ACCCN's Critical Care Nursing

728 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

the cardiovascular system in pregnancy is poorly tolerated Treatment Priorities
by some women and cardiac disease in pregnancy remains All women with cardiac disease are considered to have a
a leading cause of death in Australia. 52
‘high risk’ pregnancy and should receive maternity care
Rheumatic heart disease is the most frequently acquired by a multidisciplinary team including as a minimum,
151
heart disease and is a condition normally associated with obstetrician, midwife, cardiologist and anaesthetist.
developing countries. 144 In Australia, rheumatic heart The timing and location of delivery, choice of anaesthesia
disease is a significant concern in Aboriginals and Torres and delivery mode should each be discussed by the team
Strait Islanders with rates in Indigenous communities in with the woman, and planned well in advance. If a preg-
the Northern Territory noted to be the highest in the nant woman with cardiac disease is admitted to ICU, this
world, and are over 30 times higher than non-Indigenous multidisciplinary team should be consulted about her
¯
Australians. 145,146 Similarly in New Zealand, Maori and care. Priorities of care include:
Pacific Islanders have a much higher incidence of rheu- l Pre-pregnancy counselling: this should allow a full
matic heart disease than New Zealanders of European and frank discussion about the likely risks of preg-
ancestry. Refugee and immigrant women who have nancy for the individual and to discuss a treatment
migrated from developing countries also have a higher path. This is of particular importance for women
risk for rheumatic heart disease in pregnancy. Rheumatic who are on potentially teratogenic medication, such
heart disease is a delayed complication of acute rheu- as warfarin, and for women who may benefit from
matic fever, and results from untreated Group A strepto- surgery or interventional treatment prior to conceiv-
coccus bacterial infection. It most commonly affects the ing. Additionally, women with congenital heart disease
mitral valve, though may also affect the aortic valve and may require genetic counselling to determine the like-
usually involves restricted leaflet mobility, focal or lihood of congenital heart disease in any offspring.
generalised valvular thickening and abnormal subvalvu- l Diagnosis: standard investigations including chest
lar thickening, resulting in regurgitation and, rarely, X-ray, ECG, CT scan and MRI should be attended to
stenosis. 147
as indicated by the clinical condition. In general, diag-
A cardiac condition increasingly presenting in pregnancy nostic imaging of a critically ill woman should not be
is acute myocardial infarction (AMI), thought to be withheld due to concerns about the fetus, with
related to the changing demographics of the pregnant abdominal shielding used whenever possible. 152
population, such as older women becoming pregnant. 148 l Heart failure: as was outlined in the section on peri-
AMI is the leading cardiac cause of maternal death in the partum cardiomyopathy, the principles of treatment
UK, mostly related to undiagnosed ischaemic heart for heart failure in pregnancy are the same as for the
24
disease. Additionally, spontaneous aortic dissection and non-pregnant population.
coronary artery dissection may also occur in pregnant l Arrhythmias: commonly used drugs including digoxin,
women with no preexisting disease. 149 Signs and symp- lignocaine, flecainide, verapamil, sotalol, propranolol,
toms of heart failure and complaints of chest pain must adenosine and amiodarone; although limited studies
be investigated and not put down to the ‘minor discom- exist in the pregnant population, all have been used
forts’ of pregnancy, such as breathlessness, heartburn, safely and effectively during pregnancy. 153 Transient
fatigue and dependent oedema. Given that the cardiac neonatal hypothyroidism has been described in
output is expected to increase 40–50% in a normal preg- women on amiodarone and monitoring of neonatal
nancy, any cardiac condition resulting in poor left ventric- thyroid function is recommended. 154
ular function and/or restricted left ventricular outflow are l Cardiac surgery: interventions such as valvuloplasty
particularly associated with poor outcomes in pregnancy. may be required. Open-heart surgery is only per-
formed during pregnancy when the maternal condi-
Also relevant for the outcome of both mother and baby tion is critical, for example coronary artery dissection
is whether any valvular disease has been repaired and or severe dysfunctioning valve, because of the high
whether a tissue or mechanical valve has been inserted. chance of fetal loss associated with the woman going
Use of anticoagulants is of particular concern during on bypass. Standard care should be provided to a
pregnancy, with warfarin contraindicated for use in preg- pregnant woman, with care to nurse the woman
nancy. However, the risk of thrombosis is relatively high ≥20 weeks’ gestation with a 15 degree left lateral tilt
in pregnant women and some women remain on warfa- if possible, to reduce the negative effects of aorto-caval
rin despite the risk of associated congenital anomaly and compression. Open-heart surgery and ECMO have
the increased likelihood of miscarriage. 150
been used successfully in pregnant women with good
outcomes for mother and baby. 155,156
l Thrombus prevention: this is a priority in women with
Practice tip valvular disease/prosthetic valves, atrial fibrillation or
dilated heart chambers at risk of thrombus formation,
Congenital and acquired cardiac disease can present for the especially because of the normal hypercoagulopathy
first time during pregnancy, unmasked by the additional associated with pregnancy. Warfarin embryopathy, a
phy siological requirements of pregnancy. Women with known recognised collection of developmental anomalies
preexisting disease may experience unpredictable deteriora- such as nasal hypoplasia and epiphysis stippling, is
tion in cardiac function. associated with warfarin use in the first trimester, con-
sequently warfarin use is contraindicated. However,

Pregnancy and Postpartum Considerations 729

24
pregnant women with mechanical valves experience presentation to the emergency department. The
unacceptably high rates of valve thrombosis and ‘story’ of the injury should be considered in relation
embolism when switched to heparin, and so many to the presenting injury and likely mechanism of
cardiologists consider the risks associated with the injury; another potential sign is when the woman
continued use of warfarin in pregnancy to be lower appears evasive or reluctant to speak or disagree in
24
than the risks of stopping it. Therefore a regimen that front of her partner. Pregnancy-related violence is
balances the risk of thrombosis with that of fetal loss associated with low birth weight babies, premature
and risk of haemorrhage should be implemented, labour and fetal trauma. 162
with some variation stopping warfarin for the l Musculoskeletal injuries: pregnancy hormones, pre-
whole first trimester or from 6–12 weeks gestation and dominantly relaxin, oestrogen and progesterone,
then resumed until close to delivery; replacing affect joints and ligaments making them more lax and
warfarin with unfractionated or low molecular weight pliable. This increased joint mobility explains why
heparin for the whole pregnancy or continuing pregnant women are more likely to experience joint
warfarin throughout pregnancy and replacing it with injury, pelvic instability, back pain and strained and
heparin for delivery only. Appropriate dosing sched- dislocated joints, and combined with the altered
ules for heparin have not been confirmed with low- centre of balance with the advancing uterus, explains
dose heparin considered inadequate and high doses why pregnant women readily fall off ladders, for
of unfractionated heparin not researched. 157 example when decorating the nursery.
l Secondary prevention of rheumatic heart disease: l Motor vehicle trauma: is the most common reason for
monthly IM penicillin, e.g. 1,200,000 units of benzyl a pregnant woman to present to an emergency depart-
penicillin, to minimise repeat acute rheumatic fever ment with trauma. Unfortunately, some pregnant
and associated further valve degeneration. 158 women believe there is no legal requirement to wear
a seatbelt when pregnant and this places them and
their fetus at increased risk. 163 Additionally, many
pregnant women are not informed on the correct posi-
tioning of a seatbelt during pregnancy, and incorrect
Practice tip positioning can increase the likelihood of placental
When caring for a pregnant woman with cardiac disease or abruption in a crash (Figure 26.3).
postcardiac surgery, differences in normal haemodynamic and Trauma in pregnancy presents a number of challenges, in
respiratory parameters in pregnancy must be considered. part due to consideration of the fetus, but also given the
impact of the physiological changes of pregnancy. Over-
whelmingly, the single principle of management is to
treat the mother. Trauma assessment of the pregnant
SPECIAL CONSIDERATIONS woman should include all the usual elements (see
Chapter 23) with the following additional components.
Any health condition resulting in ICU admission may
occur in a pregnant woman. The more common of these Initial Evaluation of the Pregnant Patient:
include physical trauma, pneumonia and mental health The Primary Survey
disorders and these are described in detail below. Consideration should be given to all women of
childbearing age as to whether she may be pregnant.
TRAUMA IN PREGNANCY Determination of the presence of a pregnancy and the
The term ‘trauma’ refers to any accidental or intentional
event resulting in injury, with motor vehicle crashes, falls
and domestic violence most prevalent amongst the preg-
nant trauma population. Although pregnancy is consid-
ered a period of low risk for traumatic injury as most
women choose not to embark on risk-taking behaviour
when pregnant, those who do continue to engage in risk-
taking behaviour, such as misuse of alcohol and other
substances, experience more injury. 159 Overall, the inci-
dence of trauma in pregnancy is estimated to be in the
range of 5–8% of all pregnancies, with motor vehicle
crashes responsible for about half, and falls and assault
accounting for roughly one quarter each. 160,161
Specific causes of injury in pregnant women include:
l Domestic violence: for women who experience domes-
tic violence, 30% occurs for the first time during preg-
nancy; homicide during pregnancy and the postpartum A B
period also occurs and intentional violence by an FIGURE 26.3 Positioning of a seatbelt during pregnancy. (A) Incorrect
intimate partner is a relatively common reason for positioning; (B) correct positioning. 163

730 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

estimated gestation may be obtained from the woman (or hospitalisation rate. Anecdotally, it is rare for a
friend/relative) or may require blood tests/physical well woman of childbearing age to be admitted to ICU
examination/ultrasound. 160 If the woman is obviously with community-acquired pneumonia; women living in
pregnant, a rough estimate of gestation can be made by disabled support accommodation and pregnant women
measuring the height of the fundus from the symphysis are the exception. Varicella pneumonia is also more pro-
pubis. The height in cm equates to the number of weeks’ minent in the pregnant population. It would appear from
gestation, e.g. 22 cm = 22 weeks’ gestation. The presence studies on pregnant admissions to ICU and maternal
of fetal movement is a quick assessment of fetal wellbeing death reports that severe community-acquired pneu-
and if the woman is conscious and over 18–20 weeks’ monia in previously well women is a persisting concern
gestation, she should be able to communicate if she feels in the pregnant population.
fetal movements. The physiological adaptations of preg- It is not fully understood why pregnant women may be
nancy may initially mask serious injury, with vital signs vulnerable to severe pneumonia though the adaptations
and patient symptoms not reflective of the underlying to the mechanics of breathing and changes in the immune
injuries. 163 A pregnant woman’s condition can rapidly response may be contributing factors. 164 Additionally, it
deteriorate.
has been postulated that pregnant women are amongst
Use of Imaging in Pregnancy small children more often and may have an increased
likelihood of exposure to infective agents. Regardless, the
All radiological investigations and imaging that are clini- treatment and management of pneumonia in pregnancy
cally indicated by the maternal condition should be is no different to pneumonia in non-pregnant women:
attended to without delay over concerns for the fetus. 163 identify causative organism and administer appropriate
When possible and appropriate, use of a pelvic/abdominal antibiotics/antiviral agents as indicated, maintain oxy-
lead shield may be used to protect the developing embryo/ genation and prevent complications (see Chapter 14).
fetus. If a chest tube is necessary for a haemothorax, care Assessment of fetal wellbeing and awareness of the
should be taken to position the catheter 1–2 spaces changed respiratory parameters in pregnancy are the
higher than normal due to the raised diaphragm. obvious additional requirements.
Obstetric Assessment in Trauma Pregnancy and Influenza
If the woman’s gestation is estimated to be 22–24 weeks The WHO has recommended that all pregnant women
or more, then a CTG should be conducted to assess fetal receive the seasonal influenza vaccination since 2006, in
wellbeing (see section on fetal assessment). If there has recognition of the known increased risk that influenza
been any likelihood of blunt trauma to the abdomen poses during pregnancy and because vaccination during
(i.e. by the steering wheel or seatbelt position), then pregnancy is safe and confers immunity to the newborn
a continuous four-hour duration CTG should be done for the first few vulnerable months. In developing coun-
to identify any fetal distress resulting from a potential tries, this policy has the potential to save the lives of many
placental abruption. An abdominal ultrasound is com- women and in particular, their babies. In developed
monly done to assess fetal wellbeing and to identify any countries, maternal death caused by seasonal influenza is
trauma to the fetus. Ultrasound is also useful in detecting rare. However, the pandemic influenza, H1N1 09 (referred
free peri toneal fluid, maternal haemorrhage and may to as ‘swine flu’), which swept across the world in 2009,
assist in the diagnosis of placental abruption. 163 The pos- demonstrated how vulnerable pregnant women are to
sibility of uterine rupture should also be considered even influenza and emphasised the importance of influenza
though it is rare (<1% of pregnant trauma patients). 163 vaccination to prevent severe disease.
Also remember that the bladder becomes an abdominal
organ after 12 weeks’ gestation and is more prone to The H1N1 2009 flu epidemic killed seven pregnant/
traumatic injury. postpartum women in Australia and New Zealand in
three months. 165 Over 60 women were admitted to ICU
Potential for Perimortem Caesarean Section and a number of their babies died (see the Research

If the woman is ≥20 weeks’ gestation, perimortem caesar- vignette at the end of the chapter for more details on this
ean section should be considered early if the woman study). Women in the second half of pregnancy were over
requires resuscitation. Effective CPR is virtually impo s- 13 times more likely to be admitted to ICU with H1N1
sible after midpregnancy and the likelihood for fetal influenza than non-pregnant women of child-bearing
survival is low. age. Pregnant and postpartum women admitted to ICU
with H1N1 influenza were particularly unwell, with 14%
PNEUMONIA of women requiring ECMO. 166

Pneumonia in pregnancy is one of the more common Interestingly, the severe impact of the pandemic influenza
reasons why a pregnant woman may be admitted to ICU. on pregnant women seen during the H1N1 2009 epi-
Although studies have shown that pregnant women are demic is not dissimilar to that seen during the Spanish
not more likely to contract pneumonia than non-pregnant influenza epidemic of 1918 (also caused by H1N1 influ-
women, the severity of pneumonia experienced by women enza A) and the influenza epidemic of 1957. Each of
in these studies has not been well examined. 164 It is not these influenza epidemics has demonstrated an increased
known whether the ICU admission rate for pneumonia likelihood of maternal death from influenza and poor
is higher in the pregnant population as opposed to the maternal and neonatal outcomes.

Pregnancy and Postpartum Considerations 731

MENTAL HEALTH DISORDERS Postpartum depression
Mental health disorders during pregnancy and the post- Postnatal depression (PND) is defined as a non-psychotic
partum consist of women with preexisting disease and depressive illness; most definitions specify occurrence
women who develop signs and symptoms of mental within three months postpartum although some specify
health disease for the first time. The mental health disor- a shorter period of only one month. 173,174 Risk factors
der may be separate from the pregnancy or there may be include prior mental illness, poor social supports, rela-
173
a relationship between the pregnancy and the develop- tionship disharmony and recent life events. Depression
ment of the disorder, such as postnatal depression. in the postpartum period raises treatment issues for the
nursing mother and the developing infant. 173
Preexisting Mental Health Disorders Early diagnosis and effective treatment, just like for any
The underlying principles of management of pregnant other person with depression, is indicated. Self-harm in
the first 12 months postpartum is a severe concern for
women with a preexisting mental health disorder are the women with serious depression. Care in the ICU is no
same as for non-pregnant women: safety of the woman, different to that provided to other patients admitted with
stabilisation of the mental illness and empowerment of, severe depression. PND is not a contraindication to lacta-
and support for, the woman to make her own choices. A tion, although some medication may be contraindicated.
considerable additional challenge is maintaining stability Medication should be prescribed as warranted on clinical
of the mental health disorder if changes to medication grounds and may include antidepressants, hormonal
are required due to potential teratogenesis or contraindi- treatment and psychological treatments.
cation for use during pregnancy. Generally speaking, if
the indication for treatment is unchanged, then treatment CARING FOR PREGNANT
should be continued during pregnancy. 167 WOMEN IN ICU
Pregnant women with preexisting mental health disor-
ders may require admission to ICU due to acute deterio- Any pregnant woman in ICU is considered to be carry-
ration in their mental health. This is most likely to be as ing an ‘at-risk’ fetus. This means that fetal wellbeing
a result of cessation or alteration of their regular medica- may be compromised and that he/she is at risk of sus-
tions. 168,169 Most relapses occur in the first trimester and taining injury/suboptimal growth and development or
many women who initially stop their medication, recom- death in utero. There are circumstances when the
mence it during the pregnancy. Routine care should be woman’s clinical status would improve by delivery of
168
provided as clinically indicated, keeping in mind the the fetus, and times when the fetus needs to be delivered
additional requirements to monitor fetal wellbeing, to increase the likelihood of its’ own survival. Consid-
conduct standard antenatal assessment and consider the eration of both the maternal condition and fetal wellbe-
impact of the physiological adaptations on treatments. ing contribute to the decision on when to deliver a fetus.
Delivery prior to 24 weeks’ gestation is only an option
if the maternal condition is very critical and considered
Mental Health Disorders Related necessary to potentially save the woman’s life; it is likely
to Pregnancy that the neonate’s care in this instance would be pallia-

Suicide related to unwanted pregnancy remains a cause tive, even though babies have been know to survive when
of maternal death in countries like Australia and New born as early as 22 weeks. 175 Once gestation reaches
Zealand, especially in adolescents and in women from 28 weeks, the neonate has more than a 90% chance
cultures where childbirth outside of marriage is unaccept- of survival when cared for in a neonatal intensive
able. Depression may arise during pregnancy (antenatal care unit. 175
52
depression) although is more likely to present during the
postpartum (postpartum depression). The most severe MECHANICAL VENTILATION OF
mental health disorder related to pregnancy is puerperal THE PREGNANT WOMAN
psychosis. The provision of mechanical ventilation to a pregnant
woman occurs rarely and there is very little evidence to
guide practice. Pregnancy is considered a ‘high risk airway’
Puerperal psychosis with the reported ‘failure to intubate’ ranging from 1 in
Puerperal psychosis is a rare mental health complication 250 to 1 in 750, or approximately eight times more likely
of pregnancy, said to occur in 1/1000 births, though the than in the non-pregnant population. 176 Physiological
incidence seems to be reducing with a modern incidence changes of pregnancy that contribute to the increased
of 0.19/1000 deliveries reported. 170,171 The majority of difficulty in intubation include generalised vasodilatation
cases occur in women with preexisting mental illness, of pregnancy, increased fat deposition around the neck
such as bipolar disorder, with just 0.03/1000 deliveries and an increase in mucosal oedema. The vasodilation
occurring in women with no preexisting mental health increases the vascularisation of the upper airways in
171
disorder. It usually presents within two weeks postpar- pregnancy, increasing the likelihood of bleeding with
tum and is associated with an increased risk of suicide any instrumentation. Consequently, nasal intubation is
and infanticide. 172 Women with puerperal psychosis are not usually an option for pregnant women. Women with
frequently delusional, suffer hallucinations and require preeclampsia may also have substantial pharyngeal
acute hospitalisation for treatment. oedema.

