The gift of life

Earlier this year, the law in England changed to an ‘opt-out’ system for organ donation. This means that if you are not in an excluded group and have not confirmed whether you want to be an organ donor, it will be considered that you agree to donate your organs when you die. This month’s issue provides several brand new clinically-relevant updates in the field of solid organ transplantation from experts from around the world. 

Wales moved to an ‘opt-out’ system in 2015, whereas the rest of the UK maintained the ‘opt-in’ approach. This analysis from Madden et al. examines the effect of this legislative change on consent rates for deceased organ donation in Wales from 2015 to present. They found there was a significant increase as compared with England, although the impact was not immediate and took several years to take effect. There has been little coverage in the literature on risk factors in the donor for poor post-transplant organ quality and the role of donor management before organ retrieval. Bera et al. argue prevention of injury and promotion of repair before organ retrieval, by targeting specific pathological pathways, offers novel mechanisms for donor management beyond just physiological stabilisation

Organ donation after brain death (DBD) remains the deceased organ donation pathway of choice (Fig. 1). Manara et al. argue that increasing DBD donors in the UK can be achieved primarily by increasing consent rates to those comparable with the rest of Europe. Their work is simply everything you need to know about the current status of DBD organ donation in the UK. Donation after circulatory death (DCD) in the UK has increased over the last decade, due partly to cultural changes in end-of-life practices, as well as overcoming various ethical, legal and professional barriers. Gardiner et al. tell the story of the rise of DCD, and use data derived from publicly available sources to do so (Fig. 2). The question of how to define ‘death’ is an age-old ethical dilemma that continues to cause confusion and controversy. Some might suggest it can be defined as either circulatory-respiratory or neurological. Gardiner et al. argue there are not two different types of death, and it is not true that ‘irreversible’ means ‘permanent’ only when applied to the cessation of circulatory and respiratory functions. In their review article, they set out arguments for why permanent brain arrest is the true and sole criterion for the death of human beings. Finally, Cooper et al. set out the reasons that the ethical and practical ‘problem’ of consent for interventional research in deceased organ donors is far from resolved. They argue a failure to appreciate this may have serious implications for all, such as the prolongation of research processes or the loss of public trust in medical research generally and organ donation specifically. 

Figure 1 Schematic overview of the process of deceased organ donation.

Figure 2 Number of UK DCD cases and contribution as a percent of total deceased donations over time. Columns – number of DCD cases; Line – percent contribution of DCD (compared with total DBD and DCD).

Deep neuromuscular blockade during laparoscopic surgery might facilitate lower intra-abdominal pressure and provide adequate operating conditions, and has been proposed to have a number of other benefits. This new randomised controlled trial from Boggett et al. finds that deep neuromuscular blockade did not improve cognitive recovery or other recovery domains, and did not facilitate a reduction in intra-abdominal pressure. Many have long advocated the use of objective neuromuscular monitoring to avoid residual neuromuscular blockade (NMB). This new retrospective observational study of 30,340 cases from six Danish hospitals finds that acceleromyography was used in 88% of cases in six Danish hospitals where a non‐depolarising NMB drug was used, and in 30% of cases where succinylcholine was the sole NMB drug. These are amongst the highest rates of NMB monitoring reported. Bowdle and Jelacic urge us all to use routine quantitative twitch monitoring, and argue the trachea should not be extubated until the train-of-four ratio reaches a normalised value of at least 0.9 (Fig. 3).

Figure 3 Last recorded TOF values in 13,562 cases. A TOF value of 100 depicts the scenario where no fade is seen and the ratio is 1.0. The vertical line represents the median at 97, while the mean (SD) is 97.4 (24). 

Back in May, we were delighted to publish a new PROSPECT guideline for oncological breast surgery. This month, McCartney and Abdallah provide the context, and conclude the guidelines are an important addition to our knowledge. The next challenge, which is the same for any other new guideline, will be to see if they can be implemented with the help of our surgical and other peri-operative colleagues. Direct oral anticoagulant prescriptions now exceed those of warfarin and are increasing annually. Mayor and White call for a more pragmatic approach to these agents in the peri-operative period for patients undergoing hip fracture surgery, by focussing more on the risks associated with delay. Their editorial is essential reading for all anaesthetists, and new guidance for those caring for these patients is eagerly awaited. Lastly, Agarwal and Laycock provide their thoughts on the utility of point-of-care testing and fibrinogen concentrate in postpartum haemorrhage

Elsewhere we have: a randomised controlled trial of the effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patientsa database analysis of spinal versus general anaesthesia for surgical repair of hip fracture and subsequent risk of morbidity and mortalitya systematic review and meta-analysis of peri-articular infiltration analgesia for should surgery; and a celebration of the achievements and challenges in systematic reviews of evidence in peri-operative care as the Cochrane Anaesthesia Review Group turns 20. Over in Anaesthesia Reportsa report of the use of rocuronium ‘priming’ for tracheal intubation in COVID-19 patients has received a lot of attention on Twitter, as did a report of recurrent massive pulmonary emboli in a critically ill patient with COVID-19 and awake tracheostomy in a child with respiratory distress due to a retropharyngeal abscess

Last week, we held a TweetChat with Professor Tim Cook about his new paper on risks to health from COVID-19 for anaesthetists and intensivists. The paper was received extremely well on social media and generated much debate about the use of risk assessments for all staff members, which he argues should include environmental risk and mitigation strategies as well as personal risk. You may have seen also this new paper from Bampoe et al. about immune seroconversion to SARS-CoV-2 in frontline maternity health professionals, which was featured all over the mainstream media. 

Finally, we hope you can join us for our presentation of ‘Paper of the Year’ on the 26th of September, which also includes presentations on top airway and subspecialty papers, as well as the pitfalls and perils of publishing. 

Mike Charlesworth and Andrew Klein