4 | Organ and tissue DBD: operating theatre staff

Respect and dignity

The patient, their family and all health professionals should be treated with respect and dignity throughout the donation process.

What language should be used when talking about organ donation?

ODNZ recommends that everyone involved in deceased donation continue to refer to the person by their name and never use the words:

• cadaver
• corpse
• remains
• body
• harvest
• donor (can be used by health professionals but never when talking to the family).

These words are sometimes used inappropriately in the context of organ donation by pathologists, the police, morticians and transplant professionals. This is not acceptable. We recommend that you correct them to use words which are sensitive to the family and respectful to the patient.

Use unbiased, family-focused words such as:

• discussing organ donation
• offering the option of donation
• family agreement to donate
• declining the option of donation.

Do not use organ-focused terms such as:

• seeking consent
• obtaining consent
• requesting organs
• asking for organs
• denying consent
• refusing donation.

ODNZ recommends that during conversations with the family, the process of surgical removal of organs should be referred to as: <Patient’s name> donor operation or donor surgery.

It is acceptable to use the following terms in conversations between health professionals:

• donor surgery
• organ removal
• organ retrieval
• organ procurement
• organ donation.

It is never acceptable to use the term organ harvest, including in the OT.

ODNZ recommends that ventilation be described as:

• mechanical ventilation
• mechanical ventilatory support or
• breathing machine.

Avoid using:

• breathing
• life-support.

While it is true that the brain dead patient’s chest rises and falls with the ventilator cycle, this is not “breathing”. Ventilating a brain dead person is not “supporting life”.

Who performs the organ donation surgery?

The surgical removal of the organs is carried by out by experienced donor surgical team(s) and is treated like any other surgical operation. There is one team for the abdominal organs (liver, kidney, pancreas) and another for the thoracic organs (heart, lungs). The New Zealand donor surgical teams are based in Auckland and are comprised as outlined below.

New Zealand Cardiothoracic Donor Surgical Team:

• Lead surgeon
• Surgical assistant
• Scrub nurse
• Anaesthetist

New Zealand Abdominal Donor Surgical Team:

• Lead surgeon
• Surgical assistant
• Scrub nurse

A donor coordinator travels with the donor surgical team(s) and is present during the organ donation operation.

When an Australian donation team is involved, the donor coordinator will inform OT staff about their specific requirements. Usually they will require an anaesthetist, anaesthetic technician and a scrub nurse and do not bring instruments.

What staff are provided by the donor hospital?

The donor hospital provides:

• two circulating nurses
• anaesthetic technician
• anaesthetist in cases when the New Zealand cardiothoracic donor surgical team is not involved. (The donor coordinator will contact the anaesthetist and will inform the OT coordinator of arrangements).

The OT coordinator will determine if additional staff, including ICU staff, are allowed to observe the donor surgery.

How long does the donor surgery take?

The organ donation operation can take 3–6 hours depending on the organs being donated and the surgeons involved. As an approximate guide:

• kidney-only donation 2–3 hours
• liver and kidneys 4 hours
• liver, kidneys, heart and/or lungs 5 hours
• pancreas an additional 45 minutes
• in-situ split of liver an additional 1.5 hours.

Scheduling of the organ donation

The organ donation operation should be a considered a priority procedure to ensure that the donated organs are in optimum condition for procurement and transplantation.

An early OT time might be requested when the donor family requests minimal delay, the donor’s physiology is unstable, or the ICU is under pressure.

Which documentation is used?

The Determination of Brain Death Form is a record of the clinical assessment for the determination of brain death and records the legal time of death. It is important for all staff to understand that this is the time the patient died and not after ventilation ceases during the donor surgery.

The Authority for Organ and Tissue Removal Form replaces the normal surgical consent form and specifies which organ and tissues will be donated for transplantation or research.

The normal documentation after death is completed by the ICU staff.

When does the ventilation cease?