732 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

have also proven useful. 182,183 Critical illness and its treat-
Practice tip ment induce circumstances that make it difficult to inter-
pret these tests of fetal wellbeing with any certainty, for
Remember that pregnancy is associated with a poor tolerance example, morphine decreases the biophysical profile of
of short-term apnoea, for example during induction of anaes- the fetus. 184 With fetal mortality in pregnant women
6
thesia and/or intubation, and pre-oxygenation is important. admitted to ICU as high as 20%, the assessment of fetal
wellbeing during maternal critical illness is of prime
importance, in part to optimise timing of delivery.
The principles of mechanical ventilation in pregnancy are
the same as those for the non-obstetric population with Cardiotocograph
additional considerations including: Cardiotocographs (CTGs) consist of two pieces of infor-
mation: a Doppler recording fetal heart rate pattern and
l ensure target endpoints reflect the normal ABGs for a pressure transducer detecting uterine muscle contrac-
pregnancy tion. Both elements are recorded on a timed graph so that
l remember that a small reduction in maternal oxygen- one may consider the fetal response to uterine contrac-
ation can severely impact on fetal oxygenation because tion (Figure 26.4). Thus, CTGs provide information about
of the left shift in the oxyhaemoglobin dissociation the fetal heart rate and whether there is any uterine con-
curve associated with fetal haemoglobin 177 traction. A normal fetal heart rate is 120–160 beats/min
l permissive hypercapnia has not been evaluated in with variability in the rate. Details of the patient’s condi-
pregnancy (remember that the fetal carbon dioxide is tion and treatment, and the date and time the recording
higher than the maternal level, given the gradient was taken should be documented on the trace. Many
across the placental membrane) tertiary obstetric hospitals offer a fax CTG interpretation
l Normal tidal volumes in pregnancy are increased by service for general hospitals without maternity staff to
up to 40–50% of non-pregnant values, although the assist with interpretation of CTGs. A CTG provides supe-
mechanical provision of these larger tidal volumes rior information to an intermittent fetal heart rate (by
with respect to volutrauma has not been examined; in stethoscope or Doppler) and should be used when pos-
practice often respiratory rate is increased first and sible. The required frequency and duration of a CTG
then increases in tidal volume are only used when recording will vary according to clinical condition. For
necessary 100 example, suspected placental abruption following blunt
l a nurse caring for a ventilated pregnant patient should trauma may require four hours of continuous moni-
be alert to any patient restlessness or increasing seda- toring. A CTG is recommended during and following
tion requirements and ask for midwifery assistance to elective cardioversion and any other major procedure.
assess for the presence of labour contractions.
CTGs are usually only indicated if the fetus is >22–24
weeks’ gestation and there is the potential to act on
adverse findings, such as emergency delivery. The CTG is
Practice tip an indi cation of fetal wellbeing at the time the trace is
recorded and the fetal condition can change rapidly
Medical staff with experience in the management of a pregnant according to changes in maternal condition.
or difficult airway should be present when a pregnant woman
is intubated. Ultrasound
An ultrasound is able to measure core components of
fetal anatomy, such as head circumference and femur
Other, less common, methods to support gas exchange length, to determine fetal size as well as quantify ade-
have been reported in the literature in the form of case quacy of amniotic fluid volume. Thus ultrasound is used
studies. Of note, nitrous oxide, hyperbaric oxygen treat- to consider adequacy of fetal growth in relation to the
ment and extracorporeal membrane oxygenators have all gestation and is a component of the biophysical profile
been used successfully to treat acute conditions, such as regarding fetal movement and swallowing patterns. Serial
pulmonary embolus, in pregnant women. 178-180 ultrasounds, e.g. weekly, are used to monitor adequate
FETAL ASSESSMENT fetal growth and would be a helpful adjunct to the care
of a pregnant woman in ICU with a long term problem,
Assessment of fetal wellbeing in ICU presents a number such as Guillain–Barré syndrome.
of challenges. Most notable is that many pregnant women
in ICU receive sedative medication which has the effect
of sedating the fetus. The standard methods for Practice tip
moni toring and assessing fetal wellbeing include presence
of fetal movements, continuous cardiotocograph (CTG) There is a legal requirement in both Australia and New Zealand
monitoring, intermittent auscultation of the fetal heart for all births to be registered with the Registry of Births, Deaths
rate, ultrasounds and fetal biophysical profiles. These and Marriages. A birth in both countries is defined as the deliv-
assessments are based on the pattern and rate of the fetal ery of a baby of at least 20 weeks’ gestation or, if gestation is
heart beat, the breathing and swallowing action of the unknown, weighing at least 400 g, who is either live born or
fetus in utero, the volume of amniotic fluid and on fetal stillborn. 185,186
181
movements. Uterine artery Doppler flow measurements

Pregnancy and Postpartum Considerations 733














FHR
FHR














UA
UA
FIGURE 26.4 Normal CTG trace. FHR = fetal heart rate; UA = uterine activity.


MODIFICATIONS TO BASIC AND ADVANCED disease is moderate or severe the fetus can have a more
LIFE SUPPORT marked anaemia and erythroblastosis. When the disease
Generally speaking, all standard basic and advanced life is very severe it can cause morbus haemolyticus neonato-
rum, hydrops fetalis or stillbirth. Management of Rhesus
support algorithms can be used with only minor adapta- disease is outlined in Table 26.6.
tions for the pregnant and postpartum woman (Box
26.10). 187 First, for women over 20 weeks’ gestation, the Most Rhesus disease can be prevented by treating the Rh-
sheer bulk of the uterus and contents impair any ability negative mother during pregnancy or promptly (within
to obtain adequate circulation using cardiac compres- 72 hrs) post childbirth. 188 The mother is given an intra-
sions. Left lateral displacement of the uterus is necessary muscular injection of 500 IU of anti-D immunoglobulin
to enable optimal venous return and cardiac output. which destroys any Rh D positive fetal red blood cells in
Regardless, it is very difficult to obtain adequate perfusion her circulation before the maternal immune system can
during CPR of an obviously pregnant woman and discover them and produce antibodies. This is passive
arrangements should be made for an emergency caesar- immunity and the effect of the immunity will diminish
ean section. Delivery of the fetus within five minutes of post injection at around 4 to 6 weeks. Anti-D immuno-
a witnessed arrest is generally desired. Second, expect a globulin is used to prevent the development of anti-D
difficult intubation and try to have an experienced person antibodies and is of no use once the antibodies
intubate the trachea. Third, consider the list of obstetric are present. Administration of 500 IU of anti-D immu-
conditions that may have precipitated the arrest and noglobulin to all Rhesus D-negative pregnant women at
provide any specific appropriate treatment. Cardiac arrest 28–34 weeks is now routine care, even in the absence of
in pregnancy is a rare event and the chance of a successful any vaginal bleeding.
resuscitation is about the same as a non-pregnant arrest.

PREVENTION OF RHESUS DISEASE Practice tip
During pregnancy, a small amount of the fetal blood can The dose of anti-D immunoglobulin depends on the amount of
enter the maternal circulation. If the mother is Rh-negative fetal blood cells detected in the maternal blood using the
and the fetus is Rh-positive, the mother produces anti- Kleihauer-Betke test. The more fetal cells present, the higher the
bodies against the Rhesus D antigen on her baby’s red dose of anti-D required.
blood cells. During this, and subsequent pregnancies, the
anti-D antibodies are able to pass across the placenta to
the fetus and if the level is sufficient, cause destruction of MEDICATION ADMINISTRATION IN
Rhesus D-positive fetal red blood cells, leading to the PREGNANCY
development of Rhesus disease. The disease ranges from Many drugs used in the critical care environment have
mild to severe; when the disease is mild the fetus may not been researched for safe use in pregnant or lactating
develop mild anaemia with reticulocytosis. When the mothers. There are two key periods when consideration

734 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

medications is often a balance between the benefit of
BOX 26.10 Maternal cardiac arrest algorithm administering the drug to the pregnant woman compared
with the risk of not administering the drug.
First responder:
l Activate cardiac arrest team e.g. Code Blue and note time There are a number of anatomical, physiological, cellular
l Place the woman supine and molecular changes in pregnancy that affect the
l Commence chest compressions as per standard BLS algori- pharmacokinetic and pharmacodynamic mechanisms of
189
thm. Place hands slightly higher on the sternum than usual drugs administered during pregnancy. These include
due to raised diaphragm reduced serum protein levels (reduced protein binding
capacity), increased circulating volume (potential for
Subsequent responders: dilution), delayed gut motility (potential for increased
l Apply standard BLS and ALS algorithms gut absorption), increased glomerular filtration rate
l Commence documentation of cardiac arrest management (potential for increased excretion) and changes to mater-
e.g. time of onset nal drug-metabolising enzymes (difficult to predict
l Do not delay defibrillation metabolism pattern of regular drugs). Medication may
190
l Give standard ALS drugs and doses be classified according to the likelihood for teratogenesis,
l Use 100% oxygen however there may be little understanding about efficacy
l Monitor effectiveness of ventilation and CPR quality in pregnancy; standard adult doses may be inadequate or
l Provide the standard post-arrest care toxic during pregnancy due to the adapted physiology of
pregnancy. 189
Maternal modifications:
l Start IV above the diaphragm
l Assess for hypovolaemia and treat appropriately but Potential for Teratogenesis
cautiously A teratogen is any agent that increases the incidence of
191
l Anticipate a difficult airway a congenital anomaly. The major organs are developed
l If the woman is on a magnesium infusion, cease and by 10 weeks’ gestation, however, the recommendation
consider administration of calcium chloride 10 mL in 10% is to avoid any teratogenic drug throughout the first
solution or calcium gluconate 30mL in 10% solution to treat trimester (14 weeks). 192 Some medications exert an
hypermagnesaemia adverse effect in the second or third trimesters of preg-
l Continue all elements of resuscitation effort during and nancy, such as ACE inhibitors (fetal anuria and stillbirth),
after caesarean section indomethacin (potential premature closure of the ductus
arteriosus) and selective serotonin uptake inhibitors
Women with an obviously gravid uterus e.g. >20 weeks’ 192
gestation: (neonatal withdrawal syndrome). Medical staff pre-
l To relieve aorto-caval compression and enable more effec- scribing drugs and nursing staff administering them
tive CPR, manually displace the uterus towards the left should each check the potential impact of the medica-
l Alternatively, use a wedge to position the woman in a tion in pregnancy, and consult a pharmacist when
left lateral tilt possible.
l Remove any internal or external fetal monitors if present
l Prepare for a potential emergency caesarean section Immediately Prior to Delivery
l Call for immediate obstetrician attendance when the Besides effects on the structural development of the fetus
arrest is activated in the first trimester, the other key time for consideration
l Aim for delivery within 5 minutes of onset of resusci- of drug administration is immediately prior to delivery.
tative efforts Common sedative agents like midazolam, morphine,
fentanyl and propofol cross the placenta readily and exert
Consider and treat any possible contributing factors: an action on the fetus. 193-195 Consequently, even mature
l Haemorrhage with or without DIC term babies may be born sedated and require assistance
l Assess for placent abruption/praevia and uterine atony with breathing. Planning for delivery of a pregnant
if woman is postpartum woman in ICU should include the involvement of a
l Embolism, e.g. pulmonary, amniotic fluid paediatrician/neonatologist or the local newborn emer-
l Anaesthetic complications, e.g. high spinal block gency transport service (NETS) if no paediatricians are
l Cardiac disease, e.g. preexisting or new on site.
l Preeclampsia
l Sepsis
Therapeutic Routine Drug Therapy
Adapted from (187). in Pregnancy
For women admitted to ICU for prolonged periods of
time, for example those with Guillain–Barré syndrome,
consideration may be given to routine therapeutic
of drug therapy is paramount: during the first trimester medication in pregnancy. For example, folic acid (400 µg
when embryo/fetal malformations may occur, and daily) is recommended pre-conception and throughout
immediately prior to delivery as the newborn baby may the first trimester to prevent neural tube defects. 192
be adversely affected, e.g. sedated and unable to sponta- Similarly, iron and Vitamin D supplementation
neously breathe. The decision to administer various may be indicated dependent on blood levels. Vitamin

Pregnancy and Postpartum Considerations 735



TABLE 26.6 Management of Rhesus disease

Blood tests and management Rationale
Kleihauer-Betke test or flow cytometry Confirms that fetal blood has passed into the maternal circulation, also estimates the amount of
fetal blood that has passed into the maternal circulation
Indirect Coombs test Screens maternal blood for anti-D antibodies that may pass through the placenta and cause
haemolytic disease of the newborn
Fetal blood (or umbilical cord blood) tests
Direct Coombs test Confirms that maternal anti-D antibodies are present in the fetal/newborn circulation
Full blood count Specifically, the haemoglobin level and platelet count to assess for anaemia
Bilirubin Both total and indirect
Antenatal Care
Serial ultrasound and Doppler examinations Detect signs of fetal anaemia such as increased blood flow velocities and monitor hydrops fetalis
Quantitative analysis of maternal anti-RhD An increasing titre level suggests fetal Rhesus disease
antibodies
Intrauterine blood transfusion Blood transfused into fetal umbilical vein, method of choice since the late 1980s, more effective
than intraperitoneal transfusion
Early delivery Usually post 36 weeks gestation
Postnatal
Phototherapy for neonatal jaundice in mild Converts fat-soluble unconjugated bilirubin to water-soluble bilirubin that can be excreted by the
disease newborn
Newborn exchange transfusion Used if the neonate has moderate or severe disease; the blood for transfusion must be less than a
week old, Rh negative, ABO compatible with both the fetus and the mother, and be cross
matched against the mother’s serum




D deficiency is common, yet often unrecognised in
critically ill patients. 196 Maternal vitamin D deficiency BOX 26.11 Routine postnatal observations
is associated with childhood asthma and increased
risk of osteoporotic fracture in their offspring. 197,198 l Examination of breasts, looking for signs of engorgement,
Due attention should be paid to a pregnant woman’s mastitis, cracked nipples
nutritional status in ICU as poor nutrition during l Height, depth and texture of fundus, to ensure involution
pregnancy is associated with many poor birth outcomes is happening
and pregnancy is associated with increased nutritional l Lochia, inspection of PV loss
requirements. 199 l Examination of perineum/wound for signs of healing
l Examination for signs of deep vein thrombosis; thrombo-
CARING FOR POSTPARTUM phylaxis is often indicated in a postpartum ICU woman
WOMEN IN ICU l Mictrition and bowels; to ensure bowel and urinary pattern
returning to normal
Women admitted to ICU during the postpartum phase
are often separated from their newborn, possibly even
transferred to another hospital, and may not even set
eyes on their child for days, until they are discharged thrombophylaxis, and evaluation of her psychological
3
from ICU. Specific care that should be provided to the wellbeing and transition to motherhood (Box 26.11).
postpartum woman includes observations, assistance to
establish lactation as required and support for the mother Uterine Involution
by early nurturing of a mother–infant bond. Finally, The term ‘involution’ means the return of the uterus to
attention to psychological needs of both the woman and its normal size, tone and position. The vagina, ligaments
her partner is an important part of care. of the uterus and muscles of the pelvic floor also return
to their pre-pregnant state during the involution process.
ROUTINE POSTPARTUM OBSERVATIONS During this process, the lining of the uterus is cast off in
Ongoing surveillance of a postpartum woman is essential the lochia, more commonly referred to as PV loss, and is
in addition to any ad hoc visits provided by a midwife. later replaced by the new endometrium. Postdelivery of
Routine maternity observations include assessment of the the baby and postexpulsion of the placenta, the muscles
fundus, PV loss and perineum, assessment of the breasts of the uterus constrict the blood vessels, so the blood
and nipples, consideration of deep vein thrombosis and circulating within the uterus is dramatically decreased.

