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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Organ donation from burn-injured patientsda national perspective Taryn E. Travis, MD,a,b Laura S. Johnson, MD,a,b Lauren T. Moffatt, PhD,b Ram M. Subramanian, MD,c Marion H. Jordan, MD,a,b and Jeffrey W. Shupp, MDa,b,* a
The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC c Emory Transplant Center, Emory University Hospital, Atlanta, Georgia b
article info
abstract
Article history:
Background: There is a discrepancy between publically available data from the United
Received 10 December 2013
Network for Organ Sharing (UNOS) database and perception of the incidence of mortally
Received in revised form
burn-injured patients serving as organ donors. In the last 5 y, a single burn center referred
3 March 2014
several patients who went on to successfully donate multiple organs. However, UNOS data
Accepted 5 March 2014
indicate very few referrals of patients with burn injuries nationwide. This discrepancy in
Available online xxx
UNOS-reported occurrences versus institutional experience prompted this work. Methods: UNOS data from 1988e2012 was examined for causes of death related to thermal
Keywords:
injury, electrical injury, inhalation injury, or carbon monoxide poisoning. The National
Organ donation
Burn Repository was examined for burn center death rates and patient characteristics of
Organ transplantation
those with reported nonsurvivable burn injuries. Finally, a national survey queried the
Burn
clinical experiences and educated opinions of burn center directors, transplant surgeons,
Electrical injury
and organ procurement organization (OPO) representatives regarding organ donation in
Inhalation injury
the burn-injured population.
Carbon monoxide poisoning
Results: Between 42% and 52% of those surveyed responded. Survey data indicate that at
Procurement
least 61 patients with burn-related injuries have served as organ donors in the past 5 y
Survey
alone, versus 23 identified in 24 y of UNOS data. Survey data also indicate that inhalation
National Burn Repository
injuries were the most common burn-related injuries seen before successful organ procurement. Kidneys were the most commonly donated organs, but all major organs and tissues were represented in the experiences of surgeon and organ procurement organization respondents. Up to 10% surgeon respondents believe that patients with burn injuries should not be referred for possible organ donation. Conclusions: There are more organs donated by patients with mortal burn injuries than currently available UNOS data would suggest. Survey data suggest that these patients should be able to contribute successfully to the supply of organs needed by those on transplant waiting lists, but remain inconsistently recognized as such a resource. Knowledge about long-term organ and tissue viability from burn-injured patients is lacking, and should be the focus of future research. ª 2014 Elsevier Inc. All rights reserved.
* Corresponding author. 110 Irving Street, NW, Room 3B-55, Washington, DC 20010. Tel.: þ202 877 7347; fax: þ202 877 7302. E-mail address: [email protected] (J.W. Shupp). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.03.010
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1.
Introduction
1.1.
Case report
A 16-y-old male was involved in a house fire reportedly caused by a television explosion. The patient was found to be asystolic in the field by first responders, who estimated 15 min of down time before the initiation of Advanced Cardiac Life Support. Cardiopulmonary resuscitation continued en route to a local emergency room, and minutes after arrival, vital signs were regained. Shortly thereafter, a laryngeal mask airway was placed, and request was made for transfer to the nearest burn center, approximately 23 miles away. The patient presented to the burn center with approximately 50% total body surface area burns to the back, buttocks, bilateral upper and lower extremities, and carbonaceous debris around the nose and mouth with bronchoscopic evidence of inhalation injury. Chest x-ray showed bilateral lung infiltrates. The patient was endotracheally intubated and massive fluid resuscitation with vasopressive support was initiated. The patient had a carboxyhemoglobin level of 21.3% on initial laboratory tests at the burn center, with an estimated level of 50%e60% near the time of injury. The patient’s Glasgow Coma Score was 3T without the need for sedatives or paralytics, and he showed no evidence of brainstem activity. He lacked gag reflex, cough reflex, rectal tone, and both pupils were fixed and dilated. Referral was made to the local organ procurement organization (OPO) for evaluation of appropriateness for organ donation approximately 9 h after presentation to the burn center. An estimated 36 h after injury, brain death was confirmed by clinical examination and apnea test. The patient’s family wished to proceed with organ donation and the patient was able to donate bilateral lungs and kidneys. As of December 2012, the involved OPO reported that the patients’ bilateral lungs were donated to a single recipient who was still alive at 1-y posttransplantation. The statuses of donated kidneys were unavailable.
1.2.
Background and literature review
The gap between the number of patients awaiting organ transplant and the number of available organs has been
problematic for over half a century [1]. As of February 20, 2014, there are 121,290 patients on the waiting list for an organ transplant, with 77,325 of them in active waiting status [2]. Since 1988, the largest number of United States transplants performed in a given year occurred in 2006, with 28,940 transplants from 14,750 donors (8017 deceased and 6733 living). Although this is a large increase in transplants from those documented only 10 y prior in 1996 (19,765 transplants from 9222 donors), the disparity between organ availability and need continues to grow. The United Network for Organ Sharing (UNOS) partners with the Organ Procurement and Transplant Network (OPTN) to maintain a database of statistics that has detailed yearly organ donations and transplants since 1987. Donor causes of death are available, although burn-related injuries are not included as categories of cause. As such, it is unclear how many patients with nonsurvivable burn-related injuries contribute to the donor pool each year. The National Burn Repository (NBR) is a rolling database cataloging a 10-y record of inpatient burns in North American burn centers. In the 2012 annual report,183,036 cases are represented from 2002e2011, with 6822 of them listing death as the documented outcome [3]. On the basis of known individual burn center experiences, mortally burn-injured patients do go on to donate greatly needed organs, as did the patient described in the previously mentioned case report; however, simply referencing the national data available from OPTN would lead one to believe that it is a very rare occurrence. The following were the aims of this study: (1) to assess the number of burn-related organ donors evident in OPTN national data reporting, (2) to estimate the number of mortally burn-injured patients represented in the NBR that may have qualified as organ donors, and (3) to nationally survey professionals involved in burn care and organ transplantation in an effort to assess their experiences and opinions regarding organ donation in patients with burn injury. The overall goal was to use these data to identify reasons for discrepancies in reported numbers in databases versus actual donor figures, and codify different perspectives on referral of patients with burn injuries for organ donation.
Table 1 e Deaths per age group as reported in 2002e2011 data of the NBR. Age group (y) 0e19.9 20e29.9 30e39.9 40e49.9 50e59.9 Total
Deaths in NBR
Deaths with no comorbidities
533 329 412 645 820 2739
180 172 170 180 192 894
Average hospital length of stay (SD) (d) 13.7 22.3 12.6 19.4 14.1 16.4
25.8 65.2 34.7 38.0 26.6 40.4
Minimum hospital length of stay (d)
Maximum hospital length of stay (d)
1 1 1 1 1 1
168 508 385 232 235 508
Deaths without comorbidities are those patients with “True” recorded as a qualifier for the question of “No comorbidities” within the database. Those with “No” or “Null” recorded were not considered. Total lengths of hospital stay were examined for those patients with an outcome of death and no comorbidities. Any portion of the first 24 h of admission counts as 1 d toward hospital length of stay.
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Table 2 e Seventeen different burn-related free-text entries for causes of death within OPTN data for those patients with Other, specify listed as a cause of death. Free-text burn-related causes of death in OPTN data Third- and fourth-degree burns to 70% body surface 90% total body surface area Burn Burn 90% Burn trauma Burn victim Burns Burns on 94% of body CO CO poisoning CO poisoning Crib fire Electrical injury Electrocution Multitrauma (burns) Nonsurvivable burns Smoke inhalation
No. of patients
Years on record
1
2006
1 2 1 1 1 2 1 1 1 4 1 1 1 1 1 2
2011 2006, 2011 2008 2010 1996 2008, 2011 2009 1999 1995 1997, 2004, 2008, 2010 1994 1995 2009 2004 2010 1997, 2012
Entries corrected for spelling inaccuracies.
2.
Materials and methods
This study was approved by the Institutional Review Board of MedStar Health Research Institute.
2.1.
Case report
Medical records for the patient in question were reviewed for pertinent aspects of the case. A representative from the local OPO provided information regarding follow-up of donated organs.
Fig. 1 e Bar graph representing numbers of burn-related causes of death represented in free-text entries for donors with Other, specify listed as a cause of death in OPTN data.
2.2.
3
National Burn Repository
A data request was submitted to the American Burn Association for review of burns documented in the NBR as having an outcome of death. Data were filtered for duplicate or incomplete entries and analyzed using SAS 9.3 (SAS Institute, Inc, Carey, NC). Entries with an outcome of death were divided into different age groups, and then further into those groups of patients known to be without comorbidities based on the “no comorbidities” field in the NBR. Hospital lengths of stay were searched for the patients with an outcome of death and no comorbidities. The NBR annual report for the same period of time (2002e2011) was used for summary data.
2.3.
