The Opiate Epidemic and Organ Donation - Critical Care Canada … · 2019-09-27 ·...
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transplant.bc.ca Live Life. Pass It On. The Opiate Epidemic and Organ Donation November 7, 2018 Sean Keenan MD Provincial Medical Director, Donation Services BC Transplant
Transcript of The Opiate Epidemic and Organ Donation - Critical Care Canada … · 2019-09-27 ·...
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Live Life. Pass It On.
The Opiate Epidemic and
Organ Donation
November 7, 2018
Sean Keenan MD
Provincial Medical Director,
Donation Services
BC Transplant
transplant.bc.ca
Faculty/Presenter Disclosure
• Faculty: Sean Keenan
• Relationships with financial interests:– Grants/Research Support: none
– Speakers Bureau/Honoraria: none
– Consulting Fees: none
– Patents: none
– Other: Provincial Medical Director, Donation Services, BC
Transplant
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Plan for today
• Background on Opiate Crisis in North America
• Impact on Donation and Transplantation
– Volume and composition of cases
– NDD Declaration of Death
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Case Presentation
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Case Presentation (case altered to protect identity)
• 20 year old man found unresponsive at 10:30
am, Day 0– Known use of Percocet/Oxycontin
– Last seen 1 hour earlier at 9:30 “snoring”
– PEA
• CPR x 1 hour, Epi x 10
• In ER continued loss of pulse – Epi infusion
• Drug screen– Positive Fentanyl, Cannaboids
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Case Presentation
• After resuscitation
– Profound shock – High doses vasopressors
– Marked acidosis
• 6.80/85/81/9 – lactate 17
– Hypothermic T 30 C
– Hypoglycemic – 1.1
– ARDS secondary to aspiration
– Multiorgan injury
• AST/ALT – 4000/3800
• AKI – Cr 148
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Opiate Crisis
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What makes this a Crisis?
• In US
– 2000-2014 overdose rate doubled
– 2015 further 15% increase
– Drug overdose overtakes firearms, MVC as
number 1 cause of accidental death
– Life expectancy dropped for < 65 years old
Weiner et al. Transplantation 2017;101:678-681
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What is the Opioid Crisis
Canadian Institute for Health Information. Opioid-Related Harms in Canada. Ottawa, ON: CIHI; 2017.
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Illicit Drug Overdose Deaths in BC January 1, 2008 to January 31, 2018
Coroner’s Report
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National View of Number and Rate of Overdose Deaths
Special Advisory Committee on the Epidemic of Opioid
Overdoses. National report: Apparent opioid-related deaths
in Canada (January 2016 to June 2017) Web-based Report.
Ottawa: Public Health Agency of Canada; 2017.
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Proportion of Opioid Deaths due to FENTANYL
0
10
20
30
40
50
60
70
80
90
100
BC Alberta Manitoba Ontario Quebec NovaScotia
2016
2017
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These Opiod overdose deaths are accidental ….
Special Advisory Committee on the Epidemic of Opioid
Overdoses. National report: Apparent opioid-related deaths
in Canada (January 2016 to June 2017) Web-based Report.
Ottawa: Public Health Agency of Canada; 2017.
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Why has this happened?
• In the US
– Initial rise in prescription of opioids
• 3 DRIVING FORCES
– Moral imperative for physicians to treat pain
and relieve suffering
» Access to pain management is a
fundamental right
– Perceived under-treatment of pain
“oligoanalgesia”
» Focus on adequate pain management,
linked to reimbursement
Weiner et al. Transplantation 2017;101:678-681
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Why has this happened?
• Impact of Pharma marketing
– OxyContin
• $200 million in 2001
• 10 fold increase by 2002Weiner et al. Transplantation 2017
Dowell et al. JAMA 2017
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Opioid Crisis
• Tracking of increased opiate prescriptions noted
• Out of proportion to documented amount of pain
– Increased scrutiny
» CDC guidelines
» Prescription monitoring
» More stringent laws on prescribing
Weiner et al. Transplantation 2017;101:678-681
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What next?
• Opioid prescriptions fall
– 2015 16.6 million fewer than 2014
• Concern now is lack of access leading to
increased use of illicit opiates
– Heroin
– Fentanyl and others
Dowell et al. JAMA 2017
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US data
Dowell et al. JAMA 2017
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Illicit Drug Overdose Deaths in BC January 1, 2008 to January 31, 2018
Coroner’s Report
BC Data – Coroner’s Office
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Overdose impact on Organ Donation
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Impact of Overdose on Organ Donation
• Goldberg et al. Am J of Transplantation 2016
– Organ Procurement and Transplantation Network
(OPTN)
– 2003-2014 … 2.2% to 7.3% of total donors
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2003 2007
20102014
Increasing number of overdose organ donors
Goldberg et al. Am J of Transplantation 2016
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Durand et al.
Data from Scientific Registry of Transplant Recipients
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1.3%
13.7%
Mehra et al.