736 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Redundant muscle, fibrous and elastic tissue is disposed Lochia and Perineal Care
of – the phagocytes of the blood stream deal with this – The changes in the appearance of the lochia are described
but the process is usually incomplete and some elastic in three stages: lochia rubra, lochia serosa and lochia
tissue remains. So a uterus that has once been pregnant alba. Lochia rubra consists of blood coming chiefly
200
will never return fully to its pre-pregnant state. The decid- from the placental site, mixed with shreds of the decidua.
ual lining of the uterus is shed in the form of lochia. The Three or four days post delivery, the lochia changes to
new endometrium grows from this basal layer, beginning brownish in colour, and consists of altered blood and
to be formed at the tenth day and completed by 6 weeks serum containing leucocytes and organisms; this is called
postpartum.
lochia serosa. Seven days post delivery the lochia again
The rate of involution is measured by the rate of descent changes, the PV loss is now yellowish in appearance, and
of the uterine fundus (the top of the uterus) in relation consists mainly of cervical mucus, leucocytes and organ-
to either the belly button or the symphysis pubis. Impor- isms; this is called lochia alba. Normal lochia is not
tant markers include: offensive in odour. Offensive lochia coupled with or
without maternal pyrexia may indicate a uterine infec-
l day 1 postnatal, the height of the fundus is usually at tion. High and low vaginal swabs for culture and sensi-
the belly button tivity, and the commencement of antibiotic cover, should
l there is a steady decrease in size of around 1 cm per be initiated. Offensive lochia coupled with a high non-
day involuting (and boggy) uterus may require ultrasound to
l as the uterus reduces, it also recedes and is deeper to exclude retained placental tissue. An infected placental
palpate site may result in a secondary postpartum haemorrhage.
l by postnatal day 7, the fundal height is often only
2–3 cm above the symphysis pubis and by day 10 it is Regular assessment of the PV loss is required in the early
usually not palpable at the symphysis pubis postpartum phase. Generally this includes 1–2 hourly
l the rate of involution is slower in multiparity women, checks if the PV loss is relatively heavy (pad soaked within
if there is an infection present, or retained placental 1–2 hours) for the first day, progressing to 4 hourly checks
tissue/clots. on day 2, with further reductions in observation fre-
quency based on clinical condition. Essentially, you need
A normally contracted uterus is very hard; as you palpate to check the fundus and PV loss regularly enough to
the fundus to locate the top and feel the texture of the detect any excessive blood loss or loss of uterine tone. The
uterus, you can not push your fingertip into the tissue of colour and volume of PV loss is usually documented
the uterus. A so-called boggy uterus is one that is not along with any pad changes.
contracted properly and the fundus does not feel very
hard on palpation. Reasons for a ‘boggy uterus’ include When checking the PV loss, the perineum should also be
uterine atony, retained tissue/membrane/clot or a full examined twice a day, even for women that have had a
bladder that is impeding the uterine nerve stimulus to caesarean birth. A vulval haematoma or varicosities may
contract. The uterus responds well to tactile stimulation, have formed and require attention. For women that have
and the first treatment for a ‘boggy uterus’ is to ‘rub-up’ had a vaginal birth, check the perineum to see if there
the fundus. This involves palpating the top of the uterus was any tear or episiotomy at delivery. If there is a tear
and literally giving it a rub. The uterus will usually or any sutures, make sure to keep the region clean and
respond and you will feel it tighten and become harder. observe for signs of infection or wound dehiscence. Ice
Such an action may result in a small gush of PV loss. On packs applied to the perineum may help with any swell-
some occasions, an uterotonic, a drug that causes the ing and discomfort.
uterus to contract, may be needed to ensure the uterus is
contracting properly. If the uterus does not contract prop- Increased Potential for Deep Vein Thrombosis
erly, then the vessels that fed the placental bed will not All postpartum women have an increased likelihood for
be closed off by the uterine muscle contraction (called DVT. Preeclampsia and obstetric haemorrhage are addi-
the living ligature) and the woman will continue to bleed. tional risk factors, as is an emergency operative procedure
and postpartum immobility. Most postpartum women
admitted to ICU would fulfil the criteria that recommend
Practice tip medical thrombophylaxis. Routine postpartum care
involves examining the legs for signs of DVT and appro-
Uterotonics, drugs that cause the uterus to contract, are priate use of thromboembolic stockings, sequential
usually stored in the refrigerator. For example, syntocinon, compression devices and thrombophylaxis as required
syntometrine.
(see www.rcog.org.uk for more details). 30
BREAST CARE AND BREAST FEEDING
Practice tip A woman’s breasts and nipples should be examined once
a shift to assess their condition and identify signs of
Many midwives document fundal height by fingerwidths in complications, such as mastitis. This examination should
relation to the belly button. For example, two fingerwidths be conducted on all women, regardless of whether she
below the belly button would be notated by 2F ↓ . intends to breastfeed or not. The breasts are usually soft,
although as the milk comes in, they may become

Pregnancy and Postpartum Considerations 737

engorged; quite hard and lumpy in places, hot and tender
to touch. A reddened localised region in this setting may BOX 26.12 Principles of expressing
be indicative of mastitis and may require treatment with breast milk
antibiotics. The nipples should be examined for damage
if the woman is being expressed (or has had the infant How often should I express?
suckle). Hand expressing is usually not harmful to the Generally speaking, women are recommended to express 2–3
nipples and the nipples should not have any cracks. hrly. This may be difficult to achieve in the ICU environment.
Colostrum (or milk once it has come in) may leak from Clinicians should aim for at least 6 times per 24 hours including
the nipples; both colostrum and breast milk can be at least once overnight.
rubbed gently over the nipples to promote healthy tissue.
Machine expression may be harmful to the nipple if Hand express or machine express?
uneven and strong suction pressure is applied. It is recommended to use hand expression only in the first few
days with use of a machine reserved for when the milk has
Initiation and Establishment of Lactation come in. Always start and finish the expression by hand, as
hand expression provides a better stimulus for milk production
The establishment and maintenance of lactation is a than the machine does, and promotes release of the ‘let-down’
hormone-mediated process. The physiological trigger for reflex which will assist with milk flow and removal. Expressing
the establishment of lactation is a fall in progesterone by hand or machine should not be painful.
combined with maintained levels of prolactin and corti- Storage and transport of expressed milk
201
sol. In the initial postnatal period colostrum is pro-
duced. The normal timing for milk to ‘come in’ is between The most useful container for collection of expressed colostrum
202
3 and 4 days post-delivery, although establishment and is a 2 or 5 mL syringe and a specimen M&C container for small
‘coming in’ of breast milk may be delayed in critically ill volumes of milk. Always label the container with the woman’s
women. Additionally, the drug dopamine may hinder name, and the date and time of the expression. Use a new
203
lactation, as it inhibits prolactin secretion. It is not collection container for each expression. Breast milk must be
likely that the severity of maternal illness plays much of stored in a refrigerator and may be frozen. A ‘cooler bag’ with
a role in the initial capacity to produce milk; anecdotally, ice packs should be used to transport the milk from ICU to
100 mL of breast milk has been expressed 4 hourly from where the baby is being cared for.
a postpartum woman on ECMO. The initial regularity of
hand expression and milk removal provide the stimulus
to produce milk.
For women who prefer to breastfeed the infant, reason-
able attempts to support this decision should be made.
Most women make a decision regarding infant feeding
either before becoming pregnant or during the first
trimester and in all pregnant women, the breasts have
developed and are capable of producing milk from 22
weeks onwards. 204,205
There is some debate regarding how crucial the first
24–48 hours are for the successful establishment of lacta-
tion. 206,207 In many cultures, colostrum is considered
poisonous and breastfeeding is withheld until after 48 FIGURE 26.5 How to hand express.
hours and so clearly the absence of breast stimulation in
the first 48 hours does not prohibit the establishment of
208
lactation. Hand expressing is recommended for the first Oxytocin is most commonly known for its role in the
few days until the milk ‘comes in’, and then to start and ‘let-down reflex’ of milk during breastfeeding, but also
finish each expressing episode along with the use of a has known effects on brain areas involved in emotion
209
breast pump (see Box 26.12 for principles and Figure and stress response, increased levels of oxytocin lower
26.5 for process). It is not uncommon for only a few blood pressure among mothers who breast feed their
drops of colostrum to be expressed each time in the first babies. This is known to improve a mother’s mood,
210
couple of days. It is believed that even a small total increases pain tolerance, and also has a possible positive
expressed volume of 5–10 mL per day of colostrum may association in wound healing. Prolactin may also be
be of value to stimulate the ‘coming in’ of full milk pro- responsible for intense ‘mothering’ feelings. 203
201
duction. The two key factors that support the establish-
ment of lactation are breast stimulation (infant suckling, If the mother’s intention was to formula feed, or if the
hand expression) and milk removal. The more often you baby has died, then the lactation process may be sup-
express and remove milk, the positive feedback mecha- pressed. In practice, this means providing no stimulation
nisms ensure that more milk is produced. Frequent, short to the breasts (i.e. no hand expression). Although used
expression of the breasts is more effective than prolonged in the past, medications are no longer used to influence
infrequent expressing. Overnight expression is also this process. With no breast expression, some women
important. may still experience milk ‘coming in’ at or after Day 4

738 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

postpartum and comfort measures may assist if the is able to ‘room in’ with the mother for periods of time
breasts become very uncomfortable. Cold compresses in ICU. Skin to skin contact is usually recommended
209
214
may be of use and it is important for the critical care to promote bonding. Alternatively, the baby may be
nurse to observe for signs like reddened hot areas on the able to visit the mother in ICU or the mother may be
breast that may be an indication of mastitis. able to visit the baby in NICU. Physically seeing and
touching the baby may be an important step for the
Medication Administration and Lactation mother. Newer technologies, like Skype, have been used
Many drugs are safe to use in breastfeeding, although by some ICUs to enable the mother to see her baby in
most common critical care drugs have not been well eval- a different hospital and to watch significant events, such
211
uated. Even if the woman is receiving a medication that as the first bath.
is contraindicated during breastfeeding, you can still The use of diaries, one about the mother’s condition and
express (and discard) the milk to establish the process of one about the baby’s progress, complete with photos,
lactation, unless the woman is likely to stay on the medi- visitor and clinician entries is another strategy that may
cation long term. be useful to promote maternal-infant attachment. The
The safety of the expressed milk for the baby depends on first few days following birth are often a blur for the
three factors: the amount of the medication in the milk, mother with little recollection of events. It is also common
the oral bioavailability of the medication, and the ability to have photographs of the baby for the mother to look
212
of the infant to metabolise the medication. The gesta- at and clinicians keep in touch with the nursery where
tion and condition of the infant are relevant as the func- the baby is being cared for and gives the mother regular
tion of the gut, liver and kidney varies with maturity and updates on the baby’s condition.
illness. Consequently, advice from the baby’s neonatolo-
gist or paediatrician can help determine whether the
neonate can receive the expressed breast milk, or whether Caring for the Partner and Other
it should be discarded. Family Members
The partner is similarly ‘bowled over’ by the sudden and
PSYCHOLOGY OF THE PUERPERIUM severe illness of the mother. The partner is often torn
Major emotional changes take place in the majority of between two ICUs, with the newborn admitted to NICU
women during the puerperium, but there is a wide varia- in one hospital and the mother in ICU in another hospi-
tion in the amount of distress caused by these changes. tal. This situation is further compounded if there are
The first three days post delivery are known as the latent other children who also need the care and attention of
period because functional mental illness is very unlikely their father and need an explanation about what has hap-
to occur at this time interval. The woman is usually in pened to their mother. Most women recover and do so
state of euphoria, excitement and restlessness, extreme fairly quickly, so there is usually hope that the woman
tiredness is also present. Days 3–10 are often referred to will survive and fully recover. Usual strategies such as
as the ‘baby blues’ and are characterised by emotional explanation, open visiting and social work support are
213
lability (mood swing). The ‘baby blues’ are usually important.
characterised by thoughts of inadequacy and generalised
panic that there is something wrong with either their SUMMARY
baby or themselves. A very severe ‘baby blues’ response
may herald the onset of postnatal depression. Intensive care management of pregnant and postpartum
women is challenging for a variety of reasons including,
THE FAMILY UNIT but not limited to, the presence of the fetus, physiological
Maternal admission to ICU often separates the mother adaptations of pregnancy and due to clinical conditions
that are unique to the obstetric population. ICU staff are
from her newborn and may also be associated with a often not educationally-prepared to provide midwifery
period of heavy sedation/loss of consciousness. Thus the care and there may be difficulty in obtaining midwifery
woman may not be able to recollect the birth process and and obstetric consultation. Importantly, childbirth is
will often not have seen her baby before being transferred viewed as a normal, healthy event in our society and is
to ICU. usually a cause of celebration. A life-threatening event
associated with childbirth may seem more overwhelming
Promoting Maternal–infant Attachment due to this context. The best outcomes for both the
Promoting maternal–infant attachment depends on the mother and her baby will result from collaborative and
condition of both the mother and her baby, and their coordinated care between maternity and critical care
physical locations. The best case scenario is that the baby service providers.

Pregnancy and Postpartum Considerations 739



Case study
Carly is a 38-year-old woman who is having her second child. that the woman receives warmed fluids, catering to the obste-
Her first child was born by caesarean section 20 months ago. Carly trician’s needs, obtaining blood products and coordinating every-
has placenta praevia and has been booked for an elective repeat thing that is happening.
caesarean section at 38 weeks’ gestation at a tertiary obstetric hos-
pital. A spinal anaesthesia is established and the baby is born Support staff arrive and the hysterectomy is done with a cystos-
without complication, with Carly’s husband John present at the copy and bladder repair needed due to invasive placental tissue.
birth. However, Carly begins to bleed profusely and the obstetri- The bleeding is finally controlled though Carly is still ‘oozing’ from
cian soon identifies that the placenta is adherent to the uterus and any damaged tissue. Two drains are inserted and the wound is
he is having trouble removing the placenta. Carly has lost 1000 mL closed. Carly has had a documented acute blood loss of over
of blood very quickly and the anaesthetist increases the Hart- 7000 mL. She has received a total of 16 units of red blood cells, five
mann’s infusion and administers a litre of normal saline rapidly. He units of platelets, four units of fresh frozen plasma and four units
sends off an urgent blood crossmatch request and tells the operat- of cryoprecipitate, additional to approximately 9000 mL of crystal-
ing team they will need to convert Carly to a general anaesthesia. loids and colloids. As the wound was being sutured, an ICU bed
John is escorted out of the operating theatre and told that there was organised and arrangements made to transfer Carly to the
has been a bit of a complication and someone will be with him ICU at the general hospital, 2 km away. Carly was in theatre for
shortly. The blood loss continues at a rapid rate and the obstetri- 3.5 hours.
cian is having great difficulty trying to control the bleeding. Some
of the placental tissue has grown into the uterine wall and cannot Carly is admitted to ICU intubated and ventilated with vital signs
be separated. Total blood loss at this time is estimated to be of BP 100/55, HR 110, and her temperature is 35.1°C. Her ICU stay
4000 mL. The haematology department is called to find out where is relatively uncomplicated. Carly was warmed, filled with normal
the requested blood is, and to order fresh frozen plasma, platelets saline and given two more units of red blood cells for an Hb of
and cryoprecipitate. More normal saline is administered along with 79 g/L. She continued to have small ongoing ooze from her
1000 mL of haemaccel. Carly’s haemodynamic status is deteriorat- abdominal wound and into the two drains. As Carly was stabilised
ing. Her BP is 85/50 on the blood pressure cuff. The anaesthetist and it was clear that she would not need to return to theatre, her
would like continuous blood pressure monitoring but hasn’t had sedation was reduced and her ventilation support weaned. Her
time to put an arterial line in. He pages for another anaesthetist to urine output was initially low; this was treated with two small doses
come in to theatre to help. With the ongoing uncontrolled blood of IV frusemide with a good response. Carly was extubated over-
loss, a decision is made to proceed to hysterectomy. The obstetri- night and continued to progress well, though she was very tired
cian asks if a gynaeoncologist is available to come and assist with and her pain management needed addressing. She was transferred
the surgery. The theatre nursing staff are very busy trying to ensure back to the tertiary obstetric hospital the following day.







Research vignette
The ANZIC Influenza Investigators and Australasian Maternity Out- Results
comes Surveillance System. Critical illness due to 2009 A/H1N1 64 pregnant or postpartum women admitted to an intensive
influenza in pregnant and postpartum women: population based care unit had confirmed 2009 H1N1 influenza. Compared
cohort study. British Medical Journal 2010; 340: c1279. with non-pregnant women of childbearing age, pregnant or
Abstract postpartum women with 2009 H1N1 influenza were at increased
risk of admission to an intensive care unit (relative risk 7.4, 95%
Objective confidence interval 5.5 to 10.0). This risk was 13-fold greater
To describe the epidemiology of 2009 A/H1N1 influenza in critically (13.2, 9.6 to 18.3) for women at 20 or more weeks’ gestation.
ill pregnant women.
At the time of admission to an intensive care unit, 22 women
Design (34%) were post partum and two had miscarried. 14 women
Population based cohort study. (22%) gave birth during their stay in intensive care and 26 (41%)
were discharged from an intensive care unit with ongoing
Setting pregnancy. All subsequently delivered. 44 women (69%) were
All intensive care units in Australia and New Zealand.
mechanically ventilated. Of these, nine (14%) were treated with
Participants extracorporeal membrane oxygenation. Seven women (11%) died.
All women with 2009 H1N1 influenza who were pregnant or Of 60 births after 20 weeks’ gestation, four were stillbirths and
recently post partum and admitted to an intensive care unit in three were infant deaths. 22 (39%) of the liveborn babies were
Australia or New Zealand between 1 June and 31 August 2009. preterm and 32 (57%) were admitted to a neonatal intensive
care unit. Of 20 babies tested, two were positive for the 2009
Main outcome measures H1N1 virus.
Maternal and neonatal mortality and morbidity.

