Identified as medically suitable for organ donation (no absolute contraindications to organ donation)

http://www.dopki.eu

Eligible donation after brain death: A medically suitable person who has been declared dead based on neurologic criteria as stipulated by the law of the relevant jurisdiction. Domínguez-Gil B et al. Review. The critical pathway for deceased donation: reportable uniformity in the approach to deceased donation. Transplant International 2011.

Diff

ere

nt

wo

rdin

g –

th

e s

am

e d

efin

itio

n

16 June 2011 Swedish Intensive care Registry, SIR 4

Objectives

To examine the incidence of patients with – New severe brain damage, – who received mechanical ventilation and – were diagnosed with brain death, and – the number of actual organ donors in

the 21 Swedish county councils

16 June 2011 Swedish Intensive care Registry, SIR 5

Dataset – Who?

All deceased intensive care patients in

All Swedish ICU’s

A structured protocol for follow up of

deceased intensive care patients– SIR and

– Swedish Council for Organ & Tissue Donation

16 June 2011 Swedish Intensive care Registry, SIR 6

Dataset – What?

16 June 2011 Swedish Intensive care Registry, SIR 7

21 County councils in Sweden

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

New severe braindamage

and mechanicalventilation

and brain death and medically suitable and positive orpresumed consent

Actual organ donation

Per

cen

t o

f d

ecea

sed

wit

h .

..

Norrbotten (143) Västerbotten (285) Västernorrland (271) Jämtland (99)Gävleborg (257) Dalarna (153) Värmland (277) Uppsala (304)Västmanland (135) Örebro (254) Södermanland (187) Stockholm (1 191)Östergötland (271) Jönköping (190) Kalmar (185) Västra Götaland (1 136)Halland (191) Kronoberg (133) Blekinge (112) Region Skåne (846)Sweden (6 620)

2009-2010:83 ICU's> 81 583 admissions6 620 deaths244 actual organ donors

16 June 2011 Swedish Intensive care Registry, SIR 8

6 620 deaths in 83 ICU’s during 2009-2010

New, severe brain damage New, severe brain damage- and mechanical ventilation- and brain death- and medically suitable

New, severe brain damage- and mechanical ventilation- and brain death- and medically suitable- and positive or presumed consent- and actual organ donation

County council variations

0

.1

.2

.3

.4

.5

Eve

nt r

ate

0 200 400 600 800 1000 1200

Number deceased (2009-2010)

0

.02

.04

.06

.08

.1

.12

.14

Eve

nt r

ate

0 200 400 600 800 1000 1200

Number deceased (2009-2010)

0

.03

.06

.09

.12

.15

Eve

nt r

ate

0 200 400 600 800 1000 1200

Number deceased (2009-2010)

Potential deceased organ donors Actual organ donors

Alert limit -2SD

Alarm limit -3SD

New, severe brain damage

16 June 2011 Swedish Intensive care Registry, SIR 9

Conclusions

The number of actual organ donors varied from 0.5 % to 10.1 % of all ICU deaths

There was no obvious relationship between the proportion of patients with new severe brain damage (17.9 – 43.4 %) and the proportion of actual organ donors

May indicate that organ donors were missed in regions with a low rate of actual organ donors

Thank you!

16 June 2011 Swedish Intensive care Registry, SIR 10

Actual organ donors per million people per year2009 - 2010

0

5

10

15

20

25

Norra Uppsala-Örebro Stockholm-Gotland Sydöstra Västra Södra

Region

DP

MP

DPMP (Donors per miljon people)

Swedish Council for Organ & Tissue Donation's objective for 2014: 22 DPMP

16 June 2011 Swedish Intensive care Registry, SIR 11

Actual organ donors per million people per year2009 - 2010

0

5

10

15

20

25

30

35

40

Norrb

otte

n

Väste

rbot

ten

Jäm

tland

Väste

rnor

rland

Dalarn

a

Gävleb

org

Värm

land

Örebr

o

Västm

anlan

d

Uppsa

la

Stock

holm

V. Göt

aland

Jönk

öping

Österg

ötlan

d

Sörm

land

Hallan

d

Krono

berg

Bleking

e

Kalmar

Skåne

Sweden

County Council

Act

ual

org

an d

on

ors

per

mill

ion

peo

ple

per

yea

r Swedish Council for Organ & Tissue Donation's objective for 2014: 22 DPMP

16 June 2011 Swedish Intensive care Registry, SIR 12

New severe brain damage?

No: 4 634Yes: 1 986

Mechanical ventilation?Mechanical ventilation?

Yes: 1 795 Yes: 3 326No: 191 No: 1 308

Braindeath451

Circulatorydeath1 308

Group 120%

CirculatoryDeath3 326

Group 250%

Circulatorydeath191

Group 33%

Circulatorydeath1 344

Group 420%

Group 57%

Number of deceased patients: 6 62083 ICU’s in Sweden 2009-2010

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Why couldn’t death be diagnosed by direct criteria (brain death?

1. Withdrawal of medical treatment

2. Withholding medical treatment

3. Medically unsuitable as organ donor

4. Cardiac activity could not be restored

5. No attention was paid to the patient as a possible donor

6. The deceased was negative to organ donation

7. No access to diagnostic radiology

8. No access to competent clinical neurological examination

9. No clinical suspicion of total cerebral infarction

New, severe brain damage and mechanical ventilation and circulatory death. N 1 344.

713

236

355

235

9

31

2

0

596

Multiple choices

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Who defines medically suitable?

Transplant surgeon and coordinator!

But…

There was no contact with transplant coordinator in potential deceased organ donor cases (N 375) in:– 2009: 28/209 (13.4 %)

– 2010: 13/166 (7.8 %)All cases should be contacted!

A quality indicator in SIR

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Dataset

The data are sent electronically to SIR– validated and displayed on the SIR open website

within 6 hours from completed validation– http://avlidna.icuregswe.org

As yet only in Swedish!

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Actual (=effective) donor

Individual from whom at least one organ was recovered for the purpose of transplantation

Utilized donor– A deceased person from whom at least one organ

has been retrieved and transplanted

http://www.dopki.eu