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nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 ORGAN AND TISSUE DONATION AND RECOVERY DANA BARTLETT, RN, BSN, MSN, MA Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students. ABSTRACT Organ transplantation rates have increased in the past several decades and yet nursing education with respect to the process of organ donation and post transplant care has been inconsistent. Certain state jurisdictions, such as New Jersey, are now requiring nurses to receive continuing education on organ donation and transplantation to renew their license to practice. The goal of mandatory education is to increase nursing knowledge and participation in organ donation and transplantation programs, and to advance the role of nurses in this continuously growing area of health care.

ORGAN AND TISSUE TRANSPLANTATION · 2016-03-12 · Organ and tissue donation and transplantation are life saving and life altering therapies. From 1988 to August 2013 over 580,000

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ORGAN AND TISSUE

DONATION AND RECOVERY

DANA BARTLETT, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and author. His clinical experience includes 16

years of ICU and ER experience and over 20 years of as a poison control center

information specialist. Dana has published numerous CE and journal articles, written

NCLEX material, written textbook chapters, and done editing and reviewing for

publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the

subject of toxicology and was recently named a contributing editor, toxicology

section, for Critical Care Nurse journal. He is currently employed at the Connecticut

Poison Control Center and is actively involved in lecturing and mentoring nurses,

emergency medical residents and pharmacy students.

ABSTRACT

Organ transplantation rates have increased in the past several decades

and yet nursing education with respect to the process of organ

donation and post transplant care has been inconsistent. Certain state

jurisdictions, such as New Jersey, are now requiring nurses to receive

continuing education on organ donation and transplantation to renew

their license to practice. The goal of mandatory education is to

increase nursing knowledge and participation in organ donation and

transplantation programs, and to advance the role of nurses in this

continuously growing area of health care.

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Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses. It is the policy of

NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE)

activities.

Continuing Education Credit Designation

This educational activity is credited for 1 hour. Nurses may only claim

credit commensurate with the credit awarded for completion of this

course activity.

Statement of Learning Need

Recent studies have shown that nurses' attitudes and advocacy to

discuss transplantation among colleagues and with others increased

following the appropriate education and practice support. Additionally,

when encouraged to participate in organ donation and transplantation

education, nurses demonstrated increased confidence in working with

transplant patients and in addressing the need to educate their

communities about organ donation, encouraging others to get involved

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in local organ donation and transplantation programs.

Course Purpose

This course will provide basic learning for nurses in the coordination of

organ donation and transplantation; and, to increase nursing advocacy

to increase the rates of organ donation in their local areas.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all

have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 12/10/2016

Please take time to complete a self-assessment of knowledge,

on page 4, sample questions before reading the article.

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Opportunity to complete a self-assessment of knowledge

learned will be provided at the end of the course. 1. True or false: Registering as an organ donor or reviewing

information about organ donation is mandatory for obtaining a driver’s

license in NJ.

a. True

b. False

2. Most organ donations are from:

a. Living donors

b. Autolgous donors

c. Deceased donors

d. Xenogenic donors

3. Common complications associated with organ transplantation

include:

a. Transfusion reaction

b. Hyper-metabolic state

c. Diabetes insipidus

d. Infection

4. Someone who is specifically allowed to discuss organ donation is a

a. Registered nurse

b. Designated requestor

c. Transplant coordinator

d. UNOS representative

5. CBIGs are intended, in part, to:

a. Keep the donor patient comfortable until organs can be obtained

b. Be diagnostic criteria for brain death

c. Help medical staff determine when to remove life support

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d. Ensure that potential donor organs are well perfused and viable

Introduction

Organ and tissue donation and transplantation are life saving and life

altering therapies. From 1988 to August 2013 over 580,000 people in

the United States have received organ transplants, and the number of

donors has been slowly but steadily increasing. Tissue transplantation

is also quite common: approximately 750,000 are performed in the

United States every year. The increasing incidence of both donations

and transplants makes it imperative that nurses understand the

processes of how organs and tissues are obtained.