OPTN data
National data available via http://www.optn.transplant.hrsa.gov were searched using these parameters: Category “Donor,” Organ “All,” Report “Deceased Donors by Cause of Death.” Available options for cause of death do not include a burn injuryerelated category, but do include a category called “Other, specify” by the OPTN, which is then defined by free-text entries. A data request was submitted to the OPTN for records falling into category Other, specify for cause of death. The resulting document listed free-text causes of death along with year of donation. This document was searched for causes related to thermal injury, inhalation injury, electrical injury, or carbon monoxide (CO) poisoning and year of donation.
2.4.
Surveys
Three separate surveys were designed for audiences of burn center directors, transplant surgeons, or OPO representatives. Questions in each survey were aimed at determining the experiences of respondents and their opinions regarding referral for organ donation. Surveys for burn center directors were reviewed by two burn surgeons before dissemination. Likewise, surveys for transplant surgeons and OPO representatives were reviewed by a transplant hepatologist and an OPO medical director, respectively. Surveys were first delivered electronically, using SurveyMonkey (SurveyMonkey, Palo Alto, CA). A reminder email was sent 1 mo after initial delivery to nonresponders. Those who did not respond or were unreachable electronically were sent a hard-copy version of the survey via US Postal Service First-Class Mail. Returned hard-copy surveys were logged manually into the electronic database. No incentives for response were used. In instances where more than one survey was sent to a single program, as in burn centers with more than one director, or transplant centers with different cardiac and abdominal transplant surgeons, answers to questions related to an individual’s opinion were maintained individually, whereas answers to questions related to a program’s experience were combined to give the most comprehensive picture of donor and transplant experience for a given burn or transplant center. Response rates were calculated for a given center, thus, if a cardiac surgeon, thoracic surgeon, and hepatobiliary surgeon all responded from a given transplant
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Fig. 2 e Pie charts representing survey response rates of burn centers, OPOs, and transplant centers. For a given center where more than one individual replied, it was counted as only one response for that program.
center, these together were counted as one response of the 221 programs surveyed.
3.
Results
3.1.
National Burn Repository
there were 172 in the group aged 20e29.9 y, 170 in the group aged 30e39.9 y, 180 in the group aged 40e49.9 y, and 192 in the group aged 50e59.9 y. Of these patients, the overall mean hospital length of stay was 16.4 40.4 d, with averages of 13.7 25.8 and 22.3 65.2 d in the groups aged 0e19.9 y and 20e29.9 y, respectively (Table 1).
3.2. The NBR dataset used for this study provided data from 2002e2011. There were 183,036 cases and 6822 deaths. There were 533 deaths in patients aged 0e19.9 y, 329 deaths in patients aged 20e29.9 y, 412 deaths in patients aged 30e39.9 y, 645 deaths in patients aged 40e49.9 y, and 820 deaths in patients aged 50e59.9 y [3]. Patients with death as an outcome were searched for the absence of comorbidities. In patients aged 0e19.9 y, 180 were without any comorbidities. Similarly,
OPTN data
From 1994e2012, there are 3027 donors with Other, specify listed as cause of death. There were 17 burn-related free-text causes of death entries among those patients in available OPTN data (Table 2). These 17 causes of death were linked to 23 patients since the first free-text recorded burn-injured donor in 1994. Thirteen patients appeared to have had thermal or flame-related burn causes of death,
Table 3 e Numbers of responses coming from individual burn centers, OPOs, and transplant centers, organized by OPTN region. OPTN region
Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Eastern Vermont Region 2: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, West Virginia, Northern Virginia Region 3: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico Region 4: Oklahoma, Texas Region 5: Arizona, California, Nevada, New Mexico, Utah Region 6: Alaska, Hawaii, Idaho, Montana, Oregon, Washington Region 7: Illinois, Minnesota, North Dakota, South Dakota, Wisconsin Region 8: Colorado, Iowa, Kansas, Missouri, Nebraska, Wyoming Region 9: New York, Western Vermont Region 10: Indiana, Michigan, Ohio Region 11: Kentucky, North Carolina, South Carolina, Tennessee, Virginia Total no. responding/total no. surveyed
No. of responding burn centers
No. of responding OPOs
No. of responding transplant centers
4
0
5
4
2
10
5 5 10 1 6 6 3 8 6 58/124 (46.8%)
6 3 5 2 1 3 1 5 2 30/58 (51.7%)
9 7 11 4 13 9 6 11 9 94/221 (42.5%)
For a given center where more than one individual replied, it was counted as only one response for that program.
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Fig. 3 e Pie charts representing survey responses regarding the experiences of burn centers. Each chart depicts answers to the question, “Has your burn center ever had a nonsurvivable [burn injury type] patient become an organ donor?” Values are displayed as the percentage of responding centers and as the raw number of responding centers.
two had inhalation injury, two had electrical injury, and six had CO poisoning. Twelve of the 23 burn-injured donors recorded in OPTN data died in the 5-y span from 2008e2012 (Fig. 1).
3.3.
Surveys
Surveys contained 11e21 questions and took respondents an average of 3 min and 47 s (4:24) to complete. There were 124 burn centers, 58 OPOs, and 221 transplant centers surveyed. Response rates were 47% (58 of 124) for burn centers, 52% (30 of 58) for OPOs, and 43% (94 of 221) for transplant centers (Fig. 2). The OPTN regions with the greatest numbers of responses for each type of program were region 5 (10 burn centers), region 3 (six OPOs), and region 7 (13 transplant centers) (Table 3). Burn center directors were asked whether their burn center had ever a nonsurvivable burn-injured patient become an organ donor. This question was applied to four different types of injuries: thermal injury, inhalation injury, electrical
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injury, and CO poisoning. Forty-four percent of responding burn centers had had a thermally injured patient become an organ donor (25 of 57). Likewise, inhalation injury, electrical injury, and CO poisoning patients had gone on to become organ donors in the burn centers of 18% (10 of 57), 9% (5 of 57), and 19% (11 of 57) of respondents, respectively (Fig. 3). Those respondents who confirmed the experience of organ donors in their burn centers recalled the number of donors and organ types donated. Thermally injured patients were the most frequently reported donors, with six respondents reporting five or more patients each, whereas electrically injured patients were the most infrequently reported donors, with the five positive respondents reporting one or two patients each (Fig. 4A). Kidneys were the most frequently donated organs across all injury types, followed by livers, hearts, and corneas (Fig. 4B). Burn center directors were also asked “Should thermal injury patients be referred for organ donation?” The question was repeated for inhalation injury, electrical injury, and CO poisoning patients. Most burn center directors felt that patients with mortal burn injuries should be referred for organ donation, but numbers differed for thermal injury (84%, 52 of 62), inhalation injury (90%, 56 of 62), electrical injury (89%, 55 of 62), and CO poisoning (89%, 55 of 62) (Fig. 5). Those respondents who did not answer yes were given the opportunity to express their concerns regarding referral for organ donation. Infection burden and hypoperfusion were the most common concerns among burn clinicians, with a small number expressing concerns regarding the difficulty of organ-preserving critical care as well as patient and family unwillingness to donate (Table 4). Finally, burn center directors were asked, “If you were caring for a patient with a nonsurvivable thermal injury, inhalation injury, electrical injury, or CO poisoning, would you consider employing advanced measures such as CVVH (Continuous Veno-Venous Hemofiltration) steroids, or inotropes to preserve organs for donation?” Seventy-seven percent (46 of 60) of respondents replied yes, whereas equal numbers responded with answers of no and maybe, at 12% each (seven of 60 and seven of 60). There was no significant association between a provider’s willingness to consider advanced measures and whether that provider routinely manages critical care in his or her burn center (chi-square value of 2.448, P ¼ 0.7842). OPOs were asked whether they had ever a nonsurvivable burn-injured patient referral become a successful organ donor. This question was applied to four different types of injuries: thermal injury, inhalation injury, electrical injury, and CO poisoning. Sixty-three percent of responding OPOs had had a thermally injured patient referral become a successful organ donor (19 of 30). Likewise, inhalation injury, electrical injury, and CO poisoning patient referrals had gone on to become organ donors via the OPOs of 80% (24 of 30), 57% (17 of 24), and 57% (17 of 24) of respondents, respectively (Fig. 6). Those OPOs who confirmed having the experience of burn-injured organ donors recalled the number of donors in the past 5 y and organ types donated. Inhalation injury patients were the most frequently reported donors, with six respondents reporting five or more patients each, whereas CO poisoning patients were the most infrequently reported donors, with 13 positive
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Fig. 4 e Bar graphs representing survey responses regarding the experiences of burn centers. In (A), respondents recalled the number of patients who had gone on to become organ donorsdwith answer options anywhere from 1e5 or more. The X-axis is grouped according to the injury type with patterned bars corresponding to the number of recalled patients. The Yaxis represents the number of burn center respondents giving a particular answer. In (B), respondents recalled the types of organs or tissues donated by their patients with burn injury if known. The X-axis is grouped according to the injury type with patterned bars corresponding to the types of organs or tissues donated. The Y-axis represents the number of burn center respondents giving a particular answer.