740 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E



Research vignette, Continued
Conclusions increased risk factors within the pregnancy cohort and a potential
Pregnancy is a risk factor for critical illness related to 2009 H1N1 delay in the commencement of anti-viral treatment for severe
influenza, which causes maternal and neonatal morbidity and influenza during pregnancy. Notably, the poor maternal and neo-
mortality. natal outcomes are reflected upon. These themes are discussed
with appropriate reference to other literature, i.e. ‘what is known
Critique about the topic,’ and how this study has added to ‘what is known’.
A prospective, collaborative study was rapidly established follow- The clinical implications are also highlighted, particularly regard-
ing the onset of the H1N1 influenza pandemic in 2009. Every ICU ing the potential prevention of severe H1N1 influenza in preg-
in Australia and New Zealand (n = 187) was involved with every nancy now that a vaccine is available and recommended for all
confirmed H1N1 influenza ICU admission prospectively entered in pregnant women.
to the INFINITE database. Over 700 affected patients were admitted
to Australian and New Zealand ICUs during the three months of This is the largest study to date and is also the most comprehensive
winter (June–Aug 2009). Of these, 64 (9%) were noted to be preg- study published about influenza in pregnancy, obstetric outcomes
nant or postpartum; thus pregnant and postpartum admissions and neonatal outcomes. Although the overall numbers were still
were an over-represented cohort. 166 relative small (n = 64), it was a population-based study with con-
sistent findings across multiple clinical sites. Unfortunately, the
This pregnant and postpartum cohort was the subject of the disconnection of ICU and maternity services makes complete
follow-up study, conducted collaboratively by the ANZIC-RC and follow-up very difficult. For example, it is very challenging to
the Australasian Maternity Outcomes Surveillance System (AMOSS), follow-up a pregnant woman admitted to ICU at 21 weeks’ gesta-
in which an additional data set were retrospectively collected on tion, in a hospital where she was not booked in to receive her
all women, including data on obstetric and neonatal outcome. maternity care, when she is discharged pregnant and gives birth
The paper clearly sets the context for the study, outlining the 18 weeks later in an unrelated hospital. Even if the researcher is
increased risk of severe influenza associated with pregnancy and a aware of the intended hospital for birth, the woman may give birth
lack of data on the obstetric and neonatal outcomes. The methods in another location unexpectedly. The study clearly demonstrates
chosen to conduct this study were appropriate and in part were serious maternal and morbidity for both the mother and her baby.
selected because of the opportunity presented with the primary The results build a strong case for all pregnant women to be
INFINITE study. The method for identifying cases was described offered influenza vaccine during pregnancy; further, that the
and the inclusion criteria are clear. Notably, 28 days was used to vaccine will offer most benefit to the woman if administered prior
define postpartum and not the commonly-used definition of 42 to 20 weeks’ gestation.
days; there is no explanation for this. The AMOSS research pro- One limitation not identified by the authors is the possibility that
cesses were not well described and it is unclear how the additional the ICU admission threshold may have differed for pregnant or
data were obtained. Nevertheless, the variables collected are postpartum women. No severity of illness/severity of lung injury
stated clearly. In order to calculate relative risks, the authors used score was reported. Examination of the INFINITE cohort would
available population birthing data; whilst these data were not suggest that there was no difference in ICU admission threshold.
precise for the timeframe the study was conducted, they were the The median length of ICU stay (days), proportion requiring
best available data and the processes in which the population mechanical ventilation (%), median length of ventilation (days),
birthing data were used are clearly explained.
need for ECMO (%), vasopressor use (%), RRT (%) were not differ-
All cases are accounted for and a flow chart is included to demon- ent between the general INFINITE cohort and the pregnant/
strate this. Relative risks are reported for women in the first half of postpartum sub-set.
their pregnancy, women in the second half of their pregnancy,
postpartum women and pregnant/postpartum women compared Finally, this study is a good example of, and highlights the benefit
with non-pregnant women of childbearing age. The highest risk of, collaborative research. The study was conducted by two teams
time for maternity patients was in the second half of pregnancy. of researchers; intensive care clinicians and maternity providers.
Other additional risk factors are clearly identified including the Together, with the assistance of every ICU in Australia and New
woman’s indigenous status and high body mass index (BMI). Tables Zealand, they were able to conduct a population-based study that
and figures have been used well to communicate large amounts identified all pregnant and postpartum women admitted to ICU
of data. Figures 1 and 2, in particular, are helpful and easy to with H1N1 influenza during the winter of 2009. This level of col-
interpret. laboration enabled the researchers to study the largest possible
number of cases of a rare event. The findings of the study reflect
The discussion explores themes identified from the research find- the benefits of such a collaboration, with clinically, meaningful
ings including the risk posed by pregnancy on influenza infection, data obtained.

Pregnancy and Postpartum Considerations 741



Learning activities
1. List the key physiological adaptations of the cardiovascular 7. Outline the minimum postnatal assessment that Carly should
and respiratory systems during pregnancy. have each day she is in ICU.
2. Interpret the following ABG with reference to the normal ranges 8. John tells you that Carly breastfed their first child and was
−
for pregnancy. PaO 2 = 79; PaCO 2 = 45; pH = 7.31; HCO 3 = 18 planning to breastfeed this child. What can you do to support
3. Outline the key management priorities when caring for a the process of lactation? What milk production would you
woman in ICU with severe preeclampsia. expect over the first 2 days in ICU?
4. Explain to a colleague what placenta praevia and placenta 9. Consider the support that John and their first child might need
accreta are. whilst Carly is in ICU. How would you support the integration
Activities 5 to 11 relate to the case study. of the new family member?
5. You are assigned to Carly when she is admitted to ICU. Outline 10. Write a transfer letter that will accompany Carly back to the
the key elements of your admission assessment including tertiary obstetric hospital for the midwives who will be con-
those related to midwifery assessment. tinuing her care. Ensure that you include relevant details of
6. Within an hour of Carly’s admission to ICU, her husband John her ICU stay, including midwifery progress.
arrives and asks to see his wife. John wants to know what has 11. Discuss the potential implications of this unexpected serious
happened and is very worried about her. What would you say event for Carly and her family as she recovers and ‘life goes
to John? What can John expect over the next couple of days? back to normal’.




ONLINE RESOURCES 4. Harrison D, Penny J et al. Case mix, outcome and activity for obstetric
admissions to adult, general critical care units: a secondary analysis of the
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497–506.

Organ Donation and
27 Transplantation







Debbie Austen
Elizabeth Skewes


a report on the ‘hopelessly unconscious patient.’ The
Learning objectives committee members agreed that life support could be
withdrawn from patients diagnosed with ‘irreversible
After reading this chapter, you should be able to: coma’ or ‘brain death’ (terms they used interchangeably)
l differentiate between coma and brain death and that, with appropriate consent, the organs could be
13
l understand the process of donor identification and referral removed for transplantation. The committee’s primary
l be aware of best practice for the consent-seeking process concern was to provide an acceptable course of action to
l understand the principles of donor management permit withdrawal of mechanical ventilatory support for
the purpose of organ donation for human transplant. In
1981, a US President’s Commission declared that indivi-
dual death depended on either irreversible cessation of
circulatory and respiratory functions or irreversible cessa-
Key words tion of all functions of the entire brain. The consequent
Uniform Determination of Death Act referred to ‘whole
brain death’ as a requirement for the determination of
brain death brain death. 13
consent
coroner Legislation that defined brain death and enabled beating-
designated officer heart retrieval was enacted in New Zealand in 1964 and
Donatelife, legislation in Australia from 1982. This legislation heralded the
next of kin establishment of formal transplant programs. In Austra-
lia, the first heart and lung program commenced in 1983,
organ donation a liver transplant program in 1985, combined heart–lung
organ donor transplant in 1986, combined kidney and pancreas in
recipient 1987, single lung in 1990 and small bowel in 2010. In
2,3
retrieval New Zealand, bone was first transplanted in the early
tissue 1980s and the first heart transplant occurred in 1987.
transplant Skin transplantation occurred in 1991, lung transplanta-
tion in 1993, and liver and pancreas transplantation in
4
1998. The success of transplantation in the current era
as a viable option for end-stage organ failure is primarily
INTRODUCTION due to the discovery of the immunosuppression agent
cyclosporin A. 5
Transplantation is a life-saving and cost-effective form of
treatment that enhances the quality of life for many This chapter discusses the processes and clinical implica-
people with end-stage chronic diseases. Transplantation tions of cadaveric organ and tissue donation in Australia
surgery commenced in Australia in 1911, with a pancreas and New Zealand, within a critical care nursing context.
transplant in Launceston General Hospital, Tasmania.
Other tissue and solid organ transplantations followed,
retrieved from donors without cardiac function; the first ‘OPT-IN’ SYSTEM OF DONATION IN
cornea in 1941; kidney in 1956; and livers and hearts in AUSTRALIA AND NEW ZEALAND
1968. Transplantation in New Zealand began in the 1940s
with corneal grafting, and the first organ transplants were There are currently two general systems of approach to
kidney and heart valve transplantation in the 1960s. 1 seeking consent for cadaveric organ and tissue donation
in operation around the world. Some countries (e.g.
The first successful human-to-human transplant of any Spain, Singapore and Austria) have legislated an ‘opt out’,
kind was a corneal transplant performed in Moravia (now or presumed consent, system, where eligible persons
1
the Czech Republic) in 1905. In September of 1968 an are considered for organ retrieval at the time of their
746 ad hoc committee of Harvard Medical School produced death if they have not previously indicated their explicit

Organ Donation and Transplantation 747

objection (see Table 27.1). In Australia, New Zealand, the health departments and funding arrangements between
US, the UK and most other common-law countries, the federal and state health departments.
approach is to ‘opt in’, with specific consent required As part of the national reform package for the organ and
6,7
from the potential donor’s next of kin. In some states tissue donation and transplantation sector, all state and
of Australia (for example, New South Wales and South territory health ministers agreed to the establishment of
Australia) and in New Zealand people indicate consent a national network of organ and tissue donation agencies,
to organ donation on their driver’s licence or namely the Organ and Tissue Authority. This involved the
the Australian Organ Donor Register. 8,9,10 In Singapore, employment of specialist hospital medical directors and
the Human Organ Transplant Act of 1987 combines a senior nurses to manage the process of organ and tissue
presumed consent system with a required consent system donation as dedicated specialist clinicians employed
for the Muslim population. The informed consent legis- within the intensive care unit. 1
lations of Japan and Korea are two of the most recent to
come into force, in 1997 and 2000 respectively; before The responsibility for leading this group of dedicated
then, only living donation and donation after cardiac health professionals rests with the National Medical
death were possible. 11,12 Director who supports this team through a Community
of Practice (CoP) Program. This community of health
LEGISLATION professionals, along with the staff of the Authority, are the
Legislation governing organ and tissue donation in New DonateLife Network, working together to share informa-
Zealand and Australia take the form of Acts covering the tion, build on existing knowledge, develop expertise and
1
use of human tissue both before and after death. These solve problems in a collaborative and supported manner.
legislations enable a person to choose to be a donor, and
organ donation can proceed unless that wish is reversed THE ORGAN AND TISSUE AUTHORITY
or the family does not consent. If the deceased’s wishes Legislation governing organ and tissue donation in Aus-
are not apparent, consent for organ donation rests with tralia is based in State and Territory jurisdictions. Solid
the next of kin. In Australia the legislation defines death organ donation agencies are based in New South Wales
as the: (in partnership with the Australian Capital Territory),
l irreversible cessation of all function of the brain of Victoria (with Tasmania), South Australia, Northern
the person or Territory, Queensland and Western Australia. Separate
l irreversible cessation of circulation of blood in the state-based tissue banks facilitate tissue retrieval around
body of the person. 13 Australia apart from Western Australia, where the organ
donation agency coordinates all organ and tissue retrieval.
TYPES OF DONOR AND DONATION The Organ and Tissue Authority is the peak body that
works with all jurisdictions and sectors to provide a
Organ and tissue donation includes retrieval of organs nationally coordinated approach to organ and tissue
and tissues both after death and from a living person. donation for transplantation to maximise rates of dona-
Donations from a living person include regenerative tion. The role of the Authority is to ‘spearhead and be
tissue (blood and bone marrow) and non-regenerative accountable for a new world’s best practice national
tissue (cord blood, kidneys, liver (lobe/s), lungs (lobe/s), approach and system to achieve a significant and lasting
femoral heads). The implications of consent are different increase in the number of life-saving and life-transforming
for each type of requested tissue. For example, the collec- transplants for Australians’. 1
tion of bone marrow, retrieval of a kidney, the lobe of a
liver or lung are invasive procedures that could potentially The Authority was established in 2009 under the Austra-
14
risk the health and wellbeing of the donor. In contrast, lian Organ and Tissue Donation and Transplantation Author-
donation of a femoral head could be the end-product ity Act 2008 as an independent statutory authority within
of a total hip replacement, where the bone is otherwise the Australian Government Health and Ageing portfolio.
discarded. Similarly, cord blood from the umbilical The DonateLife Network, under the Authority, include
cord is discarded if not retrieved immediately after birth. ‘DonateLife’ agencies and hospital-based staff across Aus-
tralia dedicated to organ and tissue donation. DonateLife
After cardiac death, many people can be donors for eyes,
heart valves and cardiac tissue, long bones, pelvis, tendons, agencies were re-formed and re-named as a nationally
ligaments and skin. On occasion, and in appropriate and integrated network to manage and deliver the organ
controlled situations, some people could also be donors donation process according to national protocols and
of kidneys, liver and lungs. It is after brain death that the systems and in collaboration with their hospital-based
1
‘traditional’ organs of the heart, lungs, liver, kidneys, pan- colleagues. Legislation in New Zealand is national, with
creas and tissues can potentially be retrieved. Organ Donation New Zealand coordinating all organ and
tissue retrieval from deceased donors. 4
ORGAN DONATION AND TRANSPLANT REGULATION AND MANAGEMENT
NETWORKS IN AUSTRALASIA
In Australia, quality processes involved in organ and
The donation and transplantation process in Australia is tissue retrieval and transplant are governed by the Thera-
15
a nationally coordinated process in the healthcare system, peutics Goods Administration. In New Zealand there
a unique arrangement given the disparity between state is currently an unregulated market for medical devices

748 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E



TABLE 27.1 Type of legislation by country 80-83

Country Type of legislation Year and description of legislation
Australia Informed consent 1982, donor registry since 2000
Austria Presumed consent 1982, non-donor register since 1995
Belgium Presumed consent 1986, combined register since 1987, families informed and can object to organ donation
Bulgaria Presumed consent 1996, in practice, consent from family required
Canada Informed consent 1980
Croatia Presumed consent 2000, family consent always requested
Cyprus Presumed consent 1987
Czech Republic Presumed consent 1984
Denmark Informed consent 1990, combined register since 1990, previously presumed consent
Estonia Presumed consent no date identified
Finland Presumed consent 1985
France Presumed consent 1976, non-donor register since 1990; families can override the wishes of the deceased
Germany Informed consent 1997
Greece Presumed consent 1978
Hungary Presumed consent 1972
India Informed consent 1994
Ireland Informed consent follows UK legislation
Israel Presumed consent 1953
Italy Presumed consent 1967, combined register since 2000, families consulted before retrieval
Japan Informed consent 1997
Latvia Presumed consent no date identified
Korea Informed consent 2000
Lithuania Informed consent no date identified
Luxemburg Presumed consent 1982
The Netherlands Informed consent 1996, combined register since 1998
New Zealand Informed consent 1964
Norway Presumed consent 1973, families consulted and can refuse
Poland Presumed consent 1990, non-donor register since 1996
Portugal Presumed consent 1993, non-donor register since 1994
Romania Informed consent 1998, combined register since 1996
Singapore Presumed consent 1987, informed consent for Muslim population
Slovak Republic Presumed consent 1994
Slovenia Presumed consent 1996
Spain Presumed consent 1979, in practice, consent required from families
Sweden Presumed consent 1996, families can veto consent if wishes of the deceased are not known; previously informed
consent
Switzerland Informed consent 1996, some Cantons have presumed consent laws
Turkey Presumed consent 1979, in practice, written consent required from family
United Kingdom Informed consent 1961, donor register since 1994
United States Informed consent 1968, donor registers in some states
Note: A combined register is a register of consent and refusal.