As of 2014, the New Jersey Board of Nursing requires every

professional registered nurse to complete a one-hour course that

covers organ and tissue donation and recovery. As organ donation and

transplantation is more complex than tissue donation and

transplantation (and in many ways the two procedures are carried out

in the same way) this module will primarily focus on organ donation

and transplantation.

Epidemiology And Statistics

The first successful organ transplant was performed in 1954. Since

that time, organ and tissue donation and transplantation have become

accepted treatments for a wide variety of diseases and medical

conditions. The three most commonly donated and transplanted

organs in descending order are kidneys, liver, and heart. The organs

that can and are transplanted also include intestines, lungs, and

pancreas and multiple transplants can be done, as well. Tissue

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transplantation can be done with amnion, bone, bone marrow,

connective tissue, cord blood, corneas, heart valves, ovarian tissue,

pancreatic islet cells, skin, and veins. Most donated organs are from

the deceased.

Although the number of organ and tissue donations and

transplantations is increasing every year, the demand far exceeds the

supply. There are almost 120,000 people on the transplant waiting list

and each day 18 people die that a transplant could have saved. In New

Jersey in 2012, 551 transplants were performed. However, more than

5000 people are on the waiting list, and waiting for an organ is a long

process. In the United States the median waiting time for a kidney is

1219 days, for a liver 361 days, and for pancreas 260 days.

Transplants and donations are well established in New Jersey, but

there is a critical lack of registered donors. New Jersey ranks number

44 out of the 50 states in the percentage of registered organ and

tissue donors, and only one-third of New Jersey drivers are registered

as organ donors. Efforts have been made to increase the number of

donors. New Jersey drivers must register through Donate Life NJ

(http://donatelifenj.org/) as someone that is an organ donor or review

information about organ donation when applying for, or renewing a

driver’s license; however, the need for organ donation is still not being

met.

As tissue donation can affect the lives of 50 - 75 people and one organ

donor can save the lives of eight people, the need to increase

participation is painfully clear.

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Basics Of Organ And Tissue Donation And Transplantation

Organ Donation and Transplantation

Organ donation and transplantation can be divided into many different

categories.

Donation from deceased donors:

This is the most common type of organ donation. To date in

2013, there have been 5502 deceased donors and 3944 living

donors.

Donation from living donors:

A donation from a living donor offers several advantages. This

approach increases the possible pool of donors. It allows for a

thorough evaluation of the donor and the recipient and

planning/organization of the surgery. A living donor also

provides an organ that is, usually, well perfused.

Allogenic donation:

An allogenic donation is the donation of an organ from another

person.

Isogenic donation:

The organ is donated from an identical twin.

Autologous donation:

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Tissue is transplanted from one site in the body to another.

Autologous blood donations are relatively common.

Xenogenic donation:

The organ or tissue has been harvested from another species,

i.e., heart valves from pigs.

Donation after brain death:

Donation after brain death is performed with an organ from

someone who meets the criteria for brain death. These

donations, usually, offer an organ that is well perfused. Also,

these donors can donate multiple organs, such as, heart, both

lungs, both kidneys, liver, pancreas, and the small intestine.

Donation after cardiac death:

Donation after cardiac death increases the pool of possible

donors: a 2012 Canadian study noted that the number of

kidney transplants in some transplant programs increased by

40% when this approach was used. Typically only kidneys and

the liver are transplanted from patients that have suffered

cardiac death, but lung transplantation using this method is

also possible.

Donation of organs after cardiac death is usually considered to

be less desirable and less successful than donation after brain

death, as this method of donation and transplantation has an

inherent risk of increasing ischemia to the donated organ.

However, this issue is being actively investigated and some

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transplant centers have reported equivalent results for kidney

and liver transplants when the two methods are compared.