respondents reporting 1e3 patients each (Fig. 7A). Kidneys were the most frequently donated organs across all injury types, followed by livers and hearts (Fig. 7B), which is consistent with data from burn centers. OPOs were asked what types of challenges prevent burn-injured patient referrals from becoming successful organ donors. Common issues across injury categories were infection and hypoperfusion, echoing the concerns reported by burn centers, alongside the noteworthy frequent challenge of nonreferral of these types of patients (Table 5). Additionally, OPOs were asked, “Should thermal injury patients be referred for organ donation?” The question was repeated for inhalation injury, electrical injury, and CO poisoning patients. Every OPO respondent (100%, n ¼ 30) felt that patients with mortal burn injuries should be referred for organ donation, regardless of the injury type. Finally, OPO respondents were asked, “Would any of the above mentioned injuries (thermal injury, inhalation injury, electrical injury, CO poisoning) render a potential donor unsuitable for DCD (donation after cardiac death) (rather than DBD [donation after brain death] donation)?” All but one respondent (97%) answered no. Transplant surgeons were asked whether their transplant center had ever transplanted an organ from a burninjured donor. This question was applied to the same four types of burn injuries with regard to six different organs: lung, heart, liver, kidney, pancreas, and small bowel. Kidneys and livers were common again. Thirty-six percent of responding transplant centers (34 of 94) had transplanted a
kidney from a known inhalation injury donor, 34% (32 of 94) had transplanted a kidney from a known CO-poisoned donor, and 31% (29 of 94) had transplanted a liver from a known inhalation injury donor. Small bowel was the least commonly reported organ transplanted from any injury category (1%, one of 94 each), followed by lungs from inhalation injury donors (3%, three of 94) (Fig. 8). Transplant surgeons were then asked “Should thermal injury patients be referred for organ donation?” The question was repeated for inhalation injury, electrical injury, and CO poisoning patients. Most responding transplant surgeons felt that patients with mortal burn injuries should be referred for organ donation, but numbers differed for thermal injury (83%, 85 of 102), inhalation injury (84%, 86 of 102), electrical injury (85%, 86 of 102), and CO poisoning (82%, 83 of 102) (Fig. 9). Those respondents who did not answer yes were given the opportunity to express their concerns regarding referral for organ donation. Infection burden, hypoperfusion, and difficulty of organ-preserving critical care were the most common concerns among transplant surgeons, with an additional small number expressing concerns regarding the capabilities of hospital staff as well as patient and family unwillingness to donate (Table 6).
4.
Discussion
The general topic of burn-injured patients acting as organ donors is not well represented in a peer-reviewed literature. A
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Table 4 e Those burn surgeons who answered “No” to the question, “Should [burn injury type] patients be referred for organ donation?” were asked to give their reasons for nonreferral. Injury type/ reason for nonreferral Infection burden Hypoperfusion Difficulty of critical care Patient or family unwillingness Staff inability Other concerns*
Thermal Inhalation Electrical CO injury injury injury poisoning 6 3 0
3 0 0
0 3 2
0 5 1
0
0
0
1
1 1
0 2
0 2
0 1
This table summarizes the raw numbers of responses from surveyed burn surgeons. Each answering respondent was allowed to choose as many or as few applicable reasons as he or she wished. * Respondents’ other described concerns included ischemia time, graft organ thrombosis, and selectively chosen referral based on a cause of death.
Fig. 5 e Pie charts representing survey responses regarding the opinions of burn surgeons. Each chart depicts answers to the question, “Should [burn injury type] patients be referred for organ donation?” Answer choices were Yes, No, or Other, with free-text entry available. Values are displayed as the percentage of respondents and as the raw number of respondents.
recent review of Australia reported two patients with >90% total body surface area burns who donated kidneys after cardiac death [4]. Other published case reports of burn-injured donors have involved one brain-dead adult [5] and nine braindead children [6e8]. An additional 35 CO-poisoned adults who donated organs and tissues were identified in a 2011 systematic review of burned and CO-poisoned organ donors [9]. The infrequent representation of burn-injured organ donors in the literature would support the rarity also seen in OPTN data. Contradiction arises when the results of the present study surveys are considered. Standard criteria for donation vary based on the organ in question, but generally should include brain-dead donors younger than 50e60 y without disseminated malignancy or blood borne illness [10]. Comorbidities highlighted in the NBR include entries ranging from tobacco use to psychiatric illness to hypertension. Given that a patient with no comorbidities is more likely to be medically eligible to donate
Fig. 6 e Pie charts representing survey responses regarding the experiences of OPOs. Each chart depicts answers to the question, “Has your OPO ever had a [burn injury type] patient referral become a successful organ donor?” Values are displayed as the percentage of responding organizations and as the raw number of responding organizations.
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Fig. 7 e Bar graphs representing survey responses regarding the experiences of OPOs. In (A), respondents recalled the number of patient referrals who have become successful organ donors in the past 5 ydwith answer options anywhere from 0e5 or more. OPO respondents were given the option to select zero because the experience was contained within a span of the past 5 y. The X-axis is grouped according to the injury type with patterned bars corresponding to the number of recalled patients. The Y-axis represents the number of OPO respondents giving a particular answer. In (B), respondents recalled the types of organs or tissues donated by their burn patient referrals if known. The X-axis is grouped according to the injury type with patterned bars corresponding to the types of organs or tissues donated. The Y-axis represents the number of OPO respondents giving a particular answer.
his or her organs than a patient with the presence of one or more comorbidities, a conservative estimate of the possible organ donors presenting to NBR-reporting facilities was made by counting only mortally burn-injured patients
Table 5 e OPO respondents were asked, “What prevents [burn injury type] patients from successful organ recovery?” Injury type/ reasons for nonsuccessful organ recovery Length of time from injury Consent issues Electrolyte derangements Infection concerns Poor perfusion These patients are not referred Other concerns*
Thermal Inhalation Electrical CO injury injury injury poisoning
4
6
4
3
6 9
5 6
4 4
4 4
14 10 9
6 10 6
4 7 9
2 8 8
6
8
11
8
This table summarizes the raw numbers of responses from surveyed OPOs. Each answering respondent was allowed to choose as many or as few applicable reasons as he or she wished. * Respondents’ other described concerns included comorbidities, fluid overload, nonebrain-dead and nonedonation after cardiac death candidates, poor organ function, lack of knowledge at the referring hospital, death on arrival, and hypoxia.
confirmed to be without comorbidities, and this still resulted in nearly 900 patients younger than 60 y; over 350 of them were younger than 30 y, making them even more likely to be ideal donors [11]. Hospital lengths of stay, which can become pertinent with respect to infection burden in a burn patient, were varied between groups, with minimum of 1 d and maximum of over 1 y. Although the individual situations of each of these patients are impossible to estimate, the numbers of potentially eligible donors as estimated from the NBR reveal that these patients are either being greatly underreferred to OPOs or that OPTN data grossly underreports their contribution to the donor pool. Thirty of the 58 United States OPOs surveyed in this study responded, and up to 80% of them were able to confirm the experience of a burn-injured organ donor. In the most frequently cited category of injury for OPOs, inhalation injury, six different respondents affirmed having had five or more donors in the past 5 y alone. The experiences of these 30 OPOs suggest that in the past 5 y there have been at least 54 inhalation injury patient referrals that have gone on to successfully donate organs (Table 7). Similarly, survey responses estimate at least 50 thermally injured, 23 electrically injured, and 21 CO-poisoned patients have gone on to donate organs in the past 5 y. Although inaccuracies may exist in asking OPO representatives to recall their experiences, the general information conveyed is that these patients have indeed been contributing in some fashion to the population of organ donors in recent years, and that they have likely been doing so in numbers larger than those portrayed by OPTN data.
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Fig. 8 e Bar graphs representing survey responses regarding the experiences of transplant centers. In (A), respondents recalled whether they had ever transplanted a given organ from one of the given burn injury patient types. Transplant surgeon respondents were given the option to select “None of these” if they had never transplanted an organ from any of the named burn injury categories. The X-axis is grouped according to injury type with patterned bars corresponding to organs transplanted. The Y-axis represents the number of transplant surgery respondents giving a particular answer. In (B), respondents stated the types of organs their centers routinely transplant, which is shown for perspective on the values shown in image (A). The Y-axis represents the number of transplant surgery respondents giving a particular answer with patterned bars corresponding to organs transplanted.