Organ Donation and Transplantation 749

and complementary medicines, although an agreement
to establish a Joint Scheme for the Regulation of Therapeutic TABLE 27.2 Conditions associated with brain death 65
Products between the Governments of Australia and New
Zealand is in place. 15 Condition Incidence
The process of potential donor identification and manage- Hypotension 81%
ment in critical care is directed by the Australian and New Diabetes insipidus 53%
13
Zealand Intensive Care Society (ANZICS). Education
of health professionals is facilitated by the Australasian Disseminated intravascular coagulation 28%
Donor Awareness Program (ADAPT), in association with Arrhythmias 27%
the Australian College of Critical Care Nurses (ACCCN)
and the College of Intensive Care Medicine (CICM). Cardiac arrest 25%
Pulmonary oedema 19%
Donor criteria and organ allocation is regulated by the
Transplantation Society of Australia and New Zealand Hypoxia 11%
(TSANZ). Donor and recipient data are collated by the Acidosis 11%
Australia and New Zealand Organ Donation Registry
(ANZOD Registry). Professional groups related to this
specialty area also cover both countries. The Australasian Table 27.2 lists the conditions commonly associated with
Transplant Coordinators Association (ATCA) is com- brain death. Irrespective of the degree of external support,
posed of clinicians working as donor and/or transplant cardiac standstill will occur in a matter of hours to days
coordinators, and the Transplant Nurses Association once brain death has occurred. 13,18
(TNA) is a specialty group for nurses working with trans-
plant recipients (see Online resources). Role of Designated Specialists
According to Australian law, senior medical staff eligible
IDENTIFICATION OF ORGAN AND to certify brain death using brain death criteria must be
TISSUE DONORS appointed by the governing body of their health insti-
tution, have relevant and recent experience, and not be
The four main factors that directly influence the number involved with transplant recipient selection. The most
of multi-organ donations are: common medical specialties appointed to the role are
intensivists, neurologists and neurosurgeons in metro-
1. incidence of brain death politan centres, and general surgeons or physicians in
2. identification of potential donors rural settings. 17
3. brain death confirmation and informed consent
for donation In New Zealand the role is not appointed although
4. donor management after brain death. medical staff confirming brain death must also act inde-
pendently; neither can be members of the transplant
BRAIN DEATH team, and both must be appropriately qualified and suit-
13
The incidence of brain death determines the size of the ably experienced in the care of such patients. The New
19
Zealand Code of Practice for Transplantation also rec-
potential organ donor pool. Diagnosis of brain death is ommends that the medical staff not be involved in treat-
now widely accepted, and most developed countries have ing the recipient of the organ to be removed, and one of
legislation governing the definition of death and the the doctors should be a specialist in charge of the clinical
retrieval of organs for transplant. In Australia and New care of the patient.
16
Zealand the most common cause of brain death has
changed from traumatic head injury to cerebrovascular Testing Methods
accident, which has implications for the organs and
tissues retrieved as donors are older and often have car- The aim of testing for brain death is to determine irrever-
17
diovascular and other co-morbidities. There is no legal sible cessation of brain function. Testing does not dem-
requirement to confirm brain death if organs and tissues onstrate that every brain cell has died but that a point of
are not going to be retrieved for transplant. 13 irreversible ischaemic damage involving cessation of the
vital functions of the brainstem has been reached. There
Two medical practitioners participate in determining are a number of steps in the process, the first being the
brain death; in Australia one must be a designated speci- observation period. An observation period of at least 4
alist. Brain death is observed clinically only when the hours from onset of observed no response is recom-
patient is supported with artificial ventilation, as the mended before the first set of testing commences, in the
respiratory reflex lost due to cerebral ischaemia will result context of a patient being mechanically ventilated with a
in respiratory and cardiac arrest. Artificial (mechanical) Glasgow Coma Scale score of three, non-reacting pupils,
ventilation maintains oxygen supply to the natural pace- absent cough and gag reflexes and no spontaneous res-
13
maker of the heart that functions independently of the piratory effort. The second step is to consider the pre-
central nervous system. Brain death results in hypoten- conditions (see Box 27.1). Once the observation period
sion due to loss of vasomotor control of the autonomic has passed (during which the patient receives ongoing
nervous system, loss of temperature regulation, reduction treatment) and the preconditions have been met, formal
in hormone activity and loss of all cranial nerve reflexes. testing can occur.

750 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E














Blood flow
ceases in
RICA








FIGURE 27.1 Brain death study: four-vessel cerebral
angiography. Frontal cranial view of contrast flow
in right internal cartoid artery (RICA). Blood flow
ceases at the carotid siphon. Conclusion: if blood
flow is shown to have ceased in all the vessels, there
is no functioning cerebrum/cerebellum. (Courtesy
St George Hospital Radiology Department, Sydney).



recommended observation period of at least 2 hours, the
BOX 27.1 Preconditions of brain tests are repeated to demonstrate irreversibility. 13
death testing 13 If the preconditions outlined in Box 27.1 cannot be veri-
fied, brain death can be confirmed using cerebral blood
l Known diagnosis of injury and coma is consistent with flow imaging to demonstrate absent blood flow to the
progression to brain death. brain, by either contrast angiography or radionuclide
l Exclude involvement of drugs. scanning. Contrast angiography can be performed by
l Exclude metabolic causes for coma (e.g. severe electrolyte direct injection of contrast into both carotid arteries and
or endocrine abnormalities). one or both of the vertebral arteries, or via the vena cava
l Exclude hypothermia (core temperature greater than 35°C). or aortic arch. Brain death is confirmed when there is no
l Systolic BP >80 mmHg. blood flow above the carotid siphon 13,20-22 (see Figure
l Confirm neuromuscular conduction.
27.1). A radionuclide scan is performed by administering
a bolus of short-acting isotope intravenously or by nebu-
liser while imaging the head using a gamma camera for
15 minutes. No intracranial uptake of isotope confirms
Practice tip absent blood flow to the brain 13,20-22 (see Figure 27.2).
When testing for corneal reflex, take care not to cause corneal If brain death is confirmed, the time of death is recorded
abrasion, which might preclude the cornea from being trans- as the time of certification of the testing result (i.e. at
planted if the patient is an eye donor. Invite the next of kin to the completion of the second set of clinical tests, or
observe the second set of clinical tests to assist their compre- the documentation of the results of the cerebral blood
hension of brain death. Assign a support person to be with flow scan). 13
the family to assist in explaining and interpreting the testing
process. 84 IDENTIFICATION OF A POTENTIAL
MULTIORGAN DONOR
The second factor influencing the number of actual organ
Formal testing for brain death is undertaken using either donors is identification of a potential donor. A potential
13
clinical assessment or cerebral blood flow studies. Clini- donor is defined in this situation as a patient who is
cal assessment of the brainstem, involving assessment of suspected of, or is confirmed as, being brain dead. Inclu-
the cranial nerves and the respiratory centre (see Table sion and exclusion criteria for organ and tissue donation
23
27.3) is the most common approach to testing. Brain are constantly being reviewed and refined. Advice can
death is confirmed if there is no reaction to stimulation be sought at any stage when considering the medical
of these reflexes, with the respiratory centre tested last and suitability of potential organ donors, 24 hours a day, 7
only if the other reflexes prove to be absent. If the patient days a week, from respective state and territory organ
demonstrates no response to the first set of tests, after a donation agencies (see Online resources).

Organ Donation and Transplantation 751



TABLE 27.3 Clinical brain death testing 13,38

Test Cranial nerves/neurological function Test technique Outcome
1. Response to Trigeminal V (sensory), Facial VII (motor) Stimulus within the cranial nerve If reflex is absent, the patient
painful stimuli distribution (e.g. firm pressure over will not grimace or react.
supraorbital region)
2. Pupillary response Optic II, Oculomotor III Using torch If reflex is absent, the pupils
to light are fixed: may or may not be
dilated.
3. Corneal reflex Trigeminal V (sensory), Facial VII (motor) Using wisp of cotton wool to touch the If the reflex is absent, the eyes
cornea will not react or blink.
4. Gag reflex Glossopharyngeal IX, Vagus X Using a tongue depressor on the If reflex is absent, there is no
oropharynx or moving ETT gag or pharyngeal response.
5. Cough reflex Glossopharyngeal IX, Vagus X Using suction catheter down ETT to If reflex is absent, there is no
deliberately stimulate the carina cough response.
6. Oculovestibular Vestibulocochlear VII, Oculomotor III, Checking first that both tympanic If reflex is absent, the eyes
reflex Abducens VI membranes are intact or not remain fixed rather than
obstructed; then slowly irrigating both deviating towards the
ears with 50 mL iced water while eyes stimulus.
are held open
7. Apnoea test Medullar respiratory centre Last test to be performed when all other The period of time
reflexes have proven to be absent. disconnected from the
The patient is preoxygenated on 100% ventilator must be long
O 2 , an ABG analysis is performed to enough for the arterial
ascertain the baseline CO 2 , then carbon monoxide level to
the patient is disconnected from rise to a threshold high
mechanical ventilation but supplied enough to normally
with oxygen via catheter or T piece; stimulate respiration, i.e. an
the patient is observed for signs of arterial CO 2 >60 mmHg and
respiratory effort an arterial pH of <7.30.
8. Oculocephalic Ocular function and internuclear pathway Although not a formal component of If the reflex is absent, the eyes
reflex (doll’s eyes) in brainstem for Cranial Nerves III, IV, VI; brain death testing, this reflex may be will move with the head and
labyrinthine semicircular canals, otoliths tested as routine practice. The test must do not move within their
and neck muscle proprioceptors not be performed if an unstable orbit, indicating significant
cervical spine is suspected. Holding the brainstem injury.
eyes open, rotate the head from side to
side, observing the position of the eyes.







No blood
flow beyond
carotid
arteries









FIGURE 27.2 Brain death study: cerebral perfusion HMPAO scan. Transverse, sagittal and coronal views. No uptake is seen within the cranial vault in the
cerebrum or cerebellum. Blood flow is present in the sagittal and coronal views only to the carotid siphon. Conclusion: there is no functioning cerebrum/
cerebellum within the cranial vault. (Courtesy St George Hospital Nuclear Medicine Department, Sydney).

Seeking Consent next of kin after death has been confirmed. 13,24 Approach-
The third factor influencing the number of donors is the ing the next of kin to seek consent is part of the duty of
consent-seeking process. Common practice in Australia care to patients who may have indicated their wish to be
and New Zealand is for the treating medical staff either a donor at the time of their death. 13,25,26 The act of offering
to initiate or at least to be involved in approaching the the option of organ donation can also be considered part

752 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

13
of the duty of care to the family. This view is supported move to the bad news – the reality of the surgical inter-
by a survey of donor families, who indicated that they vention and the lack of guarantee that the organs will be
45
were grateful to have been provided with the option. 27,28,31 transplanted. Of note, a best practice approach aims to
Three elements are involved when approaching a family assist the family to make the decision that is ‘right’ for
regarding the option of organ donation: them and does not necessarily result in gaining consent.
1. their knowledge, beliefs and attitudes Meetings with the family
2. their in-hospital experience 29
3. any beliefs and biases of health professional/s con- The timing, location, content and process of discussions
ducting the approach. 30 with the family are all important considerations. An
effective protocol for communicating with the family of
The outcome of an approach cannot be predicted or potential donor must include: (1) frequent and honest
anticipated, as it may affect the ‘spirit’ in which the app- updates on the patient’s prognosis; (2) clear explanation
roach is made; a large US study demonstrated that clinical of brain death; (3) the option of organ donation not
staff were incorrect 50% of the time when asked to predict raised until the family accepts that the patient is dead;
the response of a next of kin. 31 (4) conversations held in a private and quiet setting; 32,47-50
and (5) involvement of an organ donation professional
Influence of knowledge, beliefs and attitudes with a clear definition of roles. 32
Attitudes to organ donation are influenced by spiritual There is compelling evidence that the meeting confirming
beliefs, cultural background, prior knowledge about diagnosis of brain death should be held separately or
organ donation, views on altruism and prior health expe- decoupled from the conversation about the option of
32
riences. Next of kin consider two aspects associated with organ and tissue donation. 31,34,47-50 In reality, the pace and
existing attitudes and knowledge: the decision maker(s)’ flow of discussions should be assessed on a case-by-case
own thoughts and feelings; and the previous wishes and basis, as there may be circumstances when the discussion
beliefs of the person on whose behalf they are making about organ donation is appropriately held prior to the
the decision. There is evidence of a link between consent confirmation of death. 13,25,46
rates and prior knowledge of the positive outcomes of
organ donation. 33,34 Three other influential components of this process come
from surveys completed with donor and non-donor
Delivery of relevant information families:
An important consideration for all health professionals 1. Use of inappropriate terms like ‘harvest’ to name
is that family members may have a diminished ability to the organ retrieval surgery (this is considered
receive and understand information because of their extremely harsh and undignified) and ‘life support’
stress and psychological responses at this time of family to name the ventilator (this could perpetuate the
crisis. 35,36 As interviews held with the family are the hope of a chance of survival or recovery). 13,26,36,41,51
foundation of the entire organ donation and transplant 2. Attire of the personnel involved: staff wearing sur-
process, the discussion about brain death must be clear gical scrubs or plastic aprons made families wonder
37
and emphatic, using language free of medical termino- what was being done to their relatives that required
logy, and include an explanation of the physical implica- health professionals to be wearing such clothing;
tions. 38,39 Diagrams, analogies, scans and written materials and donor coordinators not wearing uniforms
have been suggested as useful aids for enhancing under- were easier to speak to. 41
standing by next of kin. 25,40,41 One approach was to 3. Timing or use of the information from consent
describe brain death as like a jigsaw puzzle with a piece indicator sources like organ donor registers and
missing, to illustrate the relationship of the brain to the the driver’s licence. If staff come to the discussion
41
rest of the body. Opportunities for staff to train and ‘armed’ with this information, it could be seen as
role-play this scenario with programs like ADAPT (see coercive and disrespectful, so some caution and
Online resources) improves the likelihood of meeting the discretion about the introduction and use of this
needs of families. 38,42-44 information is recommended. 41
As the time of confirmation of brain death is the person’s
legal time of death, a discussion is held with the family Staff roles, delineation and involvement
to discuss their options and associated implications. Staff involved in the explanation of brain death must
Options are to: (1) cease ventilation and allow cardiac have a clear understanding of brain death themselves
49
standstill to occur; or (2) maintain ventilation and before attempting to explain it to a family. The process
haemo dynamic support to facilitate viable organ and of organ and tissue donation in critical care is significant
tissue donation. The retrieval process must be fully for all concerned. When death is confirmed it marks
explained to ensure an informed decision, but not to the end of an episode that has been catastrophic for
overload the next of kin. 25,45 Table 27.4 lists some aspects both patient and loved ones, and a potentially stressful
of the organ donation process that could be included in and exhausting experience for staff. 40,52-55 Approaching a
such a discussion. As information given to a family con- potential donor family is a multidisciplinary team effort,
tains both good news and bad news it is suggested to start and guidelines encourage treating medical staff to con-
with the good news – the benefits of donation, the right tinue their involvement with patient and family after
13
of the family to refuse consent, and the lack of cost; then brain death is confirmed, for continuity of care. Nursing

Organ Donation and Transplantation 753



TABLE 27.4 Information about the organ donation process and retrieval to assist in informed decision making 85

Decision Issues
Ensure that the next of kin (NOK) have l brain death
understanding of: l time of death
l eventual organ failure if kept ventilated in critical care
l the two options: to immediately cease ventilation or organ donation
If they choose to donate: l They will not be with the donor at time of cardiac arrest.
l Donor will remain in critical care, monitored and ventilated until going to theatre for retrieval.
l Explain the organ retrieval surgery, including the presence of an anaesthetist to monitor the
haemodynamics and ventilation. Explain to the family that the person no longer feels any pain, so
an anaesthetic is not given.
l Discuss which organs and tissue would be potentially medically suitable for retrieval for transplant.
l NOK can give specific consent; they are not obliged to grant global consent.
l Only named organs and tissues with consent are retrieved.
l Advise expected length of process.
l Explain reason for bloods being taken and stored.
l Advise that a coordinator will be present through the entire process.
l Explain how the donor will look after the retrieval.
l Organ donation will not delay funeral plans.
l Explain consent form.
l Provide copy of consent form.
l Explain privacy implications of Human Tissue Act, for donor family and transplant recipients.
l Explain reasons why donation may not proceed.
l Explain that organs may be transplanted interstate.
l In the event of an abnormality/diseases, organs will not be retrieved.
l Explain consent for research: offer copy of research page.
l The site designated officer will also sign the consent form.
If coroner’s case: l Coroner’s consent required.
l Police identification required.
l Autopsy? Brain retrieval?
l Deceased will go to the coroner’s mortuary after retrieval.
l Explain contact with coroner’s court.
If organs are retrieved and not able to l Offer options. Will be returned and placed with donor, or disposed of as medical waste.
be transplanted:
Support services: l Offer viewing of patient or a telephone call after the retrieval.
l Offer lock of hair and/or handprint.
l Provide contact details of coordinator.
l Provide printed information.
l Explain other support services available.
Follow-up information l outcome of retrieval
l recipient outcomes
l written material and letters
l availability of transplant coordinator to answer questions



staff involvement in the process of organ and tissue dona-
tion is central and intrinsic, including the practicalities of Practice tip
the process, and care of the potential donor and family
56
during the decision-making process. Donor families The multidisciplinary team involved in the process of organ
have identified nurses as being the most helpful health donation is not limited to staff within the ICU. In order for the
professionals in providing information and emotional donor’s wishes to become a reality and provide organ and
support. 13,27,51,57 tissues for transplantation the following disciplines are
involved: 1
A holistic approach to supporting families in critical care l Medical
also includes involvement of social workers and pastoral l Nursing
care workers and other allied health professionals. Often l Allied health
these health professionals have been working with the l Pastoral care
family for a number of days and act as confidants and a l Operational services
resource for information on issues such as implications l Administration
of a coronial enquiry and a religious denomination’s l Police service
stance on organ donation. Most major religions are sup- l Coroner’s and magistrate’s office
portive of organ and tissue donation for transplant and l Designated officer
would instruct the family to make the decision that they
felt was correct. 1,58

754 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

Donatelife Organ donor coordinator Role of Designated Officers
The ‘Donatelife’ organ donor coordinator acts as a Under Australian law, a ‘designated officer’ is appointed
resource and is invited into critical care when appro- by the governing body of the institution to authorise a
priate. 1,58 A professional who is an expert in donation non-coronial postmortem and the removal of tissue from
and has the time to spend with the family may be the a deceased person for transplant or other therapeutic,
best person to undertake an approach to a potential medical or scientific purposes. The designated officer
13
49
donor family. A large US study found that consent rates must be satisfied that all necessary inquiries have been
improved when conversations about brain death and made and any necessary consent has been obtained
organ donation were separated, were held in a private before granting authority. Medical, nursing and adminis-
setting and when an organ donation professional/trained trative staff can be appointed to the role, but they must
requestor was involved. 48 not act in a case if they have had clinical or personal
involvement in the donor’s case. 13
DOCUMENTATION OF CONSENT The term ‘designated officer’ is not used in New Zealand
Consent is sought for individual organs and tissues, legislation. A person with equivalent authority under the
rather than making a ‘global’ approach. If granted, the Human Tissue Act 2008 is the person lawfully in posses-
individual tissues are written on the consent form or sion of the body. In the case of a hospital, this person
59
named if the consent is being recorded over the tele- is specified as the medical officer in charge. In practice,
13
phone; only those tissues granted will be retrieved. the treating clinician undertakes this consultation with
the family.
Definition of Next of Kin
In Australia the definition of next of kin for adults and Role of Coroner and Forensic Pathologists
children is listed in strict order (see Table 27.5). In New
Zealand there is no hierarchy of next of kin, with the Because of the nature of their death, many donors are
definition including a surviving spouse or relative. In subject to coronial inquiry. In this case, permission to
13
both countries, the next of kin can override the known undertake organ and tissue retrieval is sought from the
wishes of the deceased regarding consent, but experience respective forensic pathologist and coroner according to
shows that the family rarely disagree if the wishes of the local policy and procedure as part of the consent-seeking
deceased are known. 13 process. The coronial system is very supportive of dona-
tion for transplant, and in 2009, 43% of the Australian
and 44% of New Zealand multiorgan donors were
coroner’s cases. 17
TABLE 27.5 Definition of next of kin for children and
adults in Australian legislation 13 CONSENT INDICATOR DATABASES
Donor Order of seniority Relationship The most influential variable that an individual may
have on family unit decision-making is the existence
Child 1 Parent of an advance care directive or prior indication of
2 Adult sibling (over 18 years) consent, as this information has made decision-making
‘easier’ 60,61 and preserved patient autonomy, 50,62 enabling
3 Guardian (immediately before
death) wishes of the patient to be followed even when family
decision makers would have made the opposite deci-
Adult 1 Spouse or de facto (at time of sion. Conversely, if the family members were opposed
death)
to donation despite the presence of an indication of
2 Adult offspring (over 18 years) consent from the potential donor, the retrieval would
40
3 Parent not occur on ethical grounds. Table 27.6 lists prospec-
tive donation databases available in Australia and New
4 Adult sibling (over 18 years)
Zealand.