Tissue Donation and Transplantation

Tissue donation and transplantation is performed in much the same

way as is solid organ donation and transplantation. However, the types

of tissues that can be used are more numerous, and composite

transplantation – transplantation of several tissue types in one

procedure - can also be performed.

Donation and Transplantation Complications and Risks

The most common complications and risks associated with donation

and transplantation are: 1) Rejection, 2) Infection, and 3) Increased

risk of disease. These are further explained as:

Rejection:

Rejection can be acute - up to three months post-transplantation

- or chronic. Immuno-suppressive drugs reduce the rate of

rejections, but acute rejection rate for kidney transplants is still

between 10-15% and between 15-25% for liver transplants.

Infection:

Infection associated with transplantation is uncommon, but

tuberculosis and other bacteria, Clostridium, HCV, Epstein-Barr

virus, rabies, group A streptococci, Candida albicans and molds,

and other microorganisms have all been transmitted during

transplant procedures. The risk of infection associated with

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transplantation is very small, probably < 1%; however,

surveillance for, and reporting of post-transplant infections is not

ideal so the actual number of infections is not known. In

addition, there are no universally agreed upon protocols for

screening of organ or tissue donors.

Donors who have infectious diseases such as hepatitis B,

hepatitis C, encephalitis, meningitis, pneumonia, tuberculosis,

and other infectious conditions can be considered as donors if

informed consent from the recipient is obtained and therapy and

follow-up are possible.

Increased risk of disease:

People who have had a transplant are at increased risk for

developing bone disease and orthopedic problems, cancer, heart

disease, and other medical problems.

The Process Of Organ And Tissue Transplantation

The process of organ donation is usefully divided into the following

steps.

1. Referral

2. Evaluation

3. Family discussion

4. Recovery and allocation

The process of organ and tissue transplantation starts with a referral.

Suitable cases are referred to the local Organ Procurement

Organization (OPO). There are two in New Jersey, which are:

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New Jersey Organ and Tissue Sharing Network:

The New Jersey Organ and Tissue Sharing Network operates in

northern and central New Jersey in Bergen, Essex, Hudson,

Hunterdon, Mercer, Middlesex, Morris, Monmouth, Ocean,

Passaic, Somerset, Sussex, Union, and Warren counties. Their

24-hour telephone number is 1-800-742-7365. Their website

address is https://www.njsharingnetwork.org/.

Gift of Life Donor Program:

The Gift of Life Donor Program operates in southern New Jersey

in Atlantic, Burlington, Camden, Cape May, Cumberland,

Gloucester and Salem counties. Their 24-hour telephone number

is 1-800-366-6771. Their website address is

http://www.donors1.org/.

Referral

The referral starts with identification of a patient’s clinical situation in

which organ donation may be likely or could be a possibility. These

situations are recognized by the presence of imminent death and

clinical triggers.

Federal regulations require that hospitals contact the local OPO about

all patients that have died or are near death - imminent death. When

the OPO has been contacted, it will start the process of evaluation and,

possibly matching of donor to recipient. It was in the federal

regulations that hospitals develop a definition of imminent death, and

this definition is usually:

1. A patient with acute, severe, brain injury who requires

mechanical ventilation

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2. A patient who is being evaluated for brain death

3. The presence of certain clinical findings

The clinical findings that are used most often are: 1) A Glasgow Coma

Scale of ≤ 5, and; 2) The absence of two or more cranial reflexes, i.e.,

caloric response, cough/gag reflex, corneal reflex, failure to respond to

pain, pupillary response to light, etc. The Glasgow Coma Scale and the

cranial reflexes are used because they have a high degree of inter-

observer reliability and they correlate well with outcome, i.e., the

lower the Glasgow Coma Scale and the fewer intact cranial reflexes the

worse the outcome is likely to be.

Taken as a whole, these conditions 1 and 2 listed above and the

clinical findings are referred to as clinical triggers. The clinical triggers

are identified in cases in which the patient is critically ill and near

death, and identify patients that may be donor candidates because

they are likely to die or progress to brain death.