As expected, OPOs agree without question that all mortally burn-injured patients warrant referral for organ and tissue donation. More surprisingly, burn and transplant surgeons do not consistently agree on the question of referral. Although most burn surgeons and transplant surgeons (84% and 83%, respectively) believed that thermally injured patients should be referred for organ donation, it is not unanimous. Similar trends persisted across surveyed injury types for burn and transplant surgeons, respectively; 90% and 84% for inhalation injury, 89% and 85% for electrical injury, and 89% and 82% for CO poisoning. It is important to realize that the question posed to respondents was regarding referral, not donation, as burn and transplant surgeons are not expected to decide whether a patient is appropriate for donationdin the United States, this is the responsibility of an OPO’s patient evaluation. Although the common concerns among burn and transplant clinicians (infection and hypoperfusion) align with the barriers to successful donation in referred patients as reported by OPOs, these concerns should not prevent initial referral for assessment of suitability for donation. The burn surgeon, as the clinician most likely caring for patients with nonsurvivable burn injuries, should refer patients to the local OPO according to available guidelines regardless of the injury type (Table 8). Additionally, OPOs were asked whether any of the injuries addressed in these surveys would make a patient unsuitable for a donation after cardiac death rather than donation after brain death donation, and the resounding answer was no. This particular result highlighted once again the opportunity for improved burn patient referral where it may not have been historically obvious to do so.
Outcomes research is needed to assess the long-term performance of organs transplanted from burn-injured patients. Short-term follow-up in the small number of published cases of burn-injured donors seems to indicate that these organs do not have especially poor outcomes [6e9]. Additionally, cardiac death is no longer a cause for ruling out organ donation, as evidenced by recent case reports in patients with burn injuries [4] and the responses of 97% of our answering OPOs. Currently, published recommendations for the preservation and procurement of organs in burn-injured potential donors advocate early, adequate resuscitation to preserve splanchnic perfusion and incision through nonburn infected skin when possible [7]. Given that 77% of our burn surgeon respondents were willing to use advanced measures for organ preservation, with another 12% suggesting that they would consider it on a case-by-case basis, it is in the best interest of the organ donation and transplant community to connect with the burn community in an effort to increase education and awareness as to how best to care for these scarce potential donors. Certainly in the scenario of brain death, as with the case presented in this article, there should be no question as to whether to refer a patient to the appropriate OPO, whose primary responsibility it is to determine a patient’s appropriateness for donation. Furthermore, in the scenario of burn extent leading to the futility of care in the educated opinions of burn care providers, particularly in circumstances of care limitations or comfort care measures, the goal should exist that OPOs be involved as a rule rather than as a unique circumstance. Data collection by survey is imperfect, with issues of recall bias, incomplete response, and inaccurate reporting of
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Table 6 e Those transplant surgeons who answered “No” to the question, “Should [burn injury type] patients be referred for organ donation?” were asked to give their reasons for nonreferral. Injury type/ reasons for nonreferral
Thermal Inhalation Electrical CO injury injury injury poisoning
Infection burden Hypoperfusion Difficulty of critical care Patient or family unwillingness Staff inability Other concerns*
5
5
3
0
6 6
5 5
2 4
9 4
2
2
0
0
0 9
1 7
0 8
1 7
This table summarizes the raw numbers of responses from surveyed transplant surgeons. Each answering respondent was allowed to choose as many or as few applicable reasons as he or she wished. * Respondents’ other described concerns included unknown or unavailable data regarding burn-injured donors, hypoxia, and likelihood of transplant recipients to turn down organs from burninjured patients.
organizations such as the American Burn Association or The Organ Donation Research Consortium. In addition, prospective collection of data from both the burn community and the OPOs would allow a more objective assessment of referral
Fig. 9 e Pie charts representing survey responses regarding the opinions of transplant surgeons. Each chart depicts answers to the question, “Should [burn injury type] patients be referred for organ donation?” Answer choices were Yes, No, or Other, with free-text entry available. Values are displayed as the percentage of respondents and as the raw number of respondents.
experiences [12]. Mixed-mode survey data collection is common, as recent technological advances lend themselves to the use of Internet modalities, whereas some providers may still prefer paper questionnaires [13]. This study used some common strategies to increase survey response rate, including extending the answer period during which responses were accepted and offering multiple sequential response modes, whereas not using other known strategies such as offering incentives or tailoring recontact efforts [13]. The response rates of published surveys of health professionals are frequently difficult to identify. A recent review of health care provider surveys found published response rates to 117 large scale studies ranged anywhere from 1% to >80% [13]. The response rates of 42%e52% in this study were achieved with the efforts of a small team and may have been improved with the inclusion of incentives or sponsorship from larger
Table 7 e Estimates of numbers of patients acting as organ donors in each injury category based on recalled numbers by burn surgeons (A) and OPO representatives (B). Injury type/no. of patients per burn survey data
5þ
4
3
2
1
Estimated no. of patients for category of injury
A Thermal injury Inhalation injury Electrical injury CO poisoning
6 (30) 3 (12) 4 (12) 6 (12) 6 (6)
72
3 (15) 0 (0)
1 (3)
2 (4)
4 (4)
26
0 (0)
0 (0)
0 (0)
2 (4)
3 (3)
7
1 (5)
2 (8)
1 (3)
0 (0)
7 (7)
23
4 (20) 2 (8)
3 (9)
5 (10) 3 (3)
50
6 (30) 0 (0)
2 (6)
4 (8) 10 (10)
54
0 (0)
0 (0)
0 (0)
4 (8) 10 (10)
18
0 (0)
0 (0)
2 (6)
4 (8)
21
B Thermal injury Inhalation injury Electrical injury CO poisoning
7 (7)
Respondents were asked the number of patients their programs had seen go on to become organ donors in each of the four injury categories, with response options being 0, 1, 2, 3, 4, or 5 or more. Using these responses, the right most column of A and B gives an estimate of the number of mortally burn-injured patients from each category who have donated organs in recent years. B represents recalled numbers for the past 5 y only.
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 4 ) 1 e1 1
Table 8 e Clinical triggers used in our burn center for referral to an OPO. Clinical triggers for referral to Washington Regional Transplant Community Ventilated with a Glasgow Coma Score 5 without continuous sedation Ventilated with brain death testing being considered or pursued Ventilated and do not resuscitate or limited therapy order being considered Ventilated and family is considering withdrawal of support
patterns and conversion rates; this would obviate any recall bias inherent in this approach.
5.
11
L.T.M. and M.H.J. contributed toward conception and design, critical revision of the article, and obtaining of funding. J.W.S. contributed toward conception and design, analysis and interpretation, critical revision of the article, and obtaining of funding.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
references
Conclusions
Taken together, the insights gained by the administration of a national survey, examination of OPTN national data, and analysis of the NBR indicate several things: (1) mortally burninjured patients are able to serve as organ donors, (2) clinicians caring for mortally burn-injured patients are not referring all potential organ donors, (3) not all transplant surgeons are accepting organs from burn-injured patients, (4) there are likely more burn-injured patients who become donors than OPTN data reflects, and an improvement in the way these data are collected would be beneficial, and (5) a consensus and education are needed regarding the care of burn-injured potential organ donors.
Acknowledgment This work was supported in part by Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors wish to thank Charles Wright, MD, for his insight and guidance and Stephen Lockey for his assistance with survey mailings. Author contributions: T.E.T. contributed toward conception and design, analysis and interpretation, data collection, and writing of the article. L.S.J. and R.M.S. contributed toward conception and design and critical revision of the article.
[1] Schwartz HS. Bioethical and legal considerations in increasing the supply of transplantable organs: from UAGA to “Baby Fae”. Am J Law Med 1985;10:397. [2] Organ Procurement and TransplantNetwork. UNet. 27, . http:// optn.transplant.hrsa.gov/data/; 2013. [3] American Burn Association. National Burn Repository annual report, http://ameriburn.org/NBR_annualreports.php; 2012 [4] Widdicombe NJ, Van Der Poll A, Gould A, et al. Donation after cardiac death in non-survivable burns. Anaesth Intensive Care 2013;41:380. [5] Stoehr I, Nagib R, Franke A, et al. Bilateral lung transplantation from a donor with fume poisoning. J Heart Lung Transplant 2007;26:194. [6] Todeschini DP, Maito ED, Maldotti A, et al. Brain death caused by electric shock and organ donation in children. Transplant Proc 2007;39:399. [7] Sheridan RL, Uberti E, Frank KT, Stewart B, Tompkins RG. Solid organ procurement from burn patients. J Trauma 1995;38:824. [8] Sheridan RL, et al. Solid organ procurement from burned children. J Trauma 1999;47:1060. [9] Busche MN, Knobloch K, Herold C, et al. Solid organ procurement from donors with carbon monoxide poisoning and/or burnda systematic review. Burns 2011;37:814. [10] Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis 2008;52:553. [11] American Burn Association. National Burn Repository, http:// ameriburn.org/NBR.php.; 2013. [12] Rea LM, Parker RA. Designing and conducting survey research: a comprehensive guide. In: Jossey-Bass social and behavioral sciences series. 1st ed. San Francisco: Jossey-Bass Publishers; 1992. xxiv, 254 p. [13] McLeod CC, Klabunde CN, Willis GB, et al. Health care provider surveys in the United States, 2000e2010: a review. Eval Health Prof 2013;36:106.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Organ donation from burn-injured patientsda national perspective Taryn E. Travis, MD,a,b Laura S. Johnson, MD,a,b Lauren T. Moffatt, PhD,b Ram M. Subramanian, MD,c Marion H. Jordan, MD,a,b and Jeffrey W. Shupp, MDa,b,* a
The Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington, DC Firefighters’ Burn and Surgical Research Laboratory, MedStar Health Research Institute, Washington, DC c Emory Transplant Center, Emory University Hospital, Atlanta, Georgia b
article info
abstract
Article history:
Background: There is a discrepancy between publically available data from the United
Received 10 December 2013
Network for Organ Sharing (UNOS) database and perception of the incidence of mortally
Received in revised form
burn-injured patients serving as organ donors. In the last 5 y, a single burn center referred
3 March 2014
several patients who went on to successfully donate multiple organs. However, UNOS data
Accepted 5 March 2014
indicate very few referrals of patients with burn injuries nationwide. This discrepancy in
Available online xxx
UNOS-reported occurrences versus institutional experience prompted this work. Methods: UNOS data from 1988e2012 was examined for causes of death related to thermal
Keywords:
injury, electrical injury, inhalation injury, or carbon monoxide poisoning. The National
Organ donation
Burn Repository was examined for burn center death rates and patient characteristics of
Organ transplantation
those with reported nonsurvivable burn injuries. Finally, a national survey queried the
Burn
clinical experiences and educated opinions of burn center directors, transplant surgeons,
Electrical injury
and organ procurement organization (OPO) representatives regarding organ donation in
Inhalation injury
the burn-injured population.