TABLE 27.6 Consent indicator databases in Australia and New Zealand 8,65,66,86
Country Database name Host Access to database information Availability to join
Australia Australian Organ Medicare Australia Limited to coordinators nominated by state Via Medicare offices, internet
Donor Register Donatelife agencies and tissue banks or phone (1800 777 203)
Driver’s licence State roads & transport Limited to coordinators nominated by state Driver’s licence application and
authorities donation agencies and tissue banks renewal form
New Zealand Driver’s licence Land Transport New Limited to coordinators nominated by the Driver’s licence application and
Zealand database National Transplant Donor Coordination Office renewal form

Organ Donation and Transplantation 755

CULTURAL COMPETENCE
With large cultural mixes in the Australian and New TABLE 27.7 ATCA referral information 58,76,87
Zealand populations, best practice for approaching a
family includes openness and awareness of what Section Details
information the family member(s) may need to make Personal details Address, phone number, sex, age,
their decision. As significant differences also exist within height, weight, race, religion, build,
various cultural groups, expectations of responses cannot occupation
be stereotyped. When healthcare professionals are unsure Current admission details Dates and time of hospital admission,
of how a family may perceive a situation it is best to ask, intubation, critical care admission
as acknowledgment of expectations and needs can lead Other trauma or significant event
63
to improved communication. Importantly, the most sig- Declaration of brain death Cause of death, time, date, method
nificant differences between potential donor families are of testing
socioeconomic and educational factors, rather than cul- Consent details Which organs, designated officer
tural or racial background. Therefore, individual assess- details, coroner’s details, police
64
ment must guide the approach by health professionals. details, who gave consent, which
databases accessed
ORGAN DONOR CARE Donor history Family, medical, surgical, travel, social
and sexual history
Time is critical in the management of a potential organ Blood results Blood group, biochemistry and
donor. Those patients who have sustained traumatic haematology on admission and
brain injuries deteriorate rapidly following brain death, within past 12 hours, microbiology,
exhibiting severe physiological instability requiring vigi- gas exchange
lant monitoring and specialised treatment to maintain Test results Chest X-ray including lung field
organ perfusion. This is a time of great distress for fami- measurements, ECG,
lies with the patient’s death usually the result of a sudden, echocardiogram, bronchoscopy,
unexpected illness or injury and therefore discussion sur- sputum
rounding organ and tissue donation must be undertaken Haemodynamics BP, MAP, HR, CVP, temperature
in a sensitive manner by skilled requestors who possess Admission history Cardiac arrest, temperature, renal
a strong professional commitment to the quality of the function, nutrition, drug and fluid
process. 13,36 administration
Ideally, the time between brain death and organ retrieval Physical examination Scars, trauma, needle marks, etc.
should be minimised to ensure an optimal outcome for
transplant recipients. Therefore the focus of medical man-
agement changes from ensuring brain perfusion to main-
36
taining good organ perfusion for transplantation. Early
referral, application of recognised management protocols Practice tip
and collaboration between the donation centre and
retrieval teams is paramount. Donor family care forms a All brain dead patients should be referred to the relevant
crucial part of the process, with up-to-date and accurate State DonateLife agency for advice regarding medical suita-
information essential to ensure the bereavement process bility. Contacting the State DonateLife agency for advice does
is managed appropriately. not constitute an obligation or formal referral for organ
donation. 58
REFERRAL OF POTENTIAL DONOR
If consent is granted, the referral process usually com-
mences immediately. To ensure organ viability for trans- TISSUE TYPING AND CROSS-MATCHING
plant, the time from brain death confirmation to retrieval
of organs is kept to a minimum. The longer the time delay, A vital component of the assessment and referral process
the more likely that organ failure-related complications is tissue typing, cross-matching and virology testing of the
will occur. In 2009, the median time from brain death potential donor’s blood. Blood is taken from an arterial
65
confirmation to the commencement of organ retrieval or central line of the potential donor and sent to the
was 16 hours in Australia and 12 hours in New Zealand. 17 relevant accredited laboratory (see Table 27.8). Tissue
typing identifies the human leucocyte antigen (HLA)
The referral process begins with the donor coordinator phenotype from the genes on chromosome 6. The HLA
collating the past and present medical, surgical and social molecules control actions of the immune system to
history of the potential donor, and relaying this infor- differentiate between ‘self ’ and foreign tissue, and initiate
mation to the relevant transplant units (see Table 27.7). an immune response to foreign matter. As a transplanted
Using this information, transplant teams allocate the organ will always be identified as foreign tissue by the
organs to the most suitable and appropriate recipient/s. recipient’s body, the use of immunosuppressive drugs
If the transplant team does not have a suitable recipient, suppress the immune response. A crossmatch is routinely
the offer is extended to another team in Australia or New used to predict the level of this response. Lymphocytes
Zealand on rotation using TSANZ guidelines. 23 from the potential donor are added to the potential

756 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E



TABLE 27.8 Blood tests required for organ BOX 27.2 Medical management of
donation 58,72,87,88,89 the potential donor 76

Measurement required Test Referral:
l Refer all potential organ donors to the local State DonateLife
Serology l HIV I and II
l HTLV 1 antibody agency, even if uncertain of medical suitability. Criteria for
l Hepatitis B sAg suitability change over time and vary according to recipient
l Hepatitis B sAb circumstances.
l Hepatitis B Core Ab
l Hepatitis C sAb Medical management:
l CMV (IgG) l Maintain MAP > 70 mmHg: maintain euvolaemia, if required
l EBV (excluding NSW) administer inotropic agents (e.g. noradrenaline)
l Syphilis (excluding SA) l Maintain adequate organ perfusion (monitor urine output,
l Toxoplasma IgG and IgM (SA, NT
and WA only) lactate), consider invasive haemodynamic monitoring
+
+
l HSV (WA only) l Monitor electrolytes (Na , K ) every 2 to 4 hours and correct
to normal range
NAT screen (nucleic This is not routinely performed on
acid test) all donors. Testing is currently l Suspected diabetes insipidus (UO >200 mL/h, rising serum
only available through the sodium): administer DDAVP (e.g. 4 mcg IV in adults) and
Australian Red Cross Blood replace volume loss with 5% dextrose
Service. The State Donatelife l Treat hyperglycaemia (actrapid infusion): aim blood glucose
Coordinator facilitates the
process. 5 to 8 mmol/L
l HIV NAT Screen (VIC and NSW l Keep temp >35°C. Pre-emptive use of warming blankets
routinely test) etc is advised as hypothermia may be difficult to reverse
l HCV NAT Screen (VIC and NSW once it has developed
routinely test) l Provide ongoing respiratory care (frequent suctioning,
Tissue typing Crossmatching with the blood of positioning/turning, PEEP, recruitment manoeuvres)
potential recipients of relevant l Maintain haemoglobin >80 g/L
ABO
Hormone replacement therapy:
The use of hormonal replacement therapy remains controver-
sial. Some centres use it in the setting of persistent haemody-
recipient’s serum to test whether the recipient has an namic instability (despite volume resuscitation and low dose
antibody that is specific to the donor’s HLA antigens. inotropes) and/or if cardiac ejection fraction <45%. Typical regi-
A positive crossmatch reaction, where the recipient’s mens include:
serum destroys the donor’s cells, is a contraindication l triiodothyronine (T3): 4 mcg IV bolus, then 3 mcg/h by IV
for transplantation. 58 infusion
l arginine vasopressin (AVP): 0.5 to 4.0 U/h to maintain MAP
DONOR MANAGEMENT 70 mmHg
The fourth factor influencing the number of actual organ l methylprednisolone: 15 mg/kg IV single bolus.
donors is the clinical management that the donor and
family receive after confirmation of death. The aim of
donor management is to support and optimise organ
function until organ retrieval commences, while main- will bring most of their specialised equipment with them.
taining dignity and respect for the donor and support for An anaesthetist monitors haemodynamics, ventilation
the family. All aspects of ICU treatment, apart from brain- and administers medications, which may include a long-
oriented therapy, should continue until it is certain that acting muscle relaxant given prior to the surgical proce-
13
organ donation will not occur. Ideal parameters for dure, to prevent interference in the surgical process by
biochemistry, vital signs, and urine output and clinical spinal reflexes, only after consultation with the retrieval
58
management are detailed in Box 27.2. team. No other anaesthetic agents are administered. The
local scrub staff will work with the visiting surgical teams,
RETRIEVAL SURGERY and the Donatelife donor coordinator will be present
Organ retrieval surgery occurs in the hospital where the to document the procedure and outcomes, and act as
resource for all staff present.
donor is located, with the local operating theatre staff
integral to the process. The donor is transferred to theatre Surgery may take 4–5 hours depending on the extent of
after routine preoperative checks and documentation is the retrieval; cross-clamp will occur once the surgeons
completed, including death certification and consent for have identified all the various anatomical points. The
organ and tissue retrieval. All documentation, particu- aorta is cross-clamped with vascular clamps below the
larly consent, is viewed by all members of the retrieval diaphragm and at the aortic arch, the heart is stopped and
surgical team before surgery commences. Depending on ventilation is ceased. Retrieval teams administer a cold
which organs are to be retrieved, the retrieval teams will perfusion fluid with an electrolyte mix specific to the
be tasked to abdominal organs and thoracic organs, and organs being retrieved, and remove the organs. Organs

Organ Donation and Transplantation 757

are bagged with sterile ice and perfusion fluid and trans- time, whether or not the potential donor proceeds to
ported by the retrieval teams to the transplanting hospi- donation. 1
tals. The donor’s surgical wound, from the sternal notch
to the pubis, is closed by the surgeons in a routine manner DONATION AFTER CARDIAC DEATH
and dressed with a surgical dressing. If the donor is not
a coroner’s case, the remaining lines, catheter and drains Donation after cardiac death (DCD) (also known as non-
are removed according to local policy, the patient is heart-beating donor [NHBD]) provides a solid organ
washed, and arrangements are made to transfer the donation option for a patient who has not progressed
patient to a location for family viewing or to the mor- and is not likely to progress to brain death. Prior to brain
tuary. Musculoskeletal tissue and retinal retrieval can death legislation, donation after cardiac death was the
occur after the solid organ retrieval in theatre or later in source of cadaveric kidneys for transplant. 69,70 Four cate-
the mortuary. 66,67 gories of potential DCD donors have been identified
(known as the Holland–Maastricht categories): 71,72
DONOR FAMILY CARE 1. dead on arrival (uncontrolled)
Supportive care of a donor family begins from the time 2. failed resuscitation (uncontrolled)
their family member is admitted to hospital and contin- 3. withdrawal of support (controlled)
ues beyond organ retrieval. In addition to personal factors 4. arrest following brain death (uncontrolled).
such as cultural background, family dynamics, coping DCD programs around the world are being re-established,
skills and prior experiences with loss that may influence with successful retrieval and transplant of kidneys, livers
the grieving process, the family of an organ and tissue and lungs. The Australian Organ and Tissue Authority
69
donor will be dealing with a number of unique factors. has developed a national DCD protocol that outlines an
Death of their family member was possibly sudden and ethical process that respects the rights of the patient and
unexpected; brain death can be difficult to understand ensures clinical consistency, effectiveness and safety for
when people look as if they are asleep rather than dead; both donors and recipients. Since 2005 there has been a
1
having the option of organ donation may mean making steady increase in DCD donors each year, particularly in
a decision on behalf of the person if his/her wishes were New South Wales, Victoria, Queensland and South Aus-
not known; and the process of organ donation means tralia. Since 1989 there have been 131 donors in Australia
they will not be with the person when their heart stops. 68 17
and six donors in New Zealand. The first multiorgan
DCD was performed in South Australia in 2006.

IDENTIFICATION OF A POTENTIAL
Practice tip DCD DONOR
An opportunity for staff debriefing or operational reviews of Using lessons learnt from multiorgan donor programs,
the donation and retrieval process is important, particularly in the aims of a successful DCD program are to maintain
regional or rural settings where cases may be infrequent and dignity for the donor at all times, provide the donor
the community is smaller. family with support and information, and limit warm
ischaemia time (time from withdrawal of ventilation
and treatment to confirmation of death to commence-
ment of infusion of cold perfusion fluid and/or organ
Donor families benefit from emotional and physical retrieval). Longer warm ischaemia time potentiates the
support throughout and after the organ donation process. risk of irreparable hypoxic damage to the organ. As
73
In critical care units, this support can include open visit- noted above, Maastricht category 3 is the only option that
ing times, privacy for meetings, clear and precise infor- can be controlled and possibly regulate warm ischaemia
mation and regular contact with the attending clinical time. A potential category 3 DCD donor is a person ven-
team and the Donatelife donor coordinator. After organ tilated and monitored in critical care about whom a deci-
retrieval, ongoing care can include contact with a bereave- sion has already made that further treatment is no longer
ment specialist, written material, telephone support, of benefit, and current interventions are to be withdrawn.
private or group counselling, and correspondence from Clinical suitability assessment for organ retrieval repli-
66
recipients. Most Australian and New Zealand organ cates a multiorgan donor, with medical, surgical and
donation agencies have cost-free structured aftercare and social history, virology and organ function information
follow-up programs with these features (see Online collected. Legal requirements of the consent-seeking
resources). Involvement of trained personnel with a donor process also reflect those of a multiorgan donor. Potential
family through this process can positively influence the donor families are informed that retrieval may not occur
family’s grief journey. 51 due to a number of factors, including the length of time
from treatment withdrawal to cardiac standstill. 73,74
The National Donor Family Support Service operates
through the DonateLife Network and is a nationally con-
sistent program of support that provides cadaveric organ RETRIEVAL PROCESS ALTERNATIVES
and/or tissue donor families. All families whose next of Withdrawal of treatment for a potential category 3 DCD
kin are identified as possible donors are offered end-of- patient can occur in critical care or in the operating
life support including bereavement counselling at the theatre, depending on which organs are planned for

758 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

retrieval. Death is determined by cessation of circula- with eye caps. 77,78 Support requirements for families of
tion, with recommendations that the ECG is not moni- tissue-only donors share many aspects of programs
tored (electrical activity can persist for many minutes provided for families of multi-organ donors. A sensitive
following cessation of circulation), but an arterial line approach, provision of adequate information to assist
is used to determine the time of cessation of circula- informed decision making, offers of bereavement
13
tion. If withdrawal occurs in critical care, an intraab- counselling and follow-up information of recipient
dominal catheter may be inserted via the femoral artery outcomes are evidence-based strategies of successful
after cardiac standstill to infuse cold perfusion fluid programs. 1,79
into the abdominal cavity. If the lungs are to be retrieved,
perfusion fluid is infused via bilateral intercostal cath-
69
eters. The patient is then transferred to theatre for SUMMARY
organ retrieval. When withdrawal of treatment occurs
in theatre, a catheter is not required and retrieval may Australia and New Zealand have an opt-in system of
commence after the patient is declared deceased (ces- giving consent for organ and tissue donation. After death
sation of circulation for greater than two minutes). If has been confirmed, the option of organ and tissue
the patient does not die during the window of time donation is given to the next of kin, or information
available for organ retrieval, they are transferred back from a consent indicator database is sought to determine
to ICU. 74 the wishes of the person. Each person is assessed on a
case-by-case basis to determine medical suitability for
organ and tissue retrieval for transplant. The treating
TISSUE-ONLY DONOR clinicians are not expected to make this decision and
their involvement and care is vital. Support and informa-
People confirmed as dead using cardiac criteria can be
tissue donors. Eyes (whole and corneal button) are tion is available around the clock from the respective
retrieved for cornea and sclera transplant. Musculo- donor agencies and tissue banks. Donor family care
skeletal tissue is used for bone grafting (long bones of commences at the time of the family member’s admis-
arms and legs, hemipelvis), urology procedures and treat- sion and continues as required with structured bereave-
ment of sport injuries (ligaments, tendons, fascia and ment programs specific to donor family care. In Australia
meniscus). Heart valves (bicuspid, tricuspid valves, aortic and New Zealand, consent to be an organ and tissue
and pulmonary tissue) are used for heart valve replace- donor can be indicated by people when alive or by the
ment and cardiac reconstruction. Skin (retrieved from the next of kin after death.
lower back and buttocks) is used for the treatment of There are three ‘types’ of organ or tissue donor:
burns. 75
1. multiorgan and tissue donor: after brain death has
been confirmed
IDENTIFICATION OF POTENTIAL 2. donor after cardiac death: controlled withdrawal
TISSUE-ONLY DONOR of treatment in critical care/operating suite
The most influential aspect for tissue donation is early 3. tissue-only donor: after cardiac death.
notification of the potential donor’s death to the relevant Four factors directly influence the number of multiorgan
tissue bank, ideally within hours of the person’s death. donations:
All deceased persons can be considered potential donors,
with assessment for clinical suitability on a case-by-case 1. incidence of brain death
basis. As noted earlier, there is no expectation that treat- 2. identification of potential donors
ing clinicians will be required to make that decision or 3. brain death confirmation and informed consent
make the approach to the next of kin. In general, once for donation
the death notification has been received, the determining 4. donor management after brain death.
factors are age, cause of death, time elapsed since death, There is evidence in the literature to address and guide
virology results, and presence of infection. The legal each factor, but each needs to be approached on a case-
requirements of the consent-seeking process mirror those by-case basis:
of the multiorgan donor.
l Medical suitability for every potential donor is
After checking medical suitability and the relevant asse ssed individually at the time of the person’s
consent indicator database, a coordinator from the tissue death.
bank or other trained personnel approach the next l Support and guidance from donor agencies and tissue
of kin with the option of tissue retrieval. Eyes can be banks in Australia and New Zealand are available at
retrieved up to 12 hours, and heart valves, skin and all times.
bone up to 24 hours after death. Of note, eye donors l Care and support of the potential and actual donor
can be up to 99 years old, donors of heart valve up family is a high priority for all donor agencies and
76
to 60 years and musculo skeletal up to 90 years of age. tissue banks in Australia and New Zealand.
After tissue retrieval, every effort is made to restore l Regular, routine follow-up and debriefing oppor-
anatomical appearance. Wounds are sutured closed and tunities for critical care and operating theatre staff
covered with surgical dressings, limbs given back their are important to manage stress reactions or other
form, and eye shape is restored with the lids kept closed concerns.