These clinical triggers may vary from hospital to hospital and between

different OPOs. It is also considered necessary to contact the OPO

prior to discussing organ donation with the patient’s family. In the

case of a death and possible organ or tissue donation, the referral

must be made within an hour of the death.

Donations can be made from a patient who has been declared brain

dead or from a patient who has suffered cardiac death. If a patient has

suffered a non-survivable injury but does not meet the criteria for

brain death, the decision may be made to remove the patient from life

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support, and this would be considered donation after cardiac death. If

this happens, organ donation is a possibility.

Evaluation

A donation specialist from an OPO does the evaluation of a patient and

the clinical situation for the possibility of organ donation. Once the

OPO has been contacted about a potential donor, the evaluation

specialist will immediately go to the hospital. The evaluation specialist

will examine the patient’s medical record, tests for infectious diseases

may be ordered, and a decision will be made as to whether or not

organ donation is possible. If the patient was enrolled in the state

registry as a donor, that registration is considered to be the legal

consent for the donation. If the patient was not registered as a donor

and the patient’s driver’s license did not indicate that he/she wished to

be a donor, family or next of kin will be contacted.

Viability of organs is obviously a critical concern in the donation

process. Unfortunately, the majority of donated organs come from

people who are brain dead and these organs are less viable than

organs from living donors. In addition, many people who have suffered

brain death are physiologically and hemodynamically unstable,

decreasing the potential for maintaining organs in a condition suitable

for transplant.

In response to this issue, OPOs and hospitals have adopted the use of

catastrophic brain injury guidelines (CBIGs) in the evaluation process

of organ donation. Catastrophic brain injury guidelines (CBIGs) are

recommendations used to treat people who: 1) Have suffered a

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catastrophic brain injury; and, 2) Have been assessed by a neurologist

and a neurosurgery specialist as having a non-survivable neurological

injury or neurologic death. These guidelines are intended to ensure

hemodyanamic stability and tissue perfusion. In this way, the patient’s

clinical progress as it would naturally evolve can be observed and end

of life decisions can be made. As viability of organs is obviously a

critical issue in the donations process, these CBIGs are also used if the

patient is deemed to be a potential organ donor; and, they have been

shown to help OPOs and hospitals increase the number and quality of

donated organs.

The CBIGs listed below are from the New Jersey Organ and Tissue

Sharing Network website, clinical resources section.

1. Make sure the patient is adequately hydrated and euvolemic

2. Maintain systolic blood pressure of > 100 mm Hg/MAP > 60 mm

Hg. If needed, neosynephrine up to 2 mcg/kg/minute is the

vasopressor of choice, followed by dopamine.

3. Maintain urine output of > 0.5 ml/k/hour, < 400 mL/hour.

4. Ensure adequate oxygenation and acid-base balance: Maintain

the PO2 at > 100 mm HG, maintain pH between 7.35-7.45

5. Maintain temperature between 36-37.5°C

6. Maintain normal values for coagulation/clotting, complete blood

count, electrolytes and glucose.

The CBIGs will vary from place to place. For example, some OPOs and

hospitals will recommend that the patient be maintained on all

medications he/she was receiving prior to the application of the CBIGs

and that hemodynamic monitoring be used. Tissue matching and blood

typing are an important part of the evaluation process. Blood will be

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tested to determine ABO and Rh type, a cross-match between donor

and recipient will be performed, and human leukocyte antigen (HLA)

testing will be done, as well red blood cell antibodies

Family Discussion

The transplant coordinator or evaluation specialist will meet with the

potential donor’s family to discuss the donation procedure. If the

patient had already indicated an intention to donate by registering as a

donor then in most instances this is considered the only authorization

that is needed and this process may be relatively brief. If the patient

had not expressed a preference then certainly more time will be

needed. If the procedure is to be a living donation then obviously a

family discussion is not needed. It is a requirement that anyone who

approaches a family regarding organ donation must have special

training as a designated requestor.

