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Organ transplantation is a therapy that benefits thousands of patients every year. Its expansion is, however, limited by our chronic inability to meet the transplantation needs of patients. The World Health Organization (WHO) has called governments to progress towards self-sufficiency in transplantation, primarily by maximizing donation from the deceased. This requires adopting a whole hospital approach to identify areas of current medical practice that lead to the loss of donation potential, particularly in the management of patients with severe brain injuries who die despite initial active treatment, those with devastating brain injury (DBI)—defined as any neurological condition perceived as an immediate threat to life or incompatible with good functional recovery and where withdrawal or withholding of life-sustaining therapy is being considered—and those after unsuccessful cardiopulmonary resuscitation.

The success of any donation process requires that potential brain-dead donors (PBDD) are detected and referred early to professionals responsible for their evaluation and conversion to actual donors. The intensivist plays a crucial role in organ donation. However, identification and referral of PBDDs may be suboptimal in the critical care environment. Factors influencing lower rates of detection and referral include the lack of specific training and the need to provide concomitant urgent care to other critically ill patients. Excellent communication between the ICU staff and the procurement organization is necessary to ensure the optimization of both the number and quality of organs transplanted. The organ donation process has been improved over the last two decades with the involvement and commitment of many healthcare professionals. Clinical protocols have been developed and implemented to better organize the multidisciplinary approach to organ donation. In this manuscript, we aim to highlight the main steps of organ donation, taking into account the following: early identification and evaluation of the PBDD with the use of checklists; donor management, including clinical maintenance of the PBDD with high-quality intensive care to prevent graft failure in recipients and strategies for optimizing donated organs by simplified care standards, clinical guidelines and alert tools; the key role of the intensivist in the donation process with the interaction between ICU professionals and transplant coordinators, nurse protocol managers, and communication skills training; and a final remark on the importance of the development of research with further insight into brain death pathophysiology and reversible organ damage.

Controlled donation after circulatory determination of death (cDCDD) is now a major contributor to transplant activity worldwide. However, its expansion has been complicated by inconsistent terminology, diverse clinical protocols, and ethical uncertainties. To address these challenges, the European Society for Organ Transplantation (ESOT) convened a global consensus forum involving multidisciplinary experts from various geographic regions. Four steering committees were established to address adult and pediatric donation pathways, normothermic regional perfusion, and the determination of death. Using a structured methodology, expert panels participated in two waves of surveys, complemented by an in-person consensus meeting to develop recommendations on key clinical and ethical aspects of cDCDD. This article presents the project methodology and consensus results regarding standardized terminology and definitions that are essential for successfully harmonizing international practice. Consensus was achieved on fundamental terms, including the recommended nomenclature of \"donation after circulatory determination of death,\" definitions of clinical categories such as possible and potential donors, and key time points in donation protocols. The establishment of shared terminology provides a foundation for comparing outcomes across programs, facilitating international research collaboration, and supporting evidence-based improvements in clinical practice. This consensus represents an important step toward global convergence of donation practices while maintaining core ethical values and supporting continued technological and societal progress in the field.

Bacterial infections remain a challenge to solid organ transplantation. Due to the alarming spread of carbapenem-resistant gram negative bacteria, these organisms have been frequently recognized as cause of severe infections in solid organ transplant recipients. Between 15 May and 30 September 2012 we enrolled 887 solid organ transplant recipients in Italy with the aim to describe the epidemiology of gram negative bacteria spreading, to explore potential risk factors and to assess the effect of early isolation of gram negative bacteria on recipients' mortality during the first 90 days after transplantation. During the study period 185 clinical isolates of gram negative bacteria were reported, for an incidence of 2.39 per 1000 recipient-days. Positive cultures for gram negative bacteria occurred early after transplantation (median time 26 days; incidence rate 4.33, 1.67 and 1.14 per 1,000 recipient-days in the first, second and third month after SOT, respectively). Forty-nine of these clinical isolates were due to carbapenem-resistant gram negative bacteria (26.5%; incidence 0.63 per 1000 recipient-days). Carbapenems resistance was particularly frequent among Klebsiella spp. isolates (49.1%). Recipients with longer hospital stay and those who received either heart or lung graft were at the highest risk of testing positive for any gram negative bacteria. Moreover recipients with longer hospital stay, lung recipients and those admitted to hospital for more than 48h before transplantation had the highest probability to have culture(s) positive for carbapenem-resistant gram negative bacteria. Forty-four organ recipients died (0.57 per 1000 recipient-days) during the study period. Recipients with at least one positive culture for carbapenem-resistant gram negative bacteria had a 10.23-fold higher mortality rate than those who did not. The isolation of gram-negative bacteria is most frequent among recipient with hospital stays >48 hours prior to transplant and in those receiving either heart or lung transplants. Carbapenem-resistant gram negative isolates are associated with significant mortality.

