Impact of catastrophic brain injury guidelines on organ donation rates: Results of an EAST multicenter trial
Authors: Nordham Kristen D. , Tatum Danielle , Attia Abdallah S. , Patel Mayur B. , Paramesh Anil , Duchesne Juan C. , Nahmias Jeffry , Maiga Amelia W. , Peetz Allan B. , Udekwu Pascal O. , Stiles Anquonette , Shell Chloe , Stodghill Joshua D. , Maghsoudi Taneen , Iacullo Erin , McLafferty Bryant , Coonan Erin , Boudreau Ryan M. , Zimmerman Steven A. , Shammassian Berje , Egodage Tanya , Aramento Isabella , Morris Patrick , Metheny Jacob , Farrell Michael S. , Painter Matthew D. , McCabe Owen T. , Spadafore Philomene , Wong David Tai-Wai , Serrano Jan , Sciarretta Jason D. , Kim Phillip , Hayton Ryan , Gonzales Danessa , Murry Jason , Meadows Katelyn , Jacobson Lewis E. , Williams Jamie M. , Bernard Andrew C. , Smith Brennan , Morrissey Shawna L. , Patel Nilesh , Tabello Dina , Teicher Erik , Chowdhury Sharfuddin Mahmud , Ahmad Fazal , Marcos Basem S. , West Michaela A. , Jacome Tomas H. , Davis Greggory , Marks Joshua A. , Rattigan Deviney , Haan James M. , Lightwine Kelly , Matsushima Kazuhide , Park Stephen , Santos Ariel , Shrestha Kripa , Sawyer Robert , VandenBerg Sheri , Jean Robert J. , Hicks R Chace , Lueckel Stephanie , Bugaev Nikolay , Abosena Wael , Alvarez Claudia , Lieser Mark J. , McDonald Hannah , Dumas Ryan P. , Fitzgerald Caitlin A. , Terzian William Thomas Hillman , Tian Yuqian , Mousafeiris Vasileios , Mulita Francesk , Berne John D. , Mederos Dalier R. , Smith Alison A. , Taghavi Sharven 
Published: September 2024

BACKGROUND
One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without.

METHODS
This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation.

RESULTS
A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation.

CONCLUSION
There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients.

LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level II.