Recovery and Allocation

The patient is maintained as per protocol until it has been decided to

obtain the organs. If life support is removed, as in donation after

cardiac death, the organs must be removed within 90 minutes of

extubation. Once the patient has expired, the organs and tissues are

recovered. The transplant coordinator will be working with the Organ

Procurement and Transplant Network (OPTN) and local transplant

surgeons to find the best match for the donation. The OPTN is

explained as follows:

“the unified transplant network established by the United States

Congress under the National Organ Transplant Act (NOTA) of

1984. The act called for the network to be operated by a private,

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non-profit organization under federal contract. The primary goals

of the OPTN are to increase the effectiveness and efficiency of

organ sharing and equity in the national system of organ

allocation, and to increase the supply of donated organs

available for transplantation. The United Network for Organ

Sharing (UNOS) . . . administers the OPTN under contract with

the Health Resources and Services Administration of the U.S.

Department of Health and Human Services.”

The OPTN, working through UNOS, collects, stores, and analyzes

information that pertains to donors and recipients: donor/recipient

matching, deceased and living donors, and potential recipients, the

patient waiting list, and other information such as name, gender, race,

age, height, weight, medical history, ABO blood group, peak and

current panel reactive antibody (PRA) levels, HLA data, and acceptable

donor characteristics. Race, gender, income, and social status are not

included in the database.

When an organ becomes available a computer program compares

information about the donor with recipient information in the database.

The transplant coordinator and the OPTN will be reviewing all of this

information about potential recipients and the donors. Their work and

the input of a histocompatability laboratory and a transplant team will

be coordinated and, hopefully, an allocation and a match will be made.

Summary

Organ and tissue donation and transplantation are life saving and life

altering therapies, and nurses have a key role in educating their

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communities about the existing health need to help save lives.

Despite the rise in need, there remains a critical lack of registered

organ donors that some states, such as New Jersey, are addressing

through mandatory education for nurses and local public programs.

The various organ donation and transplantation steps are supported

through regulatory agencies and healthcare policies, which include

centralized databases and specially trained support staff. Through local

awareness campaigns, such as Save A Life, potential donors may be

informed and take steps to begin the process of helping to save a life,

which begins with the proper referral through to the right

donor/recipient match.

Please take time to help NurseCe4Less.com course planners

evaluate the nursing knowledge needs met by completing the

self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

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Completing the study questions is optional and is NOT a course

requirement.

1. True or false: Registering as an organ donor or reviewing

information about organ donation is mandatory for obtaining a driver’s

license in NJ.

a. True

b. False

2. Most organ donations are from:

a. Living donors

b. Autolgous donors

c. Deceased donors

d. Xenogenic donors

3. Common complications associated with organ transplantation

include:

a. Transfusion reaction

b. Hyper-metabolic state

c. Diabetes insipidus

d. Infection

4. Someone who is specifically allowed to discuss organ donation is a

a. Registered nurse

b. Designated requestor

c. Transplant coordinator

d. UNOS representative

5. CBIGs are intended, in part, to:

a. Keep the donor patient comfortable until organs can be obtained

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b. Be diagnostic criteria for brain death

c. Help medical staff determine when to remove life support

d. Ensure that potential donor organs are well perfused and viable

Correct Answers:

1. a

2. c

3. d

4. b

5. d

References Section

The reference section of in-text citations include published works

intended as helpful material for further reading. Unpublished works

and personal communications are not included in this section, although

may appear within the study text.

1. Hoy, H., Alexander, S. and Frith, K.H. (2011). Effect of transplant

education on nurses' attitudes toward organ donation and plans to

work with transplant patients. Prog Transplant. 2011 Dec; 21(4):

317-21.

