Care of the Potential Organ Donor
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In their review article on the care of the potential organ donor, Wood et al. (Dec. 23 issue)1 emphasize the importance of the correction of hypovolemia and recommend the use of sodium bicarbonate to treat acidosis. They also remind the reader that hypernatremia in the donor can adversely affect the function of the transplant.
Fluid administration, as part of an early, goal-directed therapy, is beneficial in critical care patients with shock.2 However, there is no evidence to support the use of bicarbonate therapy in the treatment of hypoperfusion-induced acidemia. Alkali therapy does not improve hemodynamics, does not reduce the vasopressor requirement, and may even be harmful.3 It can lead to hypernatremia and extracellular fluid volume overload.4 Hemodynamic management with the use of adequate fluid resuscitation, vasopressors, and inotropic therapy is probably the cornerstone of the treatment of the potential organ donor. The use of sodium bicarbonate as standard therapy in the case of acidosis may be more deleterious than beneficial, is highly questionable, and cannot be recommended.
Frédéric M. Jacobs, M.D.
H?pital Antoine Béclère
92140 Clamart, France
frederic.jacobs@abc.ap-hop-paris.fr
References
Wood KE, Becker BN, McCartney JG, D'Alessandro AM, Coursin DB. Care of the potential organ donor. N Engl J Med 2004;351:2730-2739.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-873.
Mathieu D, Neviere R, Billard V, Fleyfel M, Wattel F. Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Crit Care Med 1991;19:1352-1356.
To the Editor: The review article by Wood and colleagues contains several puzzling statements. First, infection with the human T-cell leukemia–lymphoma virus (HTLV) is said to contraindicate donation, but an earlier report from the same institution recommended that HTLV-positive persons not be categorically excluded from donating organs.1 Second, colloid solutions are recommended for potential lung donors to minimize the formation of pulmonary edema. However, there are data indicating that "colloid-containing solutions are . . . not more effective [than crystalloids] in preserving pulmonary function"2 and they are much more expensive than crystalloids. Furthermore, the recent Saline versus Albumin Fluid Evaluation Study concluded that saline and albumin are equivalent for volume resuscitation in patients in the intensive care unit.3
Finally, although the value of hormonal therapy has not been clearly established, it has nevertheless been incorporated into the United Network for Organ Sharing critical pathway for the care of donors, which recommends that "hormonal resuscitation" be instituted when conventional management fails.4 In contrast, Wood and colleagues recommend trying other vasopressors first.
Many questions remain regarding optimal care of donors. Until they are answered, practice will be based primarily on experience, rather than hard science.
Aaron Spital, M.D.
New York Organ Donor Network
New York, NY 10001
aspital@nyodn.org
References
Shames BD, D'Alessandro AM, Sollinger HW. Human T-cell lymphotrophic virus infection in organ donors: a need to reassess policy? Am J Transplant 2002;2:658-663.
Rose BD, Post TW. Clinical physiology of acid-base and electrolyte disorders. 5th ed. New York: McGraw-Hill, 2001.
The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-2256.
Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant 2002;2:701-711.
The authors reply: The goal of our review was to provide recommendations derived from the best existing evidence and our collective experience in the care of donors at a comprehensive organ transplantation center. Unfortunately, evidence-based guidelines supported by prospective, randomized, controlled trials in this population are virtually nonexistent. The United Network for Organ Sharing regards the use of organs from donors infected with HTLV-I or HTLV-II as a protocol violation, unless subsequent confirmatory testing unequivocally indicates that the initial test result was a false positive result.1 Given the low prevalence of HTLV-I and HTLV-II among donors and the potential for false positive results with the use of highly sensitive screening assays, Shames et al. have recommended that careful consideration be given to transplanting organs from these donors.2
The optimal use of colloid or crystalloid in selected populations is open to discussion. Colloid has been recommended and has been associated with higher rates of lung procurement than crystalloid.3
In the absence of randomized or controlled trials, the use and timing of hormonal resuscitation remain speculative. Our algorithm recommending early placement of a pulmonary-artery catheter is derived from an evolving literature and from experience that suggests that improved fluid and hemodynamic management result with this approach. Cardiac recommendations by the Crystal City Meeting Group, cited by Spital, suggest that aggressive hemodynamic management with a pulmonary-artery catheter be initiated simultaneously with hormonal resuscitation.4
The use of sodium bicarbonate remains controversial, and in that way is similar to many options in the complex care of this population. Its use should be undertaken on an individualized basis.
Kenneth E. Wood, D.O.
Douglas Coursin, M.D.
Anthony D'Alessandro, M.D.