Carbon monoxide poisoning
Results: Between 42% and 52% of those surveyed responded. Survey data indicate that at
Procurement
least 61 patients with burn-related injuries have served as organ donors in the past 5 y
Survey
alone, versus 23 identified in 24 y of UNOS data. Survey data also indicate that inhalation
National Burn Repository
injuries were the most common burn-related injuries seen before successful organ procurement. Kidneys were the most commonly donated organs, but all major organs and tissues were represented in the experiences of surgeon and organ procurement organization respondents. Up to 10% surgeon respondents believe that patients with burn injuries should not be referred for possible organ donation. Conclusions: There are more organs donated by patients with mortal burn injuries than currently available UNOS data would suggest. Survey data suggest that these patients should be able to contribute successfully to the supply of organs needed by those on transplant waiting lists, but remain inconsistently recognized as such a resource. Knowledge about long-term organ and tissue viability from burn-injured patients is lacking, and should be the focus of future research. ª 2014 Elsevier Inc. All rights reserved.
* Corresponding author. 110 Irving Street, NW, Room 3B-55, Washington, DC 20010. Tel.: þ202 877 7347; fax: þ202 877 7302. E-mail address: [email protected] (J.W. Shupp). 0022-4804/$ e see front matter ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2014.03.010
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1.
Introduction
1.1.
Case report
A 16-y-old male was involved in a house fire reportedly caused by a television explosion. The patient was found to be asystolic in the field by first responders, who estimated 15 min of down time before the initiation of Advanced Cardiac Life Support. Cardiopulmonary resuscitation continued en route to a local emergency room, and minutes after arrival, vital signs were regained. Shortly thereafter, a laryngeal mask airway was placed, and request was made for transfer to the nearest burn center, approximately 23 miles away. The patient presented to the burn center with approximately 50% total body surface area burns to the back, buttocks, bilateral upper and lower extremities, and carbonaceous debris around the nose and mouth with bronchoscopic evidence of inhalation injury. Chest x-ray showed bilateral lung infiltrates. The patient was endotracheally intubated and massive fluid resuscitation with vasopressive support was initiated. The patient had a carboxyhemoglobin level of 21.3% on initial laboratory tests at the burn center, with an estimated level of 50%e60% near the time of injury. The patient’s Glasgow Coma Score was 3T without the need for sedatives or paralytics, and he showed no evidence of brainstem activity. He lacked gag reflex, cough reflex, rectal tone, and both pupils were fixed and dilated. Referral was made to the local organ procurement organization (OPO) for evaluation of appropriateness for organ donation approximately 9 h after presentation to the burn center. An estimated 36 h after injury, brain death was confirmed by clinical examination and apnea test. The patient’s family wished to proceed with organ donation and the patient was able to donate bilateral lungs and kidneys. As of December 2012, the involved OPO reported that the patients’ bilateral lungs were donated to a single recipient who was still alive at 1-y posttransplantation. The statuses of donated kidneys were unavailable.
1.2.
Background and literature review
The gap between the number of patients awaiting organ transplant and the number of available organs has been
problematic for over half a century [1]. As of February 20, 2014, there are 121,290 patients on the waiting list for an organ transplant, with 77,325 of them in active waiting status [2]. Since 1988, the largest number of United States transplants performed in a given year occurred in 2006, with 28,940 transplants from 14,750 donors (8017 deceased and 6733 living). Although this is a large increase in transplants from those documented only 10 y prior in 1996 (19,765 transplants from 9222 donors), the disparity between organ availability and need continues to grow. The United Network for Organ Sharing (UNOS) partners with the Organ Procurement and Transplant Network (OPTN) to maintain a database of statistics that has detailed yearly organ donations and transplants since 1987. Donor causes of death are available, although burn-related injuries are not included as categories of cause. As such, it is unclear how many patients with nonsurvivable burn-related injuries contribute to the donor pool each year. The National Burn Repository (NBR) is a rolling database cataloging a 10-y record of inpatient burns in North American burn centers. In the 2012 annual report,183,036 cases are represented from 2002e2011, with 6822 of them listing death as the documented outcome [3]. On the basis of known individual burn center experiences, mortally burn-injured patients do go on to donate greatly needed organs, as did the patient described in the previously mentioned case report; however, simply referencing the national data available from OPTN would lead one to believe that it is a very rare occurrence. The following were the aims of this study: (1) to assess the number of burn-related organ donors evident in OPTN national data reporting, (2) to estimate the number of mortally burn-injured patients represented in the NBR that may have qualified as organ donors, and (3) to nationally survey professionals involved in burn care and organ transplantation in an effort to assess their experiences and opinions regarding organ donation in patients with burn injury. The overall goal was to use these data to identify reasons for discrepancies in reported numbers in databases versus actual donor figures, and codify different perspectives on referral of patients with burn injuries for organ donation.
Table 1 e Deaths per age group as reported in 2002e2011 data of the NBR. Age group (y) 0e19.9 20e29.9 30e39.9 40e49.9 50e59.9 Total
Deaths in NBR
Deaths with no comorbidities
533 329 412 645 820 2739
180 172 170 180 192 894
Average hospital length of stay (SD) (d) 13.7 22.3 12.6 19.4 14.1 16.4
25.8 65.2 34.7 38.0 26.6 40.4
Minimum hospital length of stay (d)
Maximum hospital length of stay (d)
1 1 1 1 1 1
168 508 385 232 235 508
Deaths without comorbidities are those patients with “True” recorded as a qualifier for the question of “No comorbidities” within the database. Those with “No” or “Null” recorded were not considered. Total lengths of hospital stay were examined for those patients with an outcome of death and no comorbidities. Any portion of the first 24 h of admission counts as 1 d toward hospital length of stay.
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Table 2 e Seventeen different burn-related free-text entries for causes of death within OPTN data for those patients with Other, specify listed as a cause of death. Free-text burn-related causes of death in OPTN data Third- and fourth-degree burns to 70% body surface 90% total body surface area Burn Burn 90% Burn trauma Burn victim Burns Burns on 94% of body CO CO poisoning CO poisoning Crib fire Electrical injury Electrocution Multitrauma (burns) Nonsurvivable burns Smoke inhalation
No. of patients
Years on record
1
2006
1 2 1 1 1 2 1 1 1 4 1 1 1 1 1 2
2011 2006, 2011 2008 2010 1996 2008, 2011 2009 1999 1995 1997, 2004, 2008, 2010 1994 1995 2009 2004 2010 1997, 2012
Entries corrected for spelling inaccuracies.
2.
Materials and methods
This study was approved by the Institutional Review Board of MedStar Health Research Institute.
2.1.
Case report
Medical records for the patient in question were reviewed for pertinent aspects of the case. A representative from the local OPO provided information regarding follow-up of donated organs.
Fig. 1 e Bar graph representing numbers of burn-related causes of death represented in free-text entries for donors with Other, specify listed as a cause of death in OPTN data.
2.2.
3
National Burn Repository
A data request was submitted to the American Burn Association for review of burns documented in the NBR as having an outcome of death. Data were filtered for duplicate or incomplete entries and analyzed using SAS 9.3 (SAS Institute, Inc, Carey, NC). Entries with an outcome of death were divided into different age groups, and then further into those groups of patients known to be without comorbidities based on the “no comorbidities” field in the NBR. Hospital lengths of stay were searched for the patients with an outcome of death and no comorbidities. The NBR annual report for the same period of time (2002e2011) was used for summary data.
2.3.
