Transplantation of the heart after circulatory death of the donor: time for a change in law?

Procurement of organs has always been conducted according to the dead donor rule, that is, after death of the donor — but this practice is being challenged. Introduction Australia has an increasing shortfall in transplantable hearts. Over the past decade, the number of all donors per million population increased from 10.0 in 2005 to 16.1 in 2014. However, the number of heart donations per million population over the same period has declined slightly from 3.8 to 3.4, with an annual average of 3.3. Procurement of organs has always been conducted according to the dead donor rule — that is, after death of the donor — but this practice is being challenged. The law defines death in all Australian jurisdictions (eg, in s 41 of the Human Tissue Act 1982 [Vic]) as either “irreversible cessation of all functions of the brain” (brain death) or as “irreversible cessation of circulation of blood in the body” (circulatory death), but it does not define irreversible or how to determine irreversibility. Exceptionally, circulatory death is not defined in Western Australian legislation. Although the procurement of organs such as livers, kidneys and lungs is permitted after either brain death or circulatory death according to Acts in all jurisdictions, the procurement of hearts has traditionally only been from brain dead donors with functioning hearts. The definition and diagnosis of brain death is not without controversy and may explain in part why more reliance is being placed on circulatory death, which reduces availability of hearts. Alternatively, organ procurement from patients after circulatory death may be perceived as more realisable than after brain death. Indeed, circulatory death as the source of solid organs has increased from 10% of 204 donors in 2005 to 28% of 378 donors in 2014. More total organs have been procured (from 726 to 1193) but the number of hearts has increased only slightly from 72 of 204 donors (35%) to 79 of 378 donors (21%) over the same period. Only 39 hearts were procured from 189 donors (21%) during the first 6 months of 2015

Adverse Events Sustained by Children in The Intensive Care Unit: Guiding local quality improvement

Objective: To determine the frequency, nature and consequence of adverse events sustained by children admitted to a combined general and cardiac paediatric intensive care unit (PICU). Design: Retrospective analysis of data collected between January 1st 2008 and December 31st 2017 from PICU. Setting: The Royal Children’s Hospital, a paediatric tertiary referral centre in Melbourne, Victoria, Australia. The PICU has thirty beds. Results: During the study period, PICU received 15208 admissions, of which 73% sustained at least one adverse event with a frequency of 67 adverse events per 100 PICU-days and 3 per admission. One adverse event was sustained for every 35 hours of care. The risk of an adverse event was highest in children less than a month of age, or if mechanically ventilated, a high Pediatric Index of Mortality (PIM2) score, longer PICU length of stay, had a pre-existing disability or a high risk adjustment for congenital heart surgery (RACHS) score. Those patients who sustained an adverse event, as compared to those who did not, were mechanically ventilated for longer (80 hrs Vs. 7 hrs, p=<0.001), had a longer PICU length of stay (131 hrs Vs. 35 hrs, p=<0.001), had a longer hospital length of stay (484 hrs Vs. 206 hrs, p=<0.001) and had a higher mortality rate (3% vs. 0.1%, p=<0.001). Conclusion: Whilst admission to PICU is an essential aspect of care for many patients, the risk of adverse events is high and is associated with significant clinical consequences. Monitoring of adverse events as part of quality improvement enables targeted intervention to improve patient safety

Withdrawal of life-support in paediatric intensive care - a study of time intervals between discussion, decision and death