The patient is transferred to OT and mechanical ventilation and all monitoring continue until aortic cross-clamp and commencement of cold perfusion of the organs – about 1 to 2 hours after the commencement of the donor surgery. The anaesthetist can leave the OT after mechanical ventilation ceases.

The aortic cross-clamp time is recorded by the donor coordinator and this is the commencement of the cold ischaemic time of the organs.

Who closes the incision?

The abdominal team performs closure and dressing of incisions as for any operation. The cardiothoracic team will perform closure if there are no abdominal organs being donated.

When lungs are being donated, a bronchoscopy is sometimes performed before the commencement of the surgery. The thoracic team will bring a bronchoscope if required.

Incision

The incision for a multi-organ donation is commonly an extensive cruciate incision, with a long midline incision from the sternal notch to the symphysis pubis and a mid-abdominal transverse incision.

Sternotomy is mostly required even if the thoracic organs are not being donated as it allows more direct access to the liver and vena cava.

If it is known that only kidneys will be donated, the incision might be limited to a large midline abdominal incision.

Sequence of events

The thoracic and abdominal teams operate simultaneously. The abdominal team commences mobilisation and dissection of the liver, pancreas and kidneys. At the same time, the thoracic team performs the preliminary dissection of the heart and lungs. All organs are inspected to confirm suitability for transplantation. Following mobilisation of the heart and/or lungs, the thoracic team scrubs out.

Mobilisation of the abdominal organs takes 1 – 2 hours. When the abdominal team is ready, the thoracic team scrubs back in and inserts cannulae in the thoracic aorta and pulmonary artery. The abdominal team cannulates the infrarenal aorta and if the liver is to be donated, the portal vein or IVC.

The surgeons ask the anaesthetist to administer the heparin. The donor coordinator sets up the cold perfusion fluids for the abdominal organs. The cardiothoracic anaesthetist for the thoracic team sets up the cold perfusion fluids for the thoracic organs.

A cross-clamp is then placed on the supracoeliac aorta and the cold perfusion fluids for all the organs are immediately administered. The time of aortic cross-clamp is the commencement of the cold ischaemic time for the organs and is recorded by the donor coordinator.

Ventilation, monitoring and infusions are turned off after aortic cross-clamp. The cardiothoracic anaesthetist inflates the lungs before they are removed. The clinical role of the anaesthetist is now complete.

Sequence of removal

• Heart (if being donated for transplantation)
• Lungs
• Liver and iliac vessels
• Pancreas
• Kidneys (en bloc or individually)
• Heart for heart valves
• Spleen sample and lymph nodes when organs are going to be transplanted in Australia
• Eye tissue

The abdominal team prepares the liver, pancreas and kidneys for transplantation on the back table before packaging.

In-situ split on liver

Livers of younger donors can be divided and transplanted into two recipients. It is preferable for the liver to be divided during the donor surgery operation while circulation is intact. A CUSA is used for this procedure and adds an additional 1½ hours to the operation. An intra-operative cholangiogram may also be required.

Packaging of organs

All organs are stored in cold perfusion fluids and triple bagged. The organs are then placed in chilly bins filled with unsterile free flowing ice.

The donor coordinator is responsible for the packing and transport of the abdominal organs and assists with the packing of the thoracic organs. The donor coordinator completes the documentation that accompanies each organ.

Departure of donor surgical teams

The cardiothoracic team leaves immediately after the heart and/or lungs are packaged, usually 30–45 minutes after aortic cross-clamp.

The abdominal team leaves 1 – 2 hours after the thoracic team.

Heart valve tissue

The heart for heart valves can be procured by the thoracic or abdominal team. Cold perfusion fluid is not administered for heart valve donation and the heart is usually removed after the other organs. The heart is transported to the New Zealand Heart Valve Bank in Auckland where the aortic and pulmonary valves and pulmonary artery patches are carefully dissected and assessed for transplantation. The remaining heart tissue is respectfully cremated or returned to the patient, if that is the wish of the family. This is organised by the donor coordinator.