OPTN data
National data available via http://www.optn.transplant.hrsa.gov were searched using these parameters: Category “Donor,” Organ “All,” Report “Deceased Donors by Cause of Death.” Available options for cause of death do not include a burn injuryerelated category, but do include a category called “Other, specify” by the OPTN, which is then defined by free-text entries. A data request was submitted to the OPTN for records falling into category Other, specify for cause of death. The resulting document listed free-text causes of death along with year of donation. This document was searched for causes related to thermal injury, inhalation injury, electrical injury, or carbon monoxide (CO) poisoning and year of donation.
2.4.
Surveys
Three separate surveys were designed for audiences of burn center directors, transplant surgeons, or OPO representatives. Questions in each survey were aimed at determining the experiences of respondents and their opinions regarding referral for organ donation. Surveys for burn center directors were reviewed by two burn surgeons before dissemination. Likewise, surveys for transplant surgeons and OPO representatives were reviewed by a transplant hepatologist and an OPO medical director, respectively. Surveys were first delivered electronically, using SurveyMonkey (SurveyMonkey, Palo Alto, CA). A reminder email was sent 1 mo after initial delivery to nonresponders. Those who did not respond or were unreachable electronically were sent a hard-copy version of the survey via US Postal Service First-Class Mail. Returned hard-copy surveys were logged manually into the electronic database. No incentives for response were used. In instances where more than one survey was sent to a single program, as in burn centers with more than one director, or transplant centers with different cardiac and abdominal transplant surgeons, answers to questions related to an individual’s opinion were maintained individually, whereas answers to questions related to a program’s experience were combined to give the most comprehensive picture of donor and transplant experience for a given burn or transplant center. Response rates were calculated for a given center, thus, if a cardiac surgeon, thoracic surgeon, and hepatobiliary surgeon all responded from a given transplant
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Fig. 2 e Pie charts representing survey response rates of burn centers, OPOs, and transplant centers. For a given center where more than one individual replied, it was counted as only one response for that program.
center, these together were counted as one response of the 221 programs surveyed.
3.
Results
3.1.
National Burn Repository
there were 172 in the group aged 20e29.9 y, 170 in the group aged 30e39.9 y, 180 in the group aged 40e49.9 y, and 192 in the group aged 50e59.9 y. Of these patients, the overall mean hospital length of stay was 16.4 40.4 d, with averages of 13.7 25.8 and 22.3 65.2 d in the groups aged 0e19.9 y and 20e29.9 y, respectively (Table 1).
3.2. The NBR dataset used for this study provided data from 2002e2011. There were 183,036 cases and 6822 deaths. There were 533 deaths in patients aged 0e19.9 y, 329 deaths in patients aged 20e29.9 y, 412 deaths in patients aged 30e39.9 y, 645 deaths in patients aged 40e49.9 y, and 820 deaths in patients aged 50e59.9 y [3]. Patients with death as an outcome were searched for the absence of comorbidities. In patients aged 0e19.9 y, 180 were without any comorbidities. Similarly,
OPTN data
From 1994e2012, there are 3027 donors with Other, specify listed as cause of death. There were 17 burn-related free-text causes of death entries among those patients in available OPTN data (Table 2). These 17 causes of death were linked to 23 patients since the first free-text recorded burn-injured donor in 1994. Thirteen patients appeared to have had thermal or flame-related burn causes of death,
Table 3 e Numbers of responses coming from individual burn centers, OPOs, and transplant centers, organized by OPTN region. OPTN region
Region 1: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Eastern Vermont Region 2: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania, West Virginia, Northern Virginia Region 3: Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico Region 4: Oklahoma, Texas Region 5: Arizona, California, Nevada, New Mexico, Utah Region 6: Alaska, Hawaii, Idaho, Montana, Oregon, Washington Region 7: Illinois, Minnesota, North Dakota, South Dakota, Wisconsin Region 8: Colorado, Iowa, Kansas, Missouri, Nebraska, Wyoming Region 9: New York, Western Vermont Region 10: Indiana, Michigan, Ohio Region 11: Kentucky, North Carolina, South Carolina, Tennessee, Virginia Total no. responding/total no. surveyed
No. of responding burn centers
No. of responding OPOs
No. of responding transplant centers
4
0
5
4
2
10
5 5 10 1 6 6 3 8 6 58/124 (46.8%)
6 3 5 2 1 3 1 5 2 30/58 (51.7%)
9 7 11 4 13 9 6 11 9 94/221 (42.5%)
For a given center where more than one individual replied, it was counted as only one response for that program.
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Fig. 3 e Pie charts representing survey responses regarding the experiences of burn centers. Each chart depicts answers to the question, “Has your burn center ever had a nonsurvivable [burn injury type] patient become an organ donor?” Values are displayed as the percentage of responding centers and as the raw number of responding centers.
two had inhalation injury, two had electrical injury, and six had CO poisoning. Twelve of the 23 burn-injured donors recorded in OPTN data died in the 5-y span from 2008e2012 (Fig. 1).
3.3.
Surveys
Surveys contained 11e21 questions and took respondents an average of 3 min and 47 s (4:24) to complete. There were 124 burn centers, 58 OPOs, and 221 transplant centers surveyed. Response rates were 47% (58 of 124) for burn centers, 52% (30 of 58) for OPOs, and 43% (94 of 221) for transplant centers (Fig. 2). The OPTN regions with the greatest numbers of responses for each type of program were region 5 (10 burn centers), region 3 (six OPOs), and region 7 (13 transplant centers) (Table 3). Burn center directors were asked whether their burn center had ever a nonsurvivable burn-injured patient become an organ donor. This question was applied to four different types of injuries: thermal injury, inhalation injury, electrical
5
injury, and CO poisoning. Forty-four percent of responding burn centers had had a thermally injured patient become an organ donor (25 of 57). Likewise, inhalation injury, electrical injury, and CO poisoning patients had gone on to become organ donors in the burn centers of 18% (10 of 57), 9% (5 of 57), and 19% (11 of 57) of respondents, respectively (Fig. 3). Those respondents who confirmed the experience of organ donors in their burn centers recalled the number of donors and organ types donated. Thermally injured patients were the most frequently reported donors, with six respondents reporting five or more patients each, whereas electrically injured patients were the most infrequently reported donors, with the five positive respondents reporting one or two patients each (Fig. 4A). Kidneys were the most frequently donated organs across all injury types, followed by livers, hearts, and corneas (Fig. 4B). Burn center directors were also asked “Should thermal injury patients be referred for organ donation?” The question was repeated for inhalation injury, electrical injury, and CO poisoning patients. Most burn center directors felt that patients with mortal burn injuries should be referred for organ donation, but numbers differed for thermal injury (84%, 52 of 62), inhalation injury (90%, 56 of 62), electrical injury (89%, 55 of 62), and CO poisoning (89%, 55 of 62) (Fig. 5). Those respondents who did not answer yes were given the opportunity to express their concerns regarding referral for organ donation. Infection burden and hypoperfusion were the most common concerns among burn clinicians, with a small number expressing concerns regarding the difficulty of organ-preserving critical care as well as patient and family unwillingness to donate (Table 4). Finally, burn center directors were asked, “If you were caring for a patient with a nonsurvivable thermal injury, inhalation injury, electrical injury, or CO poisoning, would you consider employing advanced measures such as CVVH (Continuous Veno-Venous Hemofiltration) steroids, or inotropes to preserve organs for donation?” Seventy-seven percent (46 of 60) of respondents replied yes, whereas equal numbers responded with answers of no and maybe, at 12% each (seven of 60 and seven of 60). There was no significant association between a provider’s willingness to consider advanced measures and whether that provider routinely manages critical care in his or her burn center (chi-square value of 2.448, P ¼ 0.7842). OPOs were asked whether they had ever a nonsurvivable burn-injured patient referral become a successful organ donor. This question was applied to four different types of injuries: thermal injury, inhalation injury, electrical injury, and CO poisoning. Sixty-three percent of responding OPOs had had a thermally injured patient referral become a successful organ donor (19 of 30). Likewise, inhalation injury, electrical injury, and CO poisoning patient referrals had gone on to become organ donors via the OPOs of 80% (24 of 30), 57% (17 of 24), and 57% (17 of 24) of respondents, respectively (Fig. 6). Those OPOs who confirmed having the experience of burn-injured organ donors recalled the number of donors in the past 5 y and organ types donated. Inhalation injury patients were the most frequently reported donors, with six respondents reporting five or more patients each, whereas CO poisoning patients were the most infrequently reported donors, with 13 positive
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Fig. 4 e Bar graphs representing survey responses regarding the experiences of burn centers. In (A), respondents recalled the number of patients who had gone on to become organ donorsdwith answer options anywhere from 1e5 or more. The X-axis is grouped according to the injury type with patterned bars corresponding to the number of recalled patients. The Yaxis represents the number of burn center respondents giving a particular answer. In (B), respondents recalled the types of organs or tissues donated by their patients with burn injury if known. The X-axis is grouped according to the injury type with patterned bars corresponding to the types of organs or tissues donated. The Y-axis represents the number of burn center respondents giving a particular answer.
