Organ transplants: worth every penny

An operating team performs a liver transplant at the Victoria General site of the QEII Health Sciences Centre.

By John Gillis

Organ transplantation is one of the most impressive feats of medicine—changing patients’ lives almost immediately. Successfully retrieving and transplanting organs is a logistically complicated process that pulls on the resources of the whole hospital system without the luxury of notice.

The opportunity to retrieve organs from donors after brain or cardiac death, can’t be predicted, and it can’t be passed up even when the health care system is already strained every day.

“If we have a donor and we have organs from that donor… we always find a way to transplant them,” said Dr. Ian Alwayn, surgical lead for the Multi-Organ Transplant Program.

Every day in hospitals, a complicated balancing act goes on. At the beginning of each day, most beds are already occupied with people receiving care. Some of them will go home, while others will be admitted. New patients are being readied for scheduled surgeries. Some buffer of empty beds, OR time and other resources are held for whatever else may come in through the day. There’s little breathing room.

The Multi-Organ Transplant Program at QEII Health Sciences Centre in Halifax serves all of Atlantic Canada, so the call about a potential donor—typically following an aneurysm or multiple traumatic injuries—can come from as far away as Newfoundland. As many as four transplantation surgeries may result (liver, two kidneys or kidney/pancreas, heart) at the QEII, with each of those patients spending up to 19 days in hospital.

Blood typing and workup begin at that point, to determine which organs may be used and which waiting recipients will be called in for surgery. Timing is key and must take into account the time required to retrieve the organs and for the recipient to get to Halifax. Also important is the viable window from the point an organ is removed until it must be transplanted. That may mean a retrieval team heads to St. John’s, N.L. for organs while a recipient travels from Saint John, N.B.  to Halifax for surgery. Dr. Alwayn aims to have a liver or kidney/pancreas surgery underway eight hours after retrieval.

At the Victoria General site of the QEII, where the liver, kidney and kidney/pancreas transplants happen, a full slate of other surgeries would already be booked. The transplants require not only OR time, but intensive care unit (ICU) and intermediate care unit (IMCU) beds for the patients following surgery.

Those beds are always in short supply, said Karen Nicholls, patient flow coordinator at the QEII. To allow transplants, the day’s schedules for one or two operating rooms must frequently be cancelled, freeing the operating rooms and beds that would otherwise be used by elective patients, to allow transplants to go ahead. On some occasions scheduled surgeries may instead be put on hold in the hopes beds become available in the routine movement of patients through and out of the hospital and the planned operations can go ahead later in the day.

Organ retrieval is done by a transplant fellow, surgical resident and tissue bank staff along with an OR team in Halifax or the donation site. The transplant surgeries, which may happen in a series, or simultaneously, require a team of up to seven or more health care professionals including a fellow and on-call surgeon, anesthetist, scrub and circulating nurses, perfusonist and porter. A liver transplant can take seven to nine hours. Kidneys take three hours each.

Adding to the logistical challenge, donations seem to happen in waves. Of 115 transplants from deceased donors in 2011, 39 happened in just two months, said Kitty Connell, health services manager for the transplant program. The associated cancellations mean patients waiting for other scheduled surgeries face additional delays.

“They don’t come staggered, which really puts a strain on the ORs,” she said. “You can see how that backs up waitlists.”

The transplants also add to demand for inpatient beds throughout the hospital after recipients move out of ICU or IMCU. To ready space in unit 6B at the V ictoria General Hospital where patients spend the bulk of their stay following transplant, other patients may need to be moved to another unit. That in turn may limit the ability of those units to accept other patients. The congestion may ripple through to emergency departments where admitted patients wait for beds.

“Everybody’s working together to make sure that we can get the transplants in,” Nicholls said. “I think everyone is aware of the importance and the magnitude of getting them done. It’s a big community effort.”

And it’s an effort with a major payoff.

Liver transplant patients are usually deathly ill at the time of transplant and without another alternative. Typically, a liver transplant patient is ready to move out of ICU a day after surgery and on their way to the health they knew prior to liver failure.

“Their life changes,” said Dr. Alwayn, one of three multi-organ transplant surgeons at Capital Health, along with Dr. Mark Walsh and Dr. Michele Molinari. “All of a sudden they have a working liver.”

With new, working kidneys, patients young and old are frequently able to stop dialysis—a significant saving of health resources and a tremendous boost to the quality of patients’ lives.

“I can’t really think of much more rewarding surgeries than transplants,” said Dr. Alwayn.