University of Wisconsin Hospital and Clinics
Madison, WI 53792-9988
kew@medicine.wisc.edu
Fluid administration, as part of an early, goal-directed therapy, is beneficial in critical care patients with shock.2 However, there is no evidence to support the use of bicarbonate therapy in the treatment of hypoperfusion-induced acidemia. Alkali therapy does not improve hemodynamics, does not reduce the vasopressor requirement, and may even be harmful.3 It can lead to hypernatremia and extracellular fluid volume overload.4 Hemodynamic management with the use of adequate fluid resuscitation, vasopressors, and inotropic therapy is probably the cornerstone of the treatment of the potential organ donor. The use of sodium bicarbonate as standard therapy in the case of acidosis may be more deleterious than beneficial, is highly questionable, and cannot be recommended.
Frédéric M. Jacobs, M.D.
H?pital Antoine Béclère
92140 Clamart, France
frederic.jacobs@abc.ap-hop-paris.fr
References
Wood KE, Becker BN, McCartney JG, D'Alessandro AM, Coursin DB. Care of the potential organ donor. N Engl J Med 2004;351:2730-2739.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
Dellinger RP, Carlet JM, Masur H, et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858-873.
Mathieu D, Neviere R, Billard V, Fleyfel M, Wattel F. Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Crit Care Med 1991;19:1352-1356.
To the Editor: The review article by Wood and colleagues contains several puzzling statements. First, infection with the human T-cell leukemia–lymphoma virus (HTLV) is said to contraindicate donation, but an earlier report from the same institution recommended that HTLV-positive persons not be categorically excluded from donating organs.1 Second, colloid solutions are recommended for potential lung donors to minimize the formation of pulmonary edema. However, there are data indicating that "colloid-containing solutions are . . . not more effective [than crystalloids] in preserving pulmonary function"2 and they are much more expensive than crystalloids. Furthermore, the recent Saline versus Albumin Fluid Evaluation Study concluded that saline and albumin are equivalent for volume resuscitation in patients in the intensive care unit.3
Finally, although the value of hormonal therapy has not been clearly established, it has nevertheless been incorporated into the United Network for Organ Sharing critical pathway for the care of donors, which recommends that "hormonal resuscitation" be instituted when conventional management fails.4 In contrast, Wood and colleagues recommend trying other vasopressors first.
Many questions remain regarding optimal care of donors. Until they are answered, practice will be based primarily on experience, rather than hard science.
Aaron Spital, M.D.
New York Organ Donor Network
New York, NY 10001
aspital@nyodn.org
References
Shames BD, D'Alessandro AM, Sollinger HW. Human T-cell lymphotrophic virus infection in organ donors: a need to reassess policy? Am J Transplant 2002;2:658-663.
Rose BD, Post TW. Clinical physiology of acid-base and electrolyte disorders. 5th ed. New York: McGraw-Hill, 2001.
The SAFE Study Investigators. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004;350:2247-2256.
Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to maximize the use of organs recovered from the cadaver donor. Am J Transplant 2002;2:701-711.
The authors reply: The goal of our review was to provide recommendations derived from the best existing evidence and our collective experience in the care of donors at a comprehensive organ transplantation center. Unfortunately, evidence-based guidelines supported by prospective, randomized, controlled trials in this population are virtually nonexistent. The United Network for Organ Sharing regards the use of organs from donors infected with HTLV-I or HTLV-II as a protocol violation, unless subsequent confirmatory testing unequivocally indicates that the initial test result was a false positive result.1 Given the low prevalence of HTLV-I and HTLV-II among donors and the potential for false positive results with the use of highly sensitive screening assays, Shames et al. have recommended that careful consideration be given to transplanting organs from these donors.2
The optimal use of colloid or crystalloid in selected populations is open to discussion. Colloid has been recommended and has been associated with higher rates of lung procurement than crystalloid.3
In the absence of randomized or controlled trials, the use and timing of hormonal resuscitation remain speculative. Our algorithm recommending early placement of a pulmonary-artery catheter is derived from an evolving literature and from experience that suggests that improved fluid and hemodynamic management result with this approach. Cardiac recommendations by the Crystal City Meeting Group, cited by Spital, suggest that aggressive hemodynamic management with a pulmonary-artery catheter be initiated simultaneously with hormonal resuscitation.4
The use of sodium bicarbonate remains controversial, and in that way is similar to many options in the complex care of this population. Its use should be undertaken on an individualized basis.
Kenneth E. Wood, D.O.
Douglas Coursin, M.D.
Anthony D'Alessandro, M.D.
University of Wisconsin Hospital and Clinics
Madison, WI 53792-9988
kew@medicine.wisc.edu