| 摘要: | 研究目的:
器官移植已經是末期器官衰竭病患治療的標準選項，目前最大的挑戰仍然是器官的來源不足。就屍體捐贈而言，器官的摘取是在腦死判定後進行。然而，腦死導致不穩定的血行動力學可使潛在捐贈者無法捐贈，降低可供移植器官數目，並惡化器官品質。優質的器捐者照護可能對移植有顯著的影響。因此，我們導入了以重症醫師主導、指引式復甦的器捐者處置模式，並檢視其成效。
研究方法：
本研究以回溯性方法分析某一千三百床醫學中心於八年（西元二○○二年 ~ 二○○九年）期間內，所有腦死器官捐贈者之資料。自二零零六年三月起，導入器捐者處置指引；所有潛在器捐者皆轉由同一位重症醫師照護。此指引包含利用動脈波型分析技術作功能性血行動力學的監控、根據心搏量變異數作積極之體液復甦、及早使用血管收縮素控制尿崩症、常規使用口服劑型左旋甲狀腺素與靜脈劑型氫化可體松。器捐者處置指引導入前(二○○二年一月至二○○六年二月)與導入後(二○○六年三月至二○○九年十二月)之期間，關於器官者喪失、每一器捐者器官捐贈數、升壓強心劑的使用、無呼吸測試時休克與低血氧的發生，以及腎臟移植後之立即性器官功能，將作統計比較。
研究結果 ：
在八年期間內，共有五十四位潛在器捐者。器捐者處置指引導入前有二十二位，其中有二位因血行動力學不穩定而無法捐贈，另有一位於無呼吸測試時發生心跳停止。另外三十二位於器捐者處置指引導入後之潛在器捐者，皆順利完成器官捐贈。經比較，以器捐者處置指引照護之器捐者有較高之每一器捐者器官移植數（3.21 ± 0.92 vs. 3.91 ± 0.64, p < 0.01）、較低的術前升壓劑使用劑量：度巴明( 9.33 ± 8.21 vs. 0.19 ± 0.64, p < 0.001), 正腎上腺素 (3.00 ± 4.58 vs. 0.16 ± 063, p < 0.01)，無呼吸測試時較低的休克發生(14/19 vs. 3/32, p < 0.001)、低氧合(12/19 vs. 6/32, p = 0.001)；對應之腎移植接受者有較低的移植移植器官緩慢功能(13/30 vs. 6/39, p < 0.01)與較快之肌酐酸下降速度。
研究結論：
這篇研究顯示以重症醫師主導。依器捐者處置指引作積極之復甦，可有效地避免潛在器捐者之喪失、增加每一器捐者器官移植、可移植器官數目、確保無呼吸測試時之安全性，並改善器官品質。
Objective：
Transplantation has become the standard treatment option for patients with end-stage organ failure. The most challenge in transplantation is the shortage of organs. In deceased donor, organ procurement is made after pronouncement of brain death. However, hemodynamic instability that follows brain death often makes the donor loss, lowers organ yield and jeopardizes graft quality. Optimizing medical donor management may have considerable impact of transplantation. We instituted an intensivist in-charged donor management protocol and investigated its effect.
Materials and Methods:
Records of all brain dead donors in a 1,300-bed medical center over an 8-year period (2002 ~ 2009) were reviewed. In March 2006, a donor management protocol was instituted. All potential donors were transferred to the same intensivist. The protocol was constituted with functional hemodynamic monitoring by arterial pulse contour analysis technique, aggressive fluid resuscitation according to stroke volume variation, early use of vasopressin for diabetes insipidus and routine use of oral levothyroxin and parenteral hydrocortisone. Data regarding donor loss, organs transplanted per donor, inotropic agent use, shock or hypoxia episode at apnea test and immediate graft function after renal transplantation were compared before (January 2002 ~ February 2006,) and after (March 2006 ~ December 2009) the protocol.
Results：
There were 54 potential donors in the 8-year period. Of those, 22 were in the pre-protocol period; 2 lost due to hemodynamic instability, and one happened to cardiac arrest at apnea test. The other 32 were in the post-protocol period, all became actual donors. With comparison, the donors managed by the protocol had more organs transplanted per donor (3.21 ± 0.92 vs. 3.91 ± 0.64, p < 0.01), less preoperative dosage of inotropics : dopamine (9.33 ± 8.21 vs. 0.19 ± 0.64, p < 0.001), norepinephrine (3.00 ± 4.58 vs. 0.16 ± 063, p < 0.01), fewer shock episodes at apnea test (14/19 vs. 3/32, p < 0.001) and hypoxia （14/19 vs. 3/32, p < 0.001）, less slow graft function in renal recipients (13/30 vs. 6/39, p < 0.01) and more rapid decrease of serum creatinine level.
Conclusion：
This study shows that intensivist in-charged protocol guided donor management can reduce potential donor loss, increase organs transplanted per donor, and assure donor safety at apnea test and better graft quality. |
