Deceased organ procurement system

The Lebanese organ procurement system is based on early donor detection and referral, brain death diagnosis and aggressive management. It is based on a national organ procurement network with a central oce (NOD-Lb) where national and regional coordinators convene and communicate regularly with aliated hospitals that can be either detector and extractor hospitals (with a Hospital Organ Procurement Unit -HOPU) or only detectors.

Each hospital has to designate a Hospital Organ Procurement Unit (HOPU). This Unit is composed of an intensivist, a neurologist, a coroner, and a minimum of two Organ Procurement Coordinators (OPC) clinical supervisors or health professionals from the Intensive Care Unit (ICU) and the Emergency Room (ER).

1. Detection and Referral

All patients considered as liable to develop brain death (patients scoring less than or equal to 5 on the Glasgow Coma Scale (GCS), secondary to a severe brain injury and requiring mechanical ventilation) or patients suering from cardio-pulmonary arrests, need to be referred to NOD-LB. It is the responsibility of the Hospital Coordinator (OPC) and the ICU and ER physicians of the Hospital Organ Procurement Unit (HOPU) to ensure that this is done regardless of any medical contraindication that the patient might present.

2. Donor Evaluation

The ICU physician, the regional coordinator, the medical director and the national coordinator of NOD-Lb cooperate to evaluate the suitability of the organs and the quality of their maintenance. The regional coordinator evaluates the adequacy of the donor and the viability of his organs and tissues based on pertinent information transmitted by the NOD-Lb oce coordinator.

3. Brain death diagnosis

The system insists on the adoption of a unified brain death diagnosis protocol that confirms brain death as the irreversible loss of all functions of the brain including the brain stem followed by a confirmatory Electroencephalogram (EEG) or ancillary cerebral circulatory tests (Cerebral Angiography or Brain CT Angiography or Magnetic Resonance Angiogram or Cerebral Scintigraphy Hexa Metazine Spect). The national guidelines are based on the Lebanese law (1984/1442) and the recommendations of the Lebanese Society of Neurology.

A Brain Death Check List prepared by NOD-Lb is available for use by all participating hospitals and physicians. Three physicians have to check all the reflexes separately 6 hours apart. The death is then confirmed with one EEG flat for 30 min or a Brain CT Angiography showing the absence of circulation in the brain.

The protocol is slightly modified for children less than 5 years old. In addition to early brain death diagnosis it is imperative that the ICU physicians undertake an early and aggressive donor management in order to preserve the viability of the organs.

4. Family Approach

The law issued in 1983, makes of parental approval a legal requirement in Lebanon. Given the importance of parental consent in the Lebanese context, obtaining it, has been one of the main areas of application in the structuring of the Lebanese model which once again used the Spanish experience for inspiration.

The family of the potential donor needs to be approached through a series of interviews conducted by both the treating physician who is responsible for announcing the “death” to the family and the hospital coordinator who is in charge of requesting and securing agreement for organ donation. At least 3 one-hour interviews per family are necessary before considering the family refusal as final. This would allow the coordinator to explain brain death to the family, address their concerns and alleviate their doubts. In order to do so, he needs to have received proper training as to the best way to approach a grieving family, the most appropriate timing to choose, the knowledge of their most common fears and finally the suitable strategies to help families overcome their objections to donation.

Consent system: Lebanon has always followed an opting-in system whereby a donor indicates his will to donate by signing a donor card. Organ removal is carried on only upon approval of the family. In the absence of a signed donor card the family can still opt to donate.

5. Organ Allocation

The assessment of the suitability of potential donors and the equitable distribution of organs is the responsibility of NOD-Lb. It is also the regional coordinator’s duty to ensure the traceability of the organs and tissues. Organ distribution proceeds according to the rules and clinical protocols, established by the transplanting centers, to ensure a fair access to all patients on the national waiting list. The factors that are taken into account when matching recipients and donors include age, blood group, body size, urgency, tissue typing, time on the waiting list and the immunization status of the patient.

Other issues such a social status, religion, wealth, political aliation… are never taken into consideration.

6. Organ Retrieval

NOD-Lb coordinator on call has to supervise all organ retrievals in Lebanon to make sure of:

  • The availability of the Operating Room, the surgeons, and the special material needed for the retrieval.
  • The results of the immunology lab.
  • The availability of the specific preservation solutions.
  • The proper preservation, transportation and traceability of the donated organs.
  • The proper reconstruction of the body.

7. Organ Transplantation

NOD-Lb will make the necessary arrangements with the internal security forces and the army to ensure a timely and rapid delivery of the donated organs. The donated organs have to be transplanted within a short period of time (e.g. for the heart: 6-4 hours).

Organs Hours
Heart/Lungs 4-6
Liver 6-12
Pancreas 6-12
Kidneys 18-36
Intestines 4-6

 

Tissues Time
Corneas 21 days
Bones 5 years
Cardiac Valves 5 years
Skin 5 years
Tendons 5 years

 

8. Follow up

NOD-Lb follows the immediate results of transplantations and thanks the donating hospital and the donor’s family for their act of love.