respondents reporting 1e3 patients each (Fig. 7A). Kidneys were the most frequently donated organs across all injury types, followed by livers and hearts (Fig. 7B), which is consistent with data from burn centers. OPOs were asked what types of challenges prevent burn-injured patient referrals from becoming successful organ donors. Common issues across injury categories were infection and hypoperfusion, echoing the concerns reported by burn centers, alongside the noteworthy frequent challenge of nonreferral of these types of patients (Table 5). Additionally, OPOs were asked, “Should thermal injury patients be referred for organ donation?” The question was repeated for inhalation injury, electrical injury, and CO poisoning patients. Every OPO respondent (100%, n ¼ 30) felt that patients with mortal burn injuries should be referred for organ donation, regardless of the injury type. Finally, OPO respondents were asked, “Would any of the above mentioned injuries (thermal injury, inhalation injury, electrical injury, CO poisoning) render a potential donor unsuitable for DCD (donation after cardiac death) (rather than DBD [donation after brain death] donation)?” All but one respondent (97%) answered no. Transplant surgeons were asked whether their transplant center had ever transplanted an organ from a burninjured donor. This question was applied to the same four types of burn injuries with regard to six different organs: lung, heart, liver, kidney, pancreas, and small bowel. Kidneys and livers were common again. Thirty-six percent of responding transplant centers (34 of 94) had transplanted a
kidney from a known inhalation injury donor, 34% (32 of 94) had transplanted a kidney from a known CO-poisoned donor, and 31% (29 of 94) had transplanted a liver from a known inhalation injury donor. Small bowel was the least commonly reported organ transplanted from any injury category (1%, one of 94 each), followed by lungs from inhalation injury donors (3%, three of 94) (Fig. 8). Transplant surgeons were then asked “Should thermal injury patients be referred for organ donation?” The question was repeated for inhalation injury, electrical injury, and CO poisoning patients. Most responding transplant surgeons felt that patients with mortal burn injuries should be referred for organ donation, but numbers differed for thermal injury (83%, 85 of 102), inhalation injury (84%, 86 of 102), electrical injury (85%, 86 of 102), and CO poisoning (82%, 83 of 102) (Fig. 9). Those respondents who did not answer yes were given the opportunity to express their concerns regarding referral for organ donation. Infection burden, hypoperfusion, and difficulty of organ-preserving critical care were the most common concerns among transplant surgeons, with an additional small number expressing concerns regarding the capabilities of hospital staff as well as patient and family unwillingness to donate (Table 6).
4.
Discussion
The general topic of burn-injured patients acting as organ donors is not well represented in a peer-reviewed literature. A
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Table 4 e Those burn surgeons who answered “No” to the question, “Should [burn injury type] patients be referred for organ donation?” were asked to give their reasons for nonreferral. Injury type/ reason for nonreferral Infection burden Hypoperfusion Difficulty of critical care Patient or family unwillingness Staff inability Other concerns*
Thermal Inhalation Electrical CO injury injury injury poisoning 6 3 0
3 0 0
0 3 2
0 5 1
0
0
0
1
1 1
0 2
0 2
0 1
This table summarizes the raw numbers of responses from surveyed burn surgeons. Each answering respondent was allowed to choose as many or as few applicable reasons as he or she wished. * Respondents’ other described concerns included ischemia time, graft organ thrombosis, and selectively chosen referral based on a cause of death.
Fig. 5 e Pie charts representing survey responses regarding the opinions of burn surgeons. Each chart depicts answers to the question, “Should [burn injury type] patients be referred for organ donation?” Answer choices were Yes, No, or Other, with free-text entry available. Values are displayed as the percentage of respondents and as the raw number of respondents.
recent review of Australia reported two patients with >90% total body surface area burns who donated kidneys after cardiac death [4]. Other published case reports of burn-injured donors have involved one brain-dead adult [5] and nine braindead children [6e8]. An additional 35 CO-poisoned adults who donated organs and tissues were identified in a 2011 systematic review of burned and CO-poisoned organ donors [9]. The infrequent representation of burn-injured organ donors in the literature would support the rarity also seen in OPTN data. Contradiction arises when the results of the present study surveys are considered. Standard criteria for donation vary based on the organ in question, but generally should include brain-dead donors younger than 50e60 y without disseminated malignancy or blood borne illness [10]. Comorbidities highlighted in the NBR include entries ranging from tobacco use to psychiatric illness to hypertension. Given that a patient with no comorbidities is more likely to be medically eligible to donate
Fig. 6 e Pie charts representing survey responses regarding the experiences of OPOs. Each chart depicts answers to the question, “Has your OPO ever had a [burn injury type] patient referral become a successful organ donor?” Values are displayed as the percentage of responding organizations and as the raw number of responding organizations.
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Fig. 7 e Bar graphs representing survey responses regarding the experiences of OPOs. In (A), respondents recalled the number of patient referrals who have become successful organ donors in the past 5 ydwith answer options anywhere from 0e5 or more. OPO respondents were given the option to select zero because the experience was contained within a span of the past 5 y. The X-axis is grouped according to the injury type with patterned bars corresponding to the number of recalled patients. The Y-axis represents the number of OPO respondents giving a particular answer. In (B), respondents recalled the types of organs or tissues donated by their burn patient referrals if known. The X-axis is grouped according to the injury type with patterned bars corresponding to the types of organs or tissues donated. The Y-axis represents the number of OPO respondents giving a particular answer.
his or her organs than a patient with the presence of one or more comorbidities, a conservative estimate of the possible organ donors presenting to NBR-reporting facilities was made by counting only mortally burn-injured patients
Table 5 e OPO respondents were asked, “What prevents [burn injury type] patients from successful organ recovery?” Injury type/ reasons for nonsuccessful organ recovery Length of time from injury Consent issues Electrolyte derangements Infection concerns Poor perfusion These patients are not referred Other concerns*
Thermal Inhalation Electrical CO injury injury injury poisoning
4
6
4
3
6 9
5 6
4 4
4 4
14 10 9
6 10 6
4 7 9
2 8 8
6
8
11
8
This table summarizes the raw numbers of responses from surveyed OPOs. Each answering respondent was allowed to choose as many or as few applicable reasons as he or she wished. * Respondents’ other described concerns included comorbidities, fluid overload, nonebrain-dead and nonedonation after cardiac death candidates, poor organ function, lack of knowledge at the referring hospital, death on arrival, and hypoxia.
confirmed to be without comorbidities, and this still resulted in nearly 900 patients younger than 60 y; over 350 of them were younger than 30 y, making them even more likely to be ideal donors [11]. Hospital lengths of stay, which can become pertinent with respect to infection burden in a burn patient, were varied between groups, with minimum of 1 d and maximum of over 1 y. Although the individual situations of each of these patients are impossible to estimate, the numbers of potentially eligible donors as estimated from the NBR reveal that these patients are either being greatly underreferred to OPOs or that OPTN data grossly underreports their contribution to the donor pool. Thirty of the 58 United States OPOs surveyed in this study responded, and up to 80% of them were able to confirm the experience of a burn-injured organ donor. In the most frequently cited category of injury for OPOs, inhalation injury, six different respondents affirmed having had five or more donors in the past 5 y alone. The experiences of these 30 OPOs suggest that in the past 5 y there have been at least 54 inhalation injury patient referrals that have gone on to successfully donate organs (Table 7). Similarly, survey responses estimate at least 50 thermally injured, 23 electrically injured, and 21 CO-poisoned patients have gone on to donate organs in the past 5 y. Although inaccuracies may exist in asking OPO representatives to recall their experiences, the general information conveyed is that these patients have indeed been contributing in some fashion to the population of organ donors in recent years, and that they have likely been doing so in numbers larger than those portrayed by OPTN data.
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9
Fig. 8 e Bar graphs representing survey responses regarding the experiences of transplant centers. In (A), respondents recalled whether they had ever transplanted a given organ from one of the given burn injury patient types. Transplant surgeon respondents were given the option to select “None of these” if they had never transplanted an organ from any of the named burn injury categories. The X-axis is grouped according to injury type with patterned bars corresponding to organs transplanted. The Y-axis represents the number of transplant surgery respondents giving a particular answer. In (B), respondents stated the types of organs their centers routinely transplant, which is shown for perspective on the values shown in image (A). The Y-axis represents the number of transplant surgery respondents giving a particular answer with patterned bars corresponding to organs transplanted.