2. Chon WJ, Brennan DC. Acute renal allograft rejection: Treatment.

UpTo Date. June 5, 2013. Retrieved 11/10/2013 from

http://www.uptodate.com/contents/acute-renal-allograft-

rejection-

treatment?detectedLanguage=en&source=search_result&search=

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kidney+transplant+rejection&selectedTitle=2%7E150&provider=n

oProvider.

3. Cotler S. Treatment of acute cellular rejection in liver

transplantation. UpToDate. August 26, 2013. Retrieved

11/10/2013 from

http://www.uptodate.com/contents/acute-renal-allograft-

rejection-

treatment?detectedLanguage=en&source=search_result&search=

kidney+transplant+rejection&selectedTitle=2%7E150&provider=n

oProvider.

4. Deng R, Gu G, Wang, D, et al. Machine perfusion versus cold

storage of kidneys derived from donation after cardiac death: A

meta-analysis. PLosS One. 2013. 8:art. no. e56368

5. Engels EA, Pfieffer RM, Fraumeni JF, et al. Spectrum of cancer risk

among US solid organ transplant recipients. Journal of the

American Medical Association. 2011. 306:1891-1901.

6. Fishman JA, Greenwald MA, Grossi PA. Transmission of infection

with human allografts: Essential considerations in donor

screening. Clinical Infectious Diseases. 2012. 55:720-727.

7. Greenwald MA, Kuehnert M.J, Fishman JA. Infectious disease

transmission during organ and tissue transplantation. Emerging

Infectious Diseases. 2012. 8:e1. doi: 10.3201/eid1808.120277.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21

8. Harring TR, Nguyen NTT, Cotton RT, et al. Liver transplantation

with donation after cardiac death donors: A comprehensive

update. The Journal of Surgical Research. 2012. 178:502-511.

9. Malinoski DJ, Daly MC, Patel MS, et al. Achieving donor

management goals before deceased donor procurement is

associated with more organs transplanted per donor. Journal of

Trauma – Injury, Infection and Critical Care. 2011;71: 990-996.

10. Moser M, Sharpe M, Weernink C, et al. Five-year experience with

donation after cardiac death kidney transplantation in a Canadian

transplant program: Factors affecting outcomes. Canadian

Urological Association Journal. 2012. 6:448-452.

11. New Jersey Organ and Tissue Sharing Network. Retrieved

11/10/2013 from:

https://www.njsharingnetwork.org/

12. Organ Procurement and Transplantation Network. Retrieved

11/10/2013 from: http://optn.transplant.hrsa.gov/optn/.

13. Pruitt AA, Graus F, Rosenfeld MR. Neurological complications of

solid organ transplantation. Neurohospitalist. 2013. 3:152-166.

14. Quinn L, McTague W, Orlowski JP. Impact of catastrophic brain

injury guidelines on donor management goals at a level I trauma

center. Transplantation Proceedings. 2102. 47:2190-2192

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22

15. United Network for Organ Sharing. Retrieved 11/10/2013 from:

http://unos.org/.

16. US Department of Health and Human Services: Organ Donation.

Retrieved 11/10/2013 from: http://organdonor.gov/index.html.

17. Vanatta JM, Dean AG, Hathaway DK, et al. Liver transplant using

donors after cardiac death: A single-center approach providing

outcomes comparable to donation after brain death. Experimental

and Clinical Transplantation. 2013. 11:154-163.

18. Wadei HM, Heckman MG, Rawal B, et al. Comparison of kidney

function between donation after cardiac death and donation after

brain death kidney transplantation. Transplantation. 2013;96:

274-281.

19. Yazbek DC, de Carvalho AB, Barros CS, et al. Cardiovascular

disease in early kidney transplantation: comparison between

living and deceased donor recipients. Transplantation

Proceedings. 2012. 44:3001-306.

The information presented in this course is intended solely for the use of healthcare

professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in

addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to

address any specific situation. This publication in no way absolves facilities of their

responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own

orientation processes should review the contents of this publication to ensure

accuracy and compliance before using this publication.

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