<p>Abstract</p> <p>Background</p> <p>Scant information exists about the time-course of events during withdrawal of life-sustaining treatment. We investigated the time required for end-of-life decisions, subsequent withdrawal of life-sustaining treatment and the time to death.</p> <p>Methods</p> <p>Prospective, observational study in the ICU of a tertiary paediatric hospital.</p> <p>Results</p> <p>Data on 38 cases of withdrawal of life-sustaining treatment were recorded over a 12-month period (75% of PICU deaths). The time from the first discussion between medical staff and parents of the subject of withdrawal of life-sustaining treatment to parents and medical staff making the decision varied widely from immediate to 457 hours (19 days) with a median time of 67.8 hours (2.8 days). Large variations were subsequently also observed from the time of decision to actual commencement of the process ranging from 30 minutes to 47.3 hrs (2 days) with a median requirement of 4.7 hours. Death was apparent to staff at a median time of 10 minutes following withdrawal of life support varying from immediate to a maximum of 6.4 hours. Twenty-one per cent of children died more than 1 hour after withdrawal of treatment. Medical confirmation of death occurred at 0 to 35 minutes thereafter with the physician having left the bedside during withdrawal in 18 cases (48%) to attend other patients or to allow privacy for the family.</p> <p>Conclusions</p> <p>Wide case-by-case variation in timeframes occurs at every step of the process of withdrawal of life-sustaining treatment until death. This knowledge may facilitate medical management, clinical leadership, guidance of parents and inform organ procurement after cardiac death.</p

Monitoring quality of care in hepatocellular carcinoma: A modified delphi consensus

Although there are several established international guidelines on the management of hepatocellular carcinoma (HCC), there is limited information detailing specific indicators of good quality care. The aim of this study was to develop a core set of quality indicators (QIs) to underpin the management of HCC. We undertook a modified, two-round, Delphi consensus study comprising a working group and experts involved in the management of HCC as well as consumer representatives. QIs were derived from an extensive review of the literature. The role of the participants was to identify the most important and measurable QIs for inclusion in an HCC clinical quality registry. From an initial 94 QIs, 40 were proposed to the participants. Of these, 23 QIs ultimately met the inclusion criteria and were included in the final set. This included (a) nine related to the initial diagnosis and staging, including timing to diagnosis, required baseline clinical and laboratory assessments, prior surveillance for HCC, diagnostic imaging and pathology, tumor staging, and multidisciplinary care; (b) thirteen related to treatment and management, including role of antiviral therapy, timing to treatment, localized ablation and locoregional therapy, surgery, transplantation, systemic therapy, method of response assessment, and supportive care; and (c) one outcome assessment related to surgical mortality. Conclusion: We identified a core set of nationally agreed measurable QIs for the diagnosis, staging, and management of HCC. The adherence to these best practice QIs may lead to system-level improvement in quality of care and, ultimately, improvement in patient outcomes, including survival

It is time to abandon apneic-oxygenation testing for brain death

The apneic-oxygenation test is an integral part of clinical testing to determine brain death. The medical and legal criticisms of the test are presented together which make a strong argument that it should be abandoned. The requirement for hypercarbia to stimulate spontaneous respiration also causes intra-cranial hypertension and may exacerbate an existing brain injury and as such is a self-fulfilling test. Moreover in children, the onset of spontaneous respiration may commence at levels of blood carbon dioxide in excess of the minimum level used to define brain death. It is thus also unreliable. A number of legal cases in the United States have been adjudicated in favor of plaintiffs seeking to prevent performance of the test on the basis that it causes harm. Physicians have sought to perform the apneic-oxygenation test without consent of legal guardians but have failed. In lieu of the apneic-oxygenation test a brain scan using a lipophilic radionuclide is suggested. Demonstration of absent brain blood flow may be a more stringent test to determine brain death than apneic-oxygenation but is more reliable, less invasive, not harmful and not likely to reduce the rate of organ donation.&nbsp;</p