Proportion of Organ Donors following Overdose
United States vs Eurotransplant
<1% all years for Eurotransplant
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2017 BC Overdose Deaths and Donors
0
20
40
60
80
100
120
140
160
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Series1
Series2
Deaths
Donors
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Number of Organ Donors with positive Toxicology
(presumed overdose)
0
10
20
30
40
50
60
2013 2014 2015 2016 2017
OD donors
OD donors
2017
46 Overdose
25 positive Fentanyl
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BC increase in Deceased Donors 2013-2017
0
20
40
60
80
100
120
140
2013 2014 2015 2016 2017
Overdose
Other
2017
38%
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Southern Alberta … with permission Andreas Kramer
0
5
10
15
20
25
30
35
40
2011 2012 2013 2014 2015 2016 2017
OD
None OD
2017
37%
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TGLN data … with permission Andrew Healey
0
50
100
150
200
250
300
350
400
2014 2015 2016 2017
OD opiate
OD
Non OD
2017
8% / 12.7%
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Durand et al.
Overdose Deaths
Trauma Deaths
Medical Deaths
Infection Risk Deaths (IRDs)
Change in the Donor pool
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Hepatitis C
• In US
– Resurgence in Hepatitis C related to increased IVDU
in younger addicts … avg age donor 12 years
overdose deaths Hep C Donors
Gonzales et al. Hepatology 2018;67(4)1600-1608
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Durand et al.
Overdose Deaths
Trauma Deaths
Medical Deaths
Increase in Hepatitis C positive organ donors
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Utilization Rates Hepatitis C positive kidneys & livers
Li et al. Diseases 2018, 6, 62; doi:10.3390
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Hepatitis C positive into Hepatitis C negative
Gonzales et al. Hepatology 2018;67(4)1600-1608
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Recipient Outcomes are very good …
Durand et al.
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Impact on Organ Donation
• Increased volume of missed opportunities?
Work load
• Inability to do proper MRR
follow up of missed cases
• “Donor fatigue”
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BCKA
Neurological Determination of Death
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That afternoon …
• Shock – PEA x further 3 times
• Profound hypoxemia
– O2sats in 70% range for several hours
– Unresponsive to PEEP, recruitment attempts,
NO
• ECMO – on VV at 17:30
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Patient transfer
• Patient moved to regional ECMO centre and
more stable
– Arrived early evening Day 0
– On Propofol overnight – dc 07:00 Day 1
– Weaned off vasopressors by Day 2
– AKI resolved by Day 2
– LFTs normalizing
– ECMO – decannulated Day 3 15:50
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Neurological status
• On presentation
– Pupils fixed, dilated, no brainstem reflexes, no
response to painful stimuli
• After resuscitation
– Pupils no longer dilated or fixed, spontaneous resp
noted
• Further re-arrest x 3, profound hypoxemia, on ECMO
– Pupils fixed, no brainstem reflexes, no response to
painful stimuli throughout remainder of stay
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Neurostatus
• CT on Day 0 – diffuse cerebral edema
• CT on Day 2 – diffuse edema with evolving
changes of hypodensities within basal ganglia
and white matter
– Compatible with severe anoxic brain injury
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End of Life Discussions
• Very guarded prognosis from beginning
– Parents very interested in donation
• Day 4 post presentation
– 3 days without any sedation
• Propofol off 76 hrs
• Last Versed/Fentanyl 89 hrs
– On Fentanyl at 50 mic/hr x 2 hrs
– Midazolam at 10 mg/hr x 1 hr, 40 mins
• 22 hours off ECMO
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Brain Death Assessment
• 13:30 Day 4
– No brainstem reflexes
– No response to painful stimuli
– No spontaneous resp on Apnea test
• 16 minutes
• PaCO2 40 to 74, pH in expected range
• Pronounced dead
• BC Transplant contacted and NDD management put in
motion
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Next 24 hours
• Noted difficulty with recruitment maneuvers
• Question whether some spontaneous breathes
• With MRP present placed on T-piece and
occasional breathes noted @ ~ 08:30 Day 5
• Nuclear Med Brain Scan Day 5
– Flow to brain noted
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Next 24 hours
• Discussion with family
– MRP and 2nd colleague both of opinion patient has had a severe
anoxic brain injury and no hope of recovery
– Family do not wish life support to be continued
– Agree to DCD
• Day 5, extubated at 20:08 –
– > 108 hrs off Propofol, 120 hours since Versed, Fentanyl and ~
129 hours post-event
– No resp noted
– Asystole at 20:15
– To OR for recovery at 20:21
• 2 kidneys, liver recovered.
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Neurological Determination of Death of Overdose
• Challenge
– Uncertainty around what and how much taken
– Difficult to know when clearance sufficient
• Clinical assessment perhaps more to rule out
brain death
• Strongly consider ancillary testing
– Unclear how long to wait
– Don’t want to wait long
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Summary
• Opiate Crisis continues
– organ donors
• Canadian study of regional impact
– Increase in high risk / Hep C
– Stress on resources
– Need to focus on MRR
– Challenge of NDD in OD setting
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Thank you!
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The Opiate Epidemic and Organ Donation
1. Opiate epidemic is a real crisis
increasing number of deaths
decrease in life expectancy
no solution as yet
2. Opiate epidemic and organ donation
Increase in volume of donors
Change in donors
- more “increased” risk donors
- increase in Hep C organs available
- potential underuse of these organs
Declaration of Brain Death a challenge
- use of ancillary testing suggested
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NDD versus DCD Organs Utilized
0
10
20
30
40
50
60
70
80
Kidney Liver Lung Heart
NDD
DCD
2017 OD donors
37 NDD
9 DCD (19.6%)
Non-OD donors
32% DCD
87 29 23 17
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Durand et al.
Transplant from Donors dying of Overdose