Eye donation

Corneas and sclerae from the eyes are transplanted. Following eye donation, skin-coloured shields are carefully placed under the eyelids to maintain the shape of the eyelids.

Eye donation can take place at the end of the donor surgery or (more commonly) in the mortuary or at the funeral directors. The procedure is carried out by an ophthalmologist or by a corneal coordinator from the New Zealand National Eye Bank and takes about 30 minutes.

When an ophthalmologist carries out this procedure in the OT, an Eye Enucleation or Eye Mortuary set will be required.

When the eye donation is going to take place in the mortuary, the documentation for eye donation completed by the donor coordinator must remain with the patient.

The donated eye tissue is transported to the New Zealand National Eye Bank by the donor coordinator or by a courier arranged by the corneal coordinator.

Communication from the donor coordinator

The donor coordinator will make an early call to the theatre coordinator. At this initial call the donor coordinator will provide the following information:

• name, age and NHI of patient
• donation pathway (DBD or DCD)
• cause of death
• approximate time of donor surgery (if known)
• organ and tissues intended for donation (if known)
• contact number for donor coordinator
• approximate time of next call.

Later on, the donor coordinator will contact the theatre coordinator again and confirm:

• organs and tissues intended for donation
• donor surgical team(s) involved
• an agreed OT time
• OT and anaesthetic staff required from donor hospital
• that the donor coordinator has contacted the anaesthetist (when required)
• any additional equipment required
• the need for unsterile ice for the storage of the organs – enough to fill three large chilly bins.

The donor coordinator will call again upon landing at the local airport and/or arrival at the donor hospital, or if there is any change to the previously agreed arrival time.

Preparation by OT staff

OT staff will need to:

• arrange staff for donor surgery
• notify the OT Link Nurse (if requested)
• determine suitable time for donor surgery
• allocate a large OT wherever possible
• ensure staff involved understand brain death and the time of death and the process of organ donation (Section 3)
• arrange for unsterile ice to be available – enough to fill three large chilly bins
• notify other hospital staff if required – duty manager, other surgeons (The duty anaesthetist should be notified of the donor surgery even if not required to assist).

Food for the donor surgical team(s) is appreciated but not essential.

The New Zealand donor surgical team(s) bring most of their instruments and equipment for perfusion and packaging of organs.

The cardiothoracic team may request a bronchoscope from the donor hospital.

The following equipment will need to be supplied by the donor hospital:

The following additional items are sometimes requested:

• CUSA when liver is going to be split (if available)
• headlights for surgeons
• weighing scales for liver donations (if available).

On arrival at the donor hospital the donor surgical team(s) and the donor coordinator go to the OT. The team(s) leave all their equipment in a designated area. They require access to the OT change rooms and change into scrubs. The scrub nurses set up OT with the assistance of the circulating nurses. One circulating nurse is allocated to each scrub nurse. The donor surgical teams do their own count and use their own count sheet.

The donor coordinator goes to the ICU to meet with the donor family and the ICU staff.

Transfer of patient to OT

When the donor family, anaesthetist, anaesthetic technician and OT nurses are ready, the patient will be transferred to the OT while mechanical ventilation and all monitoring continue.

Sign-in of the patient is completed by the OT staff with the donor coordinator.

Positioning of the patient

The patient is placed in a supine position with arms tucked at their side.

Diathermy pads will be required for each of the donor surgical teams involved. External defibrillator pads are used when thoracic organs are being donated.

Checking of documentation

The donor coordinator ensures the surgeons of each of the donor surgical teams have checked:

• Determination of Death form
• Authority for Organ and Tissue Removal form
• ABO blood group
• Infectious serology testing and COVID-19 results.

Time Out

A Time Out is led by one of the lead surgeons of the donor surgical team(s) and includes:

• patient identification
• organs and tissues intended for donation
• confirmation of heparin dose
• concerns from any staff involved
• a round of introductions of all staff involved with the donor surgery.