Organ Donation and Transplantation 759



Case study
Day 1 Receiving regular physiotherapy treatments: change of position
Ms Wright, a 25-year-year-old woman, was found lying on the floor and suctioning.
of her bathroom in the early hours of the morning after falling Day 4
off a horse the previous day. She was admitted to a country 0400: Difficulty with ventilation: asynchronous breathing with
hospital via ambulance (and was able to walk to the ambulance). ventilator, bradycardic, systemic hypertension: Cushing’s response
On arrival at hospital her vital signs included: GCS 7–8, BP was queried as the cause. Sedation was increased, metoprolol and
165/85 mmHg, pulse rate (PR) 45, O 2 saturation 98%, spontaneous clonidine given with no effect; SNP was started to control the
movement of all limbs, no verbal response. Her weight was esti- marked hypertension, with a profound drop in BP; given metara-
mated at 65 kg. She was intubated and ventilated for a cerebral minol bolus and noradrenaline infusion commenced.
CT, which revealed extensive frontal contusions, skull fracture, SAH
and subdural with mass effect. She was retrieved to a metropolitan 0530: GCS 3 both pupils 5 mm and fixed, nil gag reflex or sponta-
hospital by air. neous breathing, sedation ceased, noradrenaline titrated to keep
MAP >60–80 mmHg, polyuric.
1345: On arrival, pupils are unequal and unreactive, sinus rhythm,
normotensive, GCS 3, morphine and midazolam infusion changed 0800: Morning round: probable brainstem failure noted after
to propofol. Taken immediately to theatre for bifrontal craniectomy sympathetic storm. Plan to perform set of brain death studies at
and insertion of an extraventricular drain (EVD). 1700, 24 hours after thiopentone ceased. Family conference: events
overnight discussed, probable brain death, and time planned to
1645: Admitted to critical care: intracranial pressure (ICP) 46, conduct tests. Organ donor coordinator contacted to notify of
pupils unequal, fully ventilated (SIMV, RR 20, Tv 400 mL, PEEP 5), potential donor.
sedated and paralysed, hypertensive: given stat dose of clonidine
with effect, sinus rhythm, febrile 39.5°C and active cooling 1200: Patient moved to side room for privacy, also enabling more
commenced. family members to visit at a time. Routine care including physi-
otherapy treatment continues. During this time, the family
2200: Thiopentone infusion commenced: low dose, pupils unequal broaches the subject of organ donation with the nursing staff and
and unreactive, ICP 30–35 mmHg, EVD opened when ICP social worker, who advise them that this will be discussed after
>25 mmHg. Cerebral perfusion pressure (CPP) 50–60 mmHg, brain death testing. DonateLife organ donor coordinator notified
systolic blood pressure (SBP) 120–145, mean arterial pressure of offer of organ donation by family, and asked by the medical staff
(MAP) >70 mmHg. to contact the coroner for permission to seek consent from the
Day 2 family.
0405: Clinical deterioration: ICP 44 mmHg, PR 60, BP 170/ 1430: Coroner grants permission for organ and tissue retrieval.
90 mmHg, taken for urgent CT scan: more extensive bifrontal
contusions, significant mass effect from frontal contusion. 1700: First set of brain death tests conducted: clinical brainstem
reflex testing performed by critical care senior registrar. All reflexes
0900: During morning medical round: GCS 3, no cough on suction, absent: PCO 2 64 mmHg after 10 minutes of apnoea.
pupils unequal and non-reactive, normothermic, good gas
exchange, paralysis ceased, low-dose thiopentone infusion 1750: Second set of brain death tests conducted: clinical
continues, mannitol, insulin infusion titrated for blood sugar level brainstem reflex testing performed by critical care consultant.
(BSL). Nasogastric tube (NGT) feeds commenced. Family All reflexes absent. Tests performed with family present at their
conference involving parents, intensivist, senior registrar, social request.
worker and nursing staff. Family is told that the head injury is 1800: Formal approach to family by critical care consultant to seek
life-threatening. consent for organ and tissue retrieval; family agrees.
2200: Left pupil 2 mm and reactive, right pupil 4 mm and non- 1830: Introduction of State DonateLife organ donor coordinator
reactive, spontaneous extensor response in upper limbs, GCS 5, to family to clarify consent and explain process. Blood collected
ICP 38 mmHg. Sedation increased. and sent for virology, tissue typing and cross-matching. Infor-
mation collected for referral. DonateLife organ donor coordinator
Day 3 provides written material to family which outlines process of
0830: ICP 45 mmHg, EVD open, left pupil reactive, right pupil donation, support and counselling options and grief and bereave-
non-reactive, normothermic, BP 145/75 mmHg, PR 72, strong ment information. Contact details are confirmed for follow up.
cough on suction, breathing spontaneously.
2000: Referral to transplant teams.
1600: Repeat head CT: unchanged, effaced ventricles, anterior
herniation through craniectomy, brainstem viable. CT neck: no 2015: Family completes formal identification with police for the
fracture. Thiopentone ceased. coroner.
1900: Family conference: prognosis noted as very poor, sub- 2100: Acceptance of offer by the transplant teams and identifi-
optimal neurological state with residual impairment at best, cation of potential recipients for heart, lungs, liver, kidneys and
progression to brain death a possibility. Sedation decreased. pancreas.

760 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E



Case study, Continued
2200: Family leaves the hospital to go home. Knowing that the 0630: The donor coordinator rings the next of kin to inform them
retrieval will commence in the early morning, they agree to that the retrieval has gone according to plan and promises to call
the offer by the DonateLife donor coordinator to phone them in again the following day with updates on the recipients’ progress.
the morning to confirm the outcome. Ongoing monitoring of
ventilation and haemodynamics, and care including physiotherapy Day 6
treatments.
1030: The donor coordinator contacts the transplant teams to find
Day 5 out the recipients’ progress and then phones the donor family and
0200: Retrieval commences; it takes 4 hours to retrieve the heart, the staff of critical care and the donor theatre suite. Letters detail-
lungs, liver, kidneys and pancreas. The liver is split intraoperatively ing this information are sent to the family and the staff of critical
for two recipients. care and theatre within days of the retrieval.








Research vignette
Flodén A, Forsberg A. A phenomenographic study of ICU-nurses’ achieving sample representation as for a quantitative study. There
perceptions of and attitudes to organ donation and care of poten- was no justification for the selection of 9 participants, with no
tial donors, Intensive and Critical Care Nursing 2009; 25(6), indication whether ‘data saturation’ had occurred after that
306–13. number of interviews. The interview and subsequent analysis was
Abstract clear and methodical. Participants were interviewed using open-
There is a lack of organs for transplantation and the number of ended questions, beginning with their associations to the words
potential organ donors is limited. Several studies indicate that the ‘organ donation’. Interviews were audiotaped and transcribed for
most crucial factor is the attitude to organ donation among data analysis. The timeframe of interviews was not stated. Analysis
intensive care staff. The aim of this study was to describe intensive of the interview data was performed in seven steps: familiarisa-
and critical care nurses’ (ICU-nurses) perceptions of organ donation tion, compilation, condensation, grouping, comparison, naming,
based on their experience of caring for potential organ donors. A and contrastive comparison. Transcripts and interpretation were
phenomenographic method was chosen. Nine nurses from three not returned to participants for member checking and trustwor-
different Swedish hospitals were interviewed. All were women; thiness of the analysis.
aged 36–53 years, with 3–27 years’ ICU experience. The analysis
revealed the crucial perception: ‘nothing must go wrong’. The analysis described three ‘parts’ to nurses’ perceptions of organ
donation, each with member ‘domains’: Situation (burden, respon-
The findings can be described in three parts: organ donation as a sibility, respect); Phenomenon (uncertainty and unease, success,
situation, organ donation as a phenomenon and different attitudes failure, holism, dignity); and differing Attitudes (alleviate suffering,
to organ donation. In conclusion: various perceptions adopted by duty of care to the living, remaining neutral, unpleasant process).
ICU nurses might influence the chances of a potential donor The findings were clearly articulated, with participant quotes used
becoming an actual donor. This study demonstrates that nurses to elaborate the identified issues.
who promote organ donation strive to fulfill the will of the poten-
tial donor by taking responsibility for the perception that ‘nothing The researchers provided recommendations for future research
must go wrong’. including identifying the prevalence of these same perceptions
Critique among a larger sample of Swedish ICU nurses, to inform the devel-
This small Swedish qualitative interview study was undertaken in opment of an education program for ICU nurses. A similar process
2006. The sample comprised nurses who had provided care for has been adopted by Australia and New Zealand critical care
potential organ donors that resulted or did not result in donation. nurses through the ADAPT workshops, which are targeted at
A phenomenographic method was used, and described appropri- medical, nursing, allied health professionals and those involved in
ately as an ‘exploration of the different ways people perceive expe- the support of families in critical care areas. ADAPT Workshops are
rience, assimilate … and understand different phenomena’; the facilitated by local experienced intensivists, donor family support
focus is on ‘explaining variations in perceptions’ (p. 307). coordinators, DonateLife education coordinators and qualified
bereavement consultants.
Participant selection varied between sites, but being a qualitative
study the focus was on seeking participants able to articulate Overall, this paper embraced the feeling of caring for the potential
their experiences and reflections on caring for organ donors, not organ donor and their family.

Organ Donation and Transplantation 761



Learning activities
The following learning activities relate to the case study. 5. Under which circumstances does the coroner need to be
1. What constitutes eligibility for organ donation? involved?
2. What methods are used to confirm brain death in Australia and 6. Will organ and tissue retrieval mutilate the body of the person?
New Zealand? 7. What is the time frame from identification of the donor to
3. What are the ideal observation parameters for a potential actual organ retrieval?
multi-organ donor after brain death confirmation? 8. What follow up is provided to the family of the donor?
4. Who is the legal next of kin in the consent process?





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56. Kiberd MC, Kiberd BA. Nursing attitudes towards organ donation, retrieve- on all potential donors. Transplant Nurses J 2002; 11(1): 15–16.
ment, and transplantation. Heart Lung 1992; 21(2): 106–11. 89. Rosendale JD, Kauffman HM, McBride MA, Chabalewski FL, Zaroff JG et al.
57. McCoy J, Argue PC. The role of critical care nurses in organ donation: a case Aggressive pharmacologic donor management results in more transplanted
study. Crit Care Nurse 1999; 19(2): 48–52. organs. Transplantation 2003; 75(4): 482–7.

APPENDIX A1 I. Preamble
DECLARATION OF MADRID: Critical or intensive care is a complex specialty developed
EDUCATION to serve the diverse healthcare needs of patients (and
their families) with actual or potential life-threatening
POSITION STATEMENT ON THE PROVISION OF conditions.
CRITICAL CARE NURSING EDUCATION – The role of the critical care nurse is essential to the
AUGUST 2005 multidisciplinary team needed to provide specialist
Introduction knowledge and skill when caring for critically ill patients.
At the 6th World Congress on Intensive Care and Critical The critical care nurse enhances delivery of a holistic,
Care Medicine in Madrid, Spain, 1993, the World Federa- patient-centred approach in a high-tech environment,
tion of Societies of Intensive Care and Critical Care Medi- bringing to the patient care team a unique combination
cine endorsed what has become known as the Declaration of knowledge and caring. In order to fulfil their role,
of Madrid on the Preparation of Critical Care Nurses. nurses require appropriate specialised knowledge and
skills not typically included in the basic nursing programs
In May 2003 the World Federation of Critical Care Nurses of most countries.
undertook a review of the Declaration of Madrid and
recommendations from the Australian College of Critical Government, professional and educational bodies gov-
Care Nurses’ position statement on critical care nursing erning the practice of nursing must recognise the impor-
education and other similar documents from member tance of dedicated specialised preparation for critical
associations. The current position statement aims to care nurses in order to assure the optimum healthcare
inform/assist critical care nursing associations, healthcare delivery of their community. This declaration presents
providers, educational facilities and other interested guidelines universally accepted by critical care profes-
parties in the development and provision of critical care sionals, which may be adapted to meet the educational
nursing education. and healthcare requirements of a particular country or
jurisdiction.
The first draft of this position statement was distributed
to member societies of the WFCCN between February II. Central Principles
2004 and September 2004 and changes made following
discussion and meeting of the WFCCN in Cambridge, 1. Critically ill patients and families have the right to
September 2004. receive individualised critical care from qualified
professional nurses.
The second draft of this position statement was distrib- 2. Critical care nurses must possess appropriate
uted to a wider audience including member societies knowledge, attributes and skills to effectively
of WFCCN, other international nursing and medicine respond to the needs of critically ill patients, to
organisations and individuals with an interest in critical the demands of society, and to the challenges of
care nursing between October 2004 and April 2005. advancing technology.
The third draft of this position statement was distributed 3. Where a basic nursing education program does not
to an ever-wider audience, again including member soci- include these required specialised knowledge, attri-
eties of WFCCN, other international nursing and medi- butes and skills, access to such further education
cine organisations and individuals with an interest in must be provided to nurses responsible for the care
critical care nursing between May 2005 and August 2005. of critically ill patients and their families.
4. Nurses with specialised knowledge and expertise
A full meeting of the World Federation of Critical Care in the provision of care to critically ill patients
Nurses on Saturday 27 August 2005 at the Sheraton should play an integral part in the education of
Hotel, Buenos Aires, Argentina, ratified this position critical care nurses, even when a multidisciplinary,
statement. educational approach is utilised.
5. The preparation of critical care nurses must be
based on the most current available information
and research.