Teaching hospital medical staff to handwash

Thesis (M.Ed.) -- University of Melbourne, 1992Handwashing is recognised as an important practice In the prevention and control of infections acquired in hospitals. Such nosocomial infections contribute substantially to the mortality and morbidity of patients hospitalised for other illnesses. Despite the importance of handwashing, its incidence amongst staff members, particularly amongst medical staff is widely acknowledged to be low. Few successful attempts have been made to improve staff handwashing and none have been undertaken specifically amongst medical staff. This report concerns the efficacy of a behaviour modification programme on the handwashing practices of medical officers before and after contact with patients. The study was conducted over a six-month period in 1990 in the Intensive Care Unit of the Royal Children's Hospital, Melbourne. The subjects were sixty-one medical officers. The programme consisted of two interventions: overt observation of handwashing practices for five weeks followed by feedback of previous group performance at intervals of one week for a further four weeks. The incidence of handwashing before instigation of the programme was low. Less than 15% of patient contacts were preceded or followed by handwashing and less than 5% involved handwashing at both times. Performance improved significantly during overt scrutiny of handwashing; approximately one-third of contacts were either preceded or followed by handwashing and one-fifth were both preceded and followed by handwashing. The feedback of previous performance stimulated further significant increments in handwashing practices; approximately two-thirds of patient contacts were either preceded or followed by handwashing and approximately one-half of contacts involved both activities. After a lag period of seven weeks without performance feedback, the incidence of handwashing was maintained over 5 subsequent weeks. This study demonstrated that a behaviour modification programme consisting of overt observation and group performance feedback, stimulated short-term changes in behavioural practices of medical officers important in prevention and control of nosocomial infection

A comparative study of the adoption of a new antiscorbutic remedy in England and France during voyages of discovery to Southern Lands

© 2018 Dr. James TibballsThesis in French, with appendix - Abbreviated text in English.The navies of France and England explored Indo-Pacific regions in the 18th and 19th centuries, seeking new scientific knowledge and territories. Although equal in technical and navigational skills, the health of their crews was very different. When French explorer Nicolas Baudin encountered English explorer Matthew Flinders off the south coast of Nouvelle Hollande in 1802, the English crew was healthy while the French was scorbutic. From 1795, British crews were protected from scurvy by a daily ration of lemon juice preserved in alcohol. While adoption of this innovation was judged late by sociologist Everett Rogers, according to his theory Diffusion of Innovations, its adoption almost a century later by the French was even more so. This work explores reasons for late adoption by both navies, referring to Rogers’ theory. Scurvy was inevitable during prolonged sea journeys, appearing after 2-3 months. Landfall was the only remedy, but for reasons unknown. The real cause, lack of dietary vitamin C (ascorbic acid), causing fatal haemorrhages, was discovered in 1932. However, 17th century British and French explorers had discovered that citrus fruits cured and prevented scurvy, believing erroneously that their acid content was antiscorbutic. Their discoveries were ignored. Putative causes and remedies for scurvy were proposed, in the context of prevailing medical ideologies such as Galenism or iatromechanics. In 1747 James Lind experimented and showed that only oranges and lemons cured scorbutic sailors. Lind also prepared a “rob” (heat-distilled preparation of juice) which was not tested. Half a century passed before Gilbert Blane, knowing that heat destroyed antiscorbutic property, persuaded the British Navy to adopt alcohol-preserved lemon juice. In England, debate over spurious remedies, including malt used by James Cook, delayed adoption of lemon juice. In reality, consumption of fruit and vegetables on frequent landfall during expeditions explains why Cook’s crews remained healthy. Likewise, in France, debate over spurious causes such as consumption of meat, delayed adoption of lemon juice. A vegetarian diet, which did not contain fresh produce, remained in force for over a decade. An important hindrance was, ironically, the invention of a process by Nicolas Appert in 1802 to preserve heat-sterilised food in glass jars which enabled consumption of food, otherwise available only on shore, during long sea journeys. The process prevented putrefaction of food and preserved its taste, but unknown to Appert and French authorities, also destroyed its antiscorbutic property. Not until the Crimean war in the 1850s, did French authorities realise that preserved food did not prevent scurvy in contrast to lime juice which maintained health of their British ally. A Commission was established in 1856 to investigate preparations of citrus fruit but erroneously recommended a heated preparation based on acidity and taste, not on antiscorbutic property. A decree of 1860 ordered consumption of lemon juice but could not be fulfilled. Additional decrees of 1874 and 1894 encouraged delivery and consumption of lemon juice but its need dissipated with the introduction of steamships which shortened sea journeys. Citrus juice was never effectively adopted by the French Navy, compromising voyages of discovery