Background Heart transplantation is limited by a severe donor organ shortage. Potential donors with brain death (BD) and left ventricular dysfunction due to neurogenic stunning are currently excluded from donation – although such abnormalities can be reversible with aggressive treatment including Hormonal Treatment (HT) and deferred organ retrieval. Aim To assess the recovery of left ventricular dysfunction in potential brain-dead donors with hemodynamic instability treated by aggressive treatment and HT. Methods In a single-center, observational study design, we evaluated 15 consecutive brain-dead potential donors (DBD) (8 males, age = 48 ± 15 years) with hemodynamic instability. All underwent standard hemodynamic monitoring and transthoracic 2-dimensional echo (2-DE) with assessment of Ejection Fraction (EF). Measurements were obtained before BD and after BD within 6 h, at 24 h and within 48 h. HT (with insulin, methylprednisolone, vasopressin and T3) was started as soon as possible to treat hemodynamic instability and avoid administration of norepinephrine (NE). Eligible potential heart donors underwent coronary angiography. Results After HT, we observed a normalization of hemodynamic conditions with improvement of mean arterial pressure (pre = 68 ± 8 mmHg vs post = 83 ± 13 mmHg, p < .01), cardiac index (pre = 2.4 ± 0.6 L/min/m 2 vs post 3.7 ± 1.2 L/min/m 2 , p < .05), EF (pre = 48 ± 15 vs post = 59 ± 3%, p < .01) without administration of norepinephrine (NE) in 67% of cases. Five potential donors were excluded from donation (opposition, n = 3, tubercolosis n = 1, malignancy n = 1). At pre-harvesting angiography , coronary artery stenosis was present in 2 of the 10 consented donors. Eight hearts were uneventfully transplanted. No early graft failure occurred and all eight recipients were alive at 6-month follow-up. Conclusion In BD donors, intensive treatment including HT is associated with improvement of regional and global LV function and reverse remodeling detectable by transthoracic 2DE. Donor hearts with recovered LV function may be eligible for uneventful heart transplant. The wait (in brain death), treat (with HT) and see (with 2D echo) strategy can help rescue organs suitable for heart donation.

Intensivists and co-ordinators in the Italian donation and transplantation network: targets in common and combined roles? Organ donation is an indicator of good quality in the critical care of patients with acute cerebral lesions. In Italy DBD organ donation after brain death declaration has achieved excellent results that, unfortunately, are still insufficient to meet the increasing transplantation requests. The cornerstone of the donation process is the potential donor identification: a National Registry of Deaths with Acute Cerebral Lesions (DACLs) was implemented in 2006: around 150 pmp DACLs and 60% expected brain death declarations have been identified as the reference benchmarking for the quality evaluation. Consequently, proper indicators are used to measure and compare the process efficiency among different regions. A high number of “silent brain deaths” results from the comparison with expected results, being at the same time the most important critical factor and relevant target of improvement, particularly in regions where the donation rate is low. A close cooperation between intensivists and coordinators is mandatory: in the ICUs the inadequate awareness of the intensivist role in the donation process is the main barrier, in spite of new reasons of increased interest and direct involvement: a) the new clinical and technical scenarios leading to death in ICU; b) the relevant changes in the epidemiology of acute cerebral lesions, mostly regarding elderly stroke patients; c) the effects of high quality intensive care on organ function and recovery; d) the severe shortage in ICU personnel and resources; e) the end-of-life criteria and policy when futility of treatment becomes evident. DCD organ donation after uncontrolled circulatory arrest has been implemented in Italy only by a pilot study, with good results but limited in the number of donors. This tailored experience should be now reevaluated by a national multidisciplinary committee to overcome the cultural and organizative barriers. In conclusion, organ donation should be a declared target of the whole hospital with the entire critical care personnel involved in the identification of the potential donor. The donation and transplantation network can be considered a model for organization, education, safety and quality control. The advanced experience of co-ordinators and multidisciplinary experts, supported by the peculiar network methodology, can stimulate the cooperation and influence the intensive care quality, improving at the same time the appropriateness of critical care patients management and the availability of transplantable organs.

The primary aim of this study was to describe regulations and practices concerning the family approach to discuss donation, specifically after the neurological determination of death, one of the most challenging steps in the donation pathway. A secondary objective was to assess the impact of legislation on consent rates for organ donation. The Council of Europe surveyed 39 member states about national regulations, practices, and consent rates; 34 replied. Opt-out legislation is present in 19, opt-in in 9 and a mixed system in six countries. An opt-out register is kept by 24 countries and an opt-in register by 18 countries, some keeping both. The mean consent rate was 81.2% of all family approaches. Most countries regulate how death using neurological criteria is confirmed (85.3%), while regulation of other aspects of the deceased donation pathway varies: the timing of informing the family about brain death (47.1%) and organ donation (58.8%), the profile of professional who discusses both topics with the family (52.9% and 64.7%, respectively) and the withdrawal of treatment after brain death (47.1%). We also noted a mismatch between what regulations state and what is done in practice in most countries. We suggest possible reasons for this disparity.

Human error is cause of many serious accidents in Intensive Care Units (ICU) where interaction between patients, family and staff affect at clinical, organisational, relational and safety levels. The “Non-Technical skills” (NOTECHS) are the cognitive, behavioural and interpersonal abilities that are not specific to any one professional’s expertise. Even though NOTECHS are generally considered significant in reducing the risk of errors and important in determining effectiveness, outcome and safety in the workplace, they are rarely used in clinical practice. In anaesthesia, the ANTS system (Anaesthetist Non-Technical Skills) takes into consideration four non-technical skills: task management, team working, situation awareness and decision making, and these same abilities are also efficacious in ICU. The Verona experience shows that in Neurointensive Care, particularly in organ donation, the adequacy of the ANTS System improves if two new specific aspects are also considered: emotional awareness and communication/relationship. We propose a new model of NOTECHS (NOTSOD System – Non-Technical Skills in Organ Donation) that enables staff to reduce the risk of error, to improve efficacy, effectiveness and the well-being of families and health care professionals. and it helps in proposing organ donation.