The donor coordinator will also inform OT staff:

• whether tissue is to be donated in OT or at a later time, eg in the mortuary
• if patient is under the jurisdiction of the coroner
• if the patient is returning to ICU or is to be transferred to the mortuary at the completion of the donor surgery
• of any requests from the family.

Masks

Masks should be worn by all staff in OT, and eye protection by donor surgical team(s).

Suction

After aortic cross-clamp large volumes of cold perfusion fluids are administered to rapidly cool the organs being donated. It is important for circulating nurses to monitor the suction at this time.

Cessation of ventilation

The time after aortic cross-clamp (and cessation of circulation and monitoring) can be difficult for OT staff because of the unusual silence and because the anaesthetist may leave the OT. Some OTs find it helpful to play quiet music.

Responsibilities of the donor coordinator during the donor surgery

The donor coordinator is responsible for:

• completion of all documentation to accompany organs and tissues
• perfusion of abdominal organs
• labelling, packaging and transport of organs and tissues
• communication with transplant units
• organising biopsies, if required
• arranging transport for the donor surgical teams
• providing information and support for OT staff.

Care of the patient

At the end of the donor surgery the incisions are covered with surgical dressings. The donor coordinator assists the OT staff to wash and care for the patient. All lines and tubes are removed except when a coroner or forensic pathologist requests they remain in-situ.

At this stage the patient will be pale and cold and any bruising may be more apparent.

Handprints and locks of hair are often taken for the family and the OT staff help the donor coordinator with this.

The family may wish to spend time with their family member following the donation and this usually takes place in the ICU before transfer to the mortuary. In this situation it is preferable for all of the lines and tubes be removed.

Alternatively, the patient is transferred to the mortuary.

Death documentation

The normal death documentation is completed by ICU staff.

Coroner’s autopsy

When a coronial autopsy is required the removal of lines and tubes is determined by local hospital policy. If there is any doubt about the removal of lines and tubes, it is advisable to seek advice from the ICU staff.

In all cases where the coroner has accepted jurisdiction, the police must be notified and the deceased formally identified. Usually the family is required for this identification but sometimes it is done by the ICU doctor. If the family is required to formally identify the deceased, this will be arranged by the ICU staff.

Local policy will determine if the police are required to transfer the deceased from the OT to the mortuary.

Blessing of the OT

The practice of blessing the OT is common in many hospitals. Blessing acknowledges the spiritual aspects surrounding the death of the patient and also recognises the generosity of the patient and his/her family.

Local hospital policy determines who performs the blessing.

Feedback and support for staff

The donor coordinator will provide the OT staff with information and support before, during and after the donor surgery.

The day after the donation the donor coordinator will phone to thank the staff involved and to let them know the outcome of the donation. Only general information is given about the recipients, eg the heart was transplanted to a man in his 40s. A letter of thanks is sent to the OT staff a week after the donation and this letter includes an update on the progress of the recipients.

It is important to recognise that some donations can have more impact than others on OT staff or individual OT staff members. This might be because of the age of the donor, the cause of death or specific circumstances that individual staff might relate to, eg the same age as a family member.

Confidentiality

Confidentiality and privacy is very important for the protection of the donor family and the recipients. It is important for all those involved in the donation process to maintain confidentiality.

Family support and follow-up

The donor coordinator is available to meet with the family before the donor surgery. For some families it can be reassuring to meet the donor coordinator who will be present with their family member during the donation. Some families wish to receive a phone call from the donor coordinator at the completion of the operation or the following day with the outcome of the donation.

At one week the donor coordinator writes a letter of thanks to the family on behalf of the transplant teams and the recipients and their families. This letter includes general information about the recipients unless the family has indicated that they did not wish to receive such information. Written information on brain death, the process of organ donation and bereavement are sent with this initial correspondence to the family.

The donor coordinator phones the family at approximately eight weeks to offer further information and support. Ongoing follow-up for some families can continue for many years.