As expected, OPOs agree without question that all mortally burn-injured patients warrant referral for organ and tissue donation. More surprisingly, burn and transplant surgeons do not consistently agree on the question of referral. Although most burn surgeons and transplant surgeons (84% and 83%, respectively) believed that thermally injured patients should be referred for organ donation, it is not unanimous. Similar trends persisted across surveyed injury types for burn and transplant surgeons, respectively; 90% and 84% for inhalation injury, 89% and 85% for electrical injury, and 89% and 82% for CO poisoning. It is important to realize that the question posed to respondents was regarding referral, not donation, as burn and transplant surgeons are not expected to decide whether a patient is appropriate for donationdin the United States, this is the responsibility of an OPO’s patient evaluation. Although the common concerns among burn and transplant clinicians (infection and hypoperfusion) align with the barriers to successful donation in referred patients as reported by OPOs, these concerns should not prevent initial referral for assessment of suitability for donation. The burn surgeon, as the clinician most likely caring for patients with nonsurvivable burn injuries, should refer patients to the local OPO according to available guidelines regardless of the injury type (Table 8). Additionally, OPOs were asked whether any of the injuries addressed in these surveys would make a patient unsuitable for a donation after cardiac death rather than donation after brain death donation, and the resounding answer was no. This particular result highlighted once again the opportunity for improved burn patient referral where it may not have been historically obvious to do so.
Outcomes research is needed to assess the long-term performance of organs transplanted from burn-injured patients. Short-term follow-up in the small number of published cases of burn-injured donors seems to indicate that these organs do not have especially poor outcomes [6e9]. Additionally, cardiac death is no longer a cause for ruling out organ donation, as evidenced by recent case reports in patients with burn injuries [4] and the responses of 97% of our answering OPOs. Currently, published recommendations for the preservation and procurement of organs in burn-injured potential donors advocate early, adequate resuscitation to preserve splanchnic perfusion and incision through nonburn infected skin when possible [7]. Given that 77% of our burn surgeon respondents were willing to use advanced measures for organ preservation, with another 12% suggesting that they would consider it on a case-by-case basis, it is in the best interest of the organ donation and transplant community to connect with the burn community in an effort to increase education and awareness as to how best to care for these scarce potential donors. Certainly in the scenario of brain death, as with the case presented in this article, there should be no question as to whether to refer a patient to the appropriate OPO, whose primary responsibility it is to determine a patient’s appropriateness for donation. Furthermore, in the scenario of burn extent leading to the futility of care in the educated opinions of burn care providers, particularly in circumstances of care limitations or comfort care measures, the goal should exist that OPOs be involved as a rule rather than as a unique circumstance. Data collection by survey is imperfect, with issues of recall bias, incomplete response, and inaccurate reporting of
10
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Table 6 e Those transplant surgeons who answered “No” to the question, “Should [burn injury type] patients be referred for organ donation?” were asked to give their reasons for nonreferral. Injury type/ reasons for nonreferral
Thermal Inhalation Electrical CO injury injury injury poisoning
Infection burden Hypoperfusion Difficulty of critical care Patient or family unwillingness Staff inability Other concerns*
5
5
3
0
6 6
5 5
2 4
9 4
2
2
0
0
0 9
1 7
0 8
1 7
This table summarizes the raw numbers of responses from surveyed transplant surgeons. Each answering respondent was allowed to choose as many or as few applicable reasons as he or she wished. * Respondents’ other described concerns included unknown or unavailable data regarding burn-injured donors, hypoxia, and likelihood of transplant recipients to turn down organs from burninjured patients.
organizations such as the American Burn Association or The Organ Donation Research Consortium. In addition, prospective collection of data from both the burn community and the OPOs would allow a more objective assessment of referral
Fig. 9 e Pie charts representing survey responses regarding the opinions of transplant surgeons. Each chart depicts answers to the question, “Should [burn injury type] patients be referred for organ donation?” Answer choices were Yes, No, or Other, with free-text entry available. Values are displayed as the percentage of respondents and as the raw number of respondents.
experiences [12]. Mixed-mode survey data collection is common, as recent technological advances lend themselves to the use of Internet modalities, whereas some providers may still prefer paper questionnaires [13]. This study used some common strategies to increase survey response rate, including extending the answer period during which responses were accepted and offering multiple sequential response modes, whereas not using other known strategies such as offering incentives or tailoring recontact efforts [13]. The response rates of published surveys of health professionals are frequently difficult to identify. A recent review of health care provider surveys found published response rates to 117 large scale studies ranged anywhere from 1% to >80% [13]. The response rates of 42%e52% in this study were achieved with the efforts of a small team and may have been improved with the inclusion of incentives or sponsorship from larger
Table 7 e Estimates of numbers of patients acting as organ donors in each injury category based on recalled numbers by burn surgeons (A) and OPO representatives (B). Injury type/no. of patients per burn survey data
5þ
4
3
2
1
Estimated no. of patients for category of injury
A Thermal injury Inhalation injury Electrical injury CO poisoning
6 (30) 3 (12) 4 (12) 6 (12) 6 (6)
72
3 (15) 0 (0)
1 (3)
2 (4)
4 (4)
26
0 (0)
0 (0)
0 (0)
2 (4)
3 (3)
7
1 (5)
2 (8)
1 (3)
0 (0)
7 (7)
23
4 (20) 2 (8)
3 (9)
5 (10) 3 (3)
50
6 (30) 0 (0)
2 (6)
4 (8) 10 (10)
54
0 (0)
0 (0)
0 (0)
4 (8) 10 (10)
18
0 (0)
0 (0)
2 (6)
4 (8)
21
B Thermal injury Inhalation injury Electrical injury CO poisoning
7 (7)
Respondents were asked the number of patients their programs had seen go on to become organ donors in each of the four injury categories, with response options being 0, 1, 2, 3, 4, or 5 or more. Using these responses, the right most column of A and B gives an estimate of the number of mortally burn-injured patients from each category who have donated organs in recent years. B represents recalled numbers for the past 5 y only.
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Table 8 e Clinical triggers used in our burn center for referral to an OPO. Clinical triggers for referral to Washington Regional Transplant Community Ventilated with a Glasgow Coma Score 5 without continuous sedation Ventilated with brain death testing being considered or pursued Ventilated and do not resuscitate or limited therapy order being considered Ventilated and family is considering withdrawal of support
patterns and conversion rates; this would obviate any recall bias inherent in this approach.
5.
11
L.T.M. and M.H.J. contributed toward conception and design, critical revision of the article, and obtaining of funding. J.W.S. contributed toward conception and design, analysis and interpretation, critical revision of the article, and obtaining of funding.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in the article.
references
Conclusions
Taken together, the insights gained by the administration of a national survey, examination of OPTN national data, and analysis of the NBR indicate several things: (1) mortally burninjured patients are able to serve as organ donors, (2) clinicians caring for mortally burn-injured patients are not referring all potential organ donors, (3) not all transplant surgeons are accepting organs from burn-injured patients, (4) there are likely more burn-injured patients who become donors than OPTN data reflects, and an improvement in the way these data are collected would be beneficial, and (5) a consensus and education are needed regarding the care of burn-injured potential organ donors.
Acknowledgment This work was supported in part by Health Resources and Services Administration contract 234-2005-37011C. The content is the responsibility of the authors alone and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors wish to thank Charles Wright, MD, for his insight and guidance and Stephen Lockey for his assistance with survey mailings. Author contributions: T.E.T. contributed toward conception and design, analysis and interpretation, data collection, and writing of the article. L.S.J. and R.M.S. contributed toward conception and design and critical revision of the article.
[1] Schwartz HS. Bioethical and legal considerations in increasing the supply of transplantable organs: from UAGA to “Baby Fae”. Am J Law Med 1985;10:397. [2] Organ Procurement and TransplantNetwork. UNet. 27, . http:// optn.transplant.hrsa.gov/data/; 2013. [3] American Burn Association. National Burn Repository annual report, http://ameriburn.org/NBR_annualreports.php; 2012 [4] Widdicombe NJ, Van Der Poll A, Gould A, et al. Donation after cardiac death in non-survivable burns. Anaesth Intensive Care 2013;41:380. [5] Stoehr I, Nagib R, Franke A, et al. Bilateral lung transplantation from a donor with fume poisoning. J Heart Lung Transplant 2007;26:194. [6] Todeschini DP, Maito ED, Maldotti A, et al. Brain death caused by electric shock and organ donation in children. Transplant Proc 2007;39:399. [7] Sheridan RL, Uberti E, Frank KT, Stewart B, Tompkins RG. Solid organ procurement from burn patients. J Trauma 1995;38:824. [8] Sheridan RL, et al. Solid organ procurement from burned children. J Trauma 1999;47:1060. [9] Busche MN, Knobloch K, Herold C, et al. Solid organ procurement from donors with carbon monoxide poisoning and/or burnda systematic review. Burns 2011;37:814. [10] Pascual J, Zamora J, Pirsch JD. A systematic review of kidney transplantation from expanded criteria donors. Am J Kidney Dis 2008;52:553. [11] American Burn Association. National Burn Repository, http:// ameriburn.org/NBR.php.; 2013. [12] Rea LM, Parker RA. Designing and conducting survey research: a comprehensive guide. In: Jossey-Bass social and behavioral sciences series. 1st ed. San Francisco: Jossey-Bass Publishers; 1992. xxiv, 254 p. [13] McLeod CC, Klabunde CN, Willis GB, et al. Health care provider surveys in the United States, 2000e2010: a review. Eval Health Prof 2013;36:106.