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III. Recommendations for Critical Care 6. Close collaboration between the healthcare and
Nursing Education higher education sectors is important, in order
The World Federation of Critical Care Nurses believes that that post-registration critical care nursing educa-
critically ill patients have very special needs and must be tion be provided at a standard that meets the
cared for by nurses with specialist skills, knowledge and expectations of both sectors.
attitudes. 7. Graduates of post-registration courses in critical
care must be able to demonstrate clinical compe-
The following recommendations have been adopted tence as well as a sound theoretical knowledge
to represent universal principles to help guide health base. A strong emphasis on the application of
services, educational facilities and critical care nursing theory to practice, and the assessment of clinical
organisations in the development of appropriate educa- competence, should be an integral component of
tional programs for nurses who are required to care for post-registration critical care courses.
critically ill patients and their families: 8. The provision of appropriate clinical experience
to facilitate the development of clinical compe-
1. As a minimum, the critical care dimensions of the tence should be a collaborative responsibility
following topics should be included in programs between education and healthcare providers. Crit-
to prepare critical care nurses. The categories are ical care nursing students should have access to
not listed in order of importance. support and guidance from appropriately experi-
l Anatomy and physiology enced staff such as clinical teachers and nurse
l Pathophysiology preceptors.
l Pharmacology 9. Clinical teachers and nurse preceptors for post-
l Clinical assessment (including interpretation registration critical care nursing students should
of diagnostic and laboratory results) be appropriately supported in their role by both
l Illnesses and alterations of vital body education and healthcare providers.
functions 10. Critical care education providers should have in
l Plans of care and nursing interventions place policies and processes for recognition of
l Medical interventions and prescriptions with prior learning and alternative entry pathways
resulting nursing care responsibilities into formal post-registration specialist courses,
l Psychosocial aspects (including cultural and in order to create a more flexible yet consistent
spiritual needs) means for students to attain recognition of
l Technology applications competence.
l Patient and family education 11. Healthcare and higher education providers
l Legal and ethical issues need to establish strategies to help reduce the
l Professional nursing issues and roles in critical financial burden faced by nurses undertaking
care, including clinical teaching strategies, post-registration critical care courses.
team leadership and management issues 12. Education providers must implement educational
l Use of current research findings to deliver strategies to facilitate access to post-registration
evidence-based multidisciplinary care courses for critical care nurses from a range of
l Caring for the carer (including dealing with geographical locations.
stress and peer support) 13. Innovative strategies need to be implemented to
2. Programs preparing critical care nurses to func- address the deficit of qualified critical care nurses,
tion at a specialist level of practice should be rather than resorting to short training courses to
provided at a post-registration level and con- resolve the problem. Such strategies could include
ducted by a higher education provider (for comprehensive critical care workforce planning,
example, a university or equivalent provider). innovative retention strategies, refresher ‘train-
3. The curricula of critical care nursing post- ing’, professional development programs and the
registration courses must provide an appropriate provision of greater support for nurses under-
mix of theoretical and clinical experience, to taking post-registration critical care courses.
prepare nurses to meet the challenges of clinical 14. Providers of short critical care training courses
practice effectively. should seek credit transfer (recognition of prior
4. WFCCN recommends that national critical learning) within the higher education sector for
care nursing associations establish agreed Stan- nurses completing these courses.
dards for Specialist Critical Care Nursing to be
utilised as a framework for both critical care REFERENCES
curriculum development and assessment of clini-
cal practice. Australian College of Critical Care Nurses, Critical Care Nursing Education Advi-
sory Committee. Position statement on postgraduate critical care nursing edu-
5. Post-registration courses for critical care nurses cation—October 1999. Aust Critical Care 1999; 12(4): 160–4.
must provide a balance between clinically ori- World Federation of Societies of Intensive and Critical Care Medicine. Declaration
ented content and broader generic content that of Madrid on the Preparation of Critical Care Nurses. Aust Critical Care 1993;
enables the specialist nurse to contribute to the 6(2): 24.
profession through processes such as research, International Nursing Council. The global shortage of registered nurses: an over-
view of issues and actions (and accompanying issues, papers). Available from:
practice development and leadership. www.icn.ch/global/#3

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APPENDIX A2 Governments, hospital boards and professional bodies
DECLARATION OF BUENOS AIRES: that inform and support the provision of critical care
services must recognise the importance of providing ade-
WORKFORCE quately skilled, educated and available critical care nurses,
POSITION STATEMENT ON THE PROVISION doctors and other support staff to assure the health and
OF CRITICAL CARE NURSING WORKFORCE safety of some of the most vulnerable patients in the
healthcare system.
– AUGUST 2005
Introduction This declaration presents guidelines universally
accepted by critical care professionals, which may be
In May 2003 the World Federation of Critical Care adapted to meet the critical care nursing workforce
Nurses undertook a review of available national critical and system requirements of a particular country or
care nursing associations’ position statements on critical jurisdiction.
care nursing workforce requirements. The current posi-
tion statement aims to inform and assist critical care II. Central Principles
nursing associations, health services, governments and
other interested stakeholders in the development and 1. Every patient must be cared for in an environment
provision of appropriate critical care nursing workforce that best meets his or her individual needs. It is the
requirements. right of patients whose condition requires admis-
sion to a critical care unit to be cared for by regis-
The first draft of this position statement was distributed tered nurses. In addition the patient must have
to member societies of the WFCCN between February immediate access to a registered nurse with a post-
2004 and September 2004 and changes made following registration critical care nursing qualification
discussion and meeting of the WFCCN in Cambridge (see Appendix A1).
September 2004. 2. There should be congruence between the needs of
the patient and the skills, knowledge and attributes
The second draft of this position statement was
distributed to a wider audience including member of the nurse caring for the patient.
societies of WFCCN, other international nursing and 3. Unconscious and ventilated patients should have
medicine organisations and individuals with an interest a minimum of one nurse to one patient. High-
in critical care nursing between October 2004 and dependency patients in a critical care unit may
April 2005. have a lesser nurse : patient ratio. Some patients
receiving complex therapies in certain critical care
The third draft of this position statement was distributed environments may require more than one nurse to
to an ever-wider audience, again including member soci- one patient.
eties of WFCCN, other international nursing and medi- 4. When calculating nurse-to-patient ratios and roster
cine organisations and individuals with an interest in requirements in critical care, consideration and
critical care nursing between May 2005 and August 2005. care must be given to the skill sets and attributes
of nursing and support colleagues within the
A full meeting of the World Federation of Critical Care
Nurses on Saturday 27 August 2005 at the Sheraton nursing shift team, as they vary and require
Hotel, Buenos Aires, Argentina, ratified this position re-evaluation with fluctuations in patient care
statement. requirements.
5. Adequate nursing staff positions must also be in
I. Preamble place to assist with nursing education, in-service
training, quality assurance and research programs,
Critical or intensive care is a complex specialty developed management and leadership activities and, where
to serve the diverse healthcare needs of patients (and institutionally required, external liaison and
their families) with actual or potential life-threatening support services beyond the confines of the critical
conditions. care unit.
6. Critical care nurses should focus their labour on
Development of the nursing workforce within critical
care units requires careful planning and execution to roles and tasks that require advanced skill, exper-
ensure an appropriate balance and mix of staff skills and tise and knowledge of best practice in patient care.
attributes that allow for safe and effective care. In parallel Therefore, adequate numbers of support staff
is the provision of a learning environment for novice should be employed to preserve the talents of criti-
critical care nurses, a flexibility to respond to changes in cal care nurses for patient care and professional
demand and efficiencies to ensure economic sustain- responsibilities wherever possible.
ability without clinical compromise. 7. Flexible workforce strategies and incentives should
be employed by management to recruit, retain and
Critical care nursing workforce planning must be consid- remunerate expert critical care nurses at the patient
ered in the context of the total hospital requirement for bedside, and to ensure appropriate succession
access to critical care beds in addition to the regional planning for future leadership needs. Additionally,
requirement for integrated and accessible critical care ser- contingencies should be in place to respond to
vices across a number of hospitals and institutions in a fluctuating and unexpected demands on the criti-
population-defined health service. cal care service.

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III. Recommended Critical Care Nursing to assist with manual handling, cleaning and
Workforce Requirements domestic duty staff and other personnel exist to
As a minimum, the critical care unit should maintain allow nursing staff to focus on direct patient care
or strive to achieve the following nursing workforce and associated professional requirements.
requirements: 9. Appropriately skilled and qualified medical staff
are appointed and accessible to the unit for
1. Critically ill patients (clinically determined) decision making and advice at all times. A
require one registered nurse at all times. medical director is appointed to work collab-
2. High-dependency patients (clinically determined) oratively with the head nurse in order to provide
in a critical care unit require no less than one policy/protocol, direction and collaborative
registered nurse for two patients at all times. support.
3. Where necessary, extra registered nurses may 10. Remuneration levels for nursing staff are such
provide additional Assistance, Coordination, that they are competitive with similar professions
Contingency (for late admission, sick staff), Edu- in the country and are scaled in such a way as to
cation, Supervision and Support to a subset of reward and retain qualified, experienced and
patients and nurses in a critical care unit (some- senior critical care nurses.
times referred to as an ACCESS nurse). 11. Appropriate, accessible and functional levels
4. A critical care unit must have a dedicated head of equipment and technology are available
nurse (otherwise called charge nurse or similar) and maintained to meet the demands of the
to manage and lead the unit. This person must expected patient load at any given time, and
have a recognised post-registration critical care nursing staff are adequately trained and skilled
nursing qualification. It is also recommended that in the application of such equipment and
the head nurse/nurse in charge have management technology.
qualifications. 12. Adequate occupational health and safety regula-
5. Each shift must have a designated nurse in charge tions should be in place and enforced to protect
to deputise for the head nurse and to ensure nurses from hazards of manual handling and
direction and supervision of the unit activities occupational exposure.
throughout the shift. This person must have a 13. Organised and structured peer support and
recognised post-registration critical care nursing debriefing procedures are in place to ensure
qualification. nursing staff support and wellbeing following
6. A critical care unit must have a dedicated nurse critical incident exposure.
educator to provide education, training and
quality improvement activities for the unit nursing REFERENCES
staff. This person(s) must have a recognised post-
registration critical care nursing qualification. Australian College of Critical Care Nurses Position Statement on Intensive Care
7. Resources must be allocated to support nursing Nursing Staffing, Available from: www.acccn.com.au
time and costs associated with quality assurance British Association of Critical Care Nursing. Position Statement. Nurse–patient
ratios in critical care. Nursing in Critical Care 2001; 2: 59–63.
activities, nursing and team research initiatives, Williams GF, Clarke T. A consensus driven method to measure the required
education and attendance at seminars and number of intensive care nurses in Australia. Aust Critical Care 2001; 14(3):
conferences. 106–15.
8. Adequate support staff within the critical care International Nursing Council. The global shortage of registered nurses: an over-
view of issues and actions (and accompanying issues, papers). Available from:
area, including: administrative staff, support staff www.icn.ch/global/#3

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APPENDIX A3 Nurses are accountable for their own actions and inac-
DECLARATION OF MANILLA: tions in safeguarding human rights, while National
PATIENT RIGHTS Nurses Associations (NNAs) have a responsibility to par-
ticipate in the development of health and social legisla-
POSITION STATEMENT ON THE RIGHTS OF tion related to patient rights.
THE CRITICALLY ILL PATIENT – AUGUST 2007 Where nurses face a ‘dual loyalty’ involving conflict
Introduction between their professional duties and their obligations to
At the 1st World Federation of Critical Care Nurses their employer or other authority, the nurse’s primary
responsibility is to those who require care.
(WFCCN) meeting in Cambridge in 2004 the WFCCN
chose to develop a position statement on Rights of the
Critically Ill Patient. The existing situation was considered Nurses’ rights
and similar documents from other organisations were Nurses have the right to practice in accordance with the
examined. This was then discussed further at the 2nd nursing legislation of the country in which they work and
Congress of WFCCN in Buenos Aires, August 2005. to adopt the ICN Code of Ethics for Nurses or their own
national ethical code. They also have a right to practice
The current position statement aims to inform and assist
critical care nursing associations, health services, educa- in an environment that provides personal safety, freedom
tional facilities and other interested parties in the devel- from abuse and violence, threats or intimidation. Nurses
opment of patient’s rights for the critically ill. individually and collectively through their national
nurses associations have a duty to speak up when there
I. Preamble are violations of human rights, particularly those related
to access to essential health care and patient safety.
In 1948 the United Nations proclaimed the Universal Dec-
laration of Human Rights. The rights of individuals have National nurses’ associations need to ensure an effective
been proclaimed and expanded since then in many state- mechanism through which nurses can seek confidential
ments and nations. The specific rights in health care have advice, counsel, support and assistance in dealing with
been stated by many nations and some health care groups. difficult human rights situations.
Critical care nursing is specialised nursing care of criti-
cally ill patients who have manifest or potential distur- Background
bance of vital organ functions. Nurses deal with human rights issues daily, in all aspects
of their professional role. As such, they may be pressured
The World Federation of Critical Care Nurses (WFCCN) to apply their knowledge and skills in ways that are
has considered the rights of critically ill patients. WFCCN detrimental to patients and others. There is a need for
have agreed that the statement on patient’s rights from increased vigilance, and a requirement to be well
the International Council of Nurses (ICN) covers the informed, about how new technology and experimenta-
requirements for a position statement on the rights tion can violate human rights. Furthermore nurses are
of the critically ill patient. increasingly facing complex human rights issues, arising
The WFCCN accept and support the ICN position state- from conflict situations within jurisdictions, political
ment on Nurses and Human Rights reproduced below. upheaval and wars. The application of human rights
protection should emphasise vulnerable groups such as
II. Nurses and Human Rights women, children, elderly, refugees and stigmatised
ICN Position groups. To prepare nurses to adequately address human
rights, human rights issues and the nurses’ role need
The International Council of Nurses (ICN) views health to be included in all levels of nursing education
care as a right of all individuals, regardless of financial, programmes.
political, geographic, racial or religious considerations.
1
This right includes the right to choose or decline care, ICN endorses the Universal Declaration of Human Rights
including the right to accept or refuse treatment or nour- and ICN addresses human rights issues through a number
ishment; informed consent; confidentiality, and dignity, of mechanisms including advocacy and lobbying, posi-
including the right to die with dignity. It involves both tion statements, fact sheets, and other means.
the rights of those seeking care and the providers. Adopted in 1998

Human Rights and the nurse’s role Revised in 2006
Nurses have an obligation to safeguard and actively (Replaces previous ICN Position: The Nurse’s Role in Safe-
2
promote people’s health rights at all times and in all guarding Human Rights, adopted 1983, updated 1993) .
places. This includes assuring that adequate care is pro-
vided within the resources available and in accordance REFERENCES
with nursing ethics. As well, the nurse is obliged to ensure
that patients receive appropriate information in under- Universal Declaration of Human Rights, New York: United Nations, 1948.
International Council of Nurses Position Statement on Nurses and Human Rights,
standable language prior to consenting to treatment or Adopted in 1998, revised in 2006. Accessed on December 2008. Available from
procedures, including participation in research. http://www.icn.ch/pshumrights.htm

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APPENDIX A4 together the representatives of Critical Care Societies
DECLARATION OF VIENNA: PATIENT from around the world (national and international) with
the aim of pledging their efforts and resources towards
SAFETY IN INTENSIVE CARE MEDICINE improving the care of our patients. Together with the
societies signing this Declaration of Vienna (Appendix 1)
PATIENT SAFETY IN INTENSIVE CARE will be senior representatives from the political world,
MEDICINE: THE DECLARATION OF VIENNA our partners in industry and of course patient representa-
A declaration by the Executive Committee tives themselves. The meeting will assess problems and
of the European Society of Intensive solutions from around the world irrespective of geo-
graphical, political or economic factors. This unique part-
Care Medicine nership will allow collaborations to be fostered and for
Patient safety in intensive care medicine partnerships to develop. We hope to be able to use this
group to raise the profile of the patient safety agenda and
Improving the outcome of critically ill patients remains therefore change the way we practice everyday with resul-
an ideal that every practicing Intensivist strives to achieve. tant benefits for all.
Every year there are many hundreds of research papers
published that help us to better understand the physio-
logy and pathophysiology of our patients and also how From efficacy to effectiveness
our treatment strategies interact and eventually alter a Patient safety in intensive care medicine is best evaluated
patient’s course. Many of these papers focus on discrete in terms of two dimensions:
parts of the therapeutic regimes that we are able to deliver;
however, few have had a significant impact on overall • at the individual patient level, by doing good and not
outcome measures that are relevant to patients them- doing harm to any individual patient;
selves. One area of medicine that is often overlooked, but • at the collective level by doing good and not doing
can impact significantly on relevant patient outcomes, is harm to groups of patients, by increasing the safety
the process of care. The way we practice, the culture we and the effectiveness of our interventions or in other
work in, the climate that our professional demeanor words, the cost–benefit ratio.
creates can all dramatically impact on outcome measures. Although at the level of the individual patient there is
Unfortunately, these topics are often not easy to explain, little difficulty in explaining what is meant by the concept
difficult to study and do not attract research funding that of safe practice, at a collective level this is far more
stimulates scientific minds to address the problem. This complex. Partly this is because often the concepts are
paper describes how the European Society of Intensive more easily addressed by complex statistical approaches
Care Medicine (ESICM) aims to raise patient safety to the when addressing groups of patients and the fact that they
top of the scientific agenda with the hope of ultimately relate to the two pillars of quality, efficacy and effective-
increasing the quality of care delivered to our patients ness. This difference between efficacy and effectiveness
5
and improving their outcomes. is very important to understand. Efficacy relates to the
6
The Institute of Medicine (IOM) published in 1999 their capacity of an intervention to produce an effect, for
seminal report entitled ‘To err is human: building a safer instance in a research trial, effectiveness relates to how
health system’. This paper described quality as the degree well this translates to improved outcomes in real-life
1
to which health services for individuals and populations pragmatic situations. The standards for the evaluation
increase the likelihood of desired health outcomes and and reporting of the efficacy of an intervention are now
are consistent with current professional knowledge. Safety reasonably well established, despite several concerns sur-
7
was defined as the absence of clinical error, either by rounding methodological pitfalls. These standards have
8
commission (unintentionally doing the wrong thing) or been described both for the individual level situation
2
omission (unintentionally not doing the right thing) , and also where the evidence is arising from a variety of
9
and error as the failure of a planned action to be com- different sources. When we move from efficacy to effec-
pleted as intended or the use of a wrong plan to achieve tiveness, the picture is not so clear. These problems are
an aim. The accumulation of errors results in accidents. usually seen when trying to translate research scenarios
The authors delineated just how common failure to into everyday clinical practice, or when trying to develop
provide quality care is, with between 44,000 and 98,000 or assess clinical practice recommendations or guidelines.
patients dying each year in the USA as a result of a clinical The definitive answer about the risk–benefit balance of
error. This makes medical error the eighth leading cause any intervention can only be made when the balance
of death, more frequent than motor vehicle accidents between the expected benefits and the expected risks is
(43,458), breast cancer (42,458) and AIDS (16,516). assessed in the real world, outside of the experimental
Despite the awareness of patient safety and quality of care setting. To move from what is known about the benefits,
issues increasing in both patient and political arenas, this the risks and the limitations of a certain intervention
has not translated through to groundbreaking research when applied in a very strict usually non-generalizable
studies that have ignited the topic with significant cohort of patients to everyday practice is very difficult.
outcome benefits. 3,4 This often relates to patient case mix differences, severity
of illness differences and the effects of multiple interven-
To improve the profile of these subjects, the ESICM in tions impacting on each other that were not fully assessed
2009 has launched a major initiative that will bring in the original trial.

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If we take clinical practice guidelines, there are many practice. An important dimension of this problem, which
examples of recommendations that have been suggested can either be caused by errors of action or by errors of
following single trials that have been subsequently refuted omission in the process of care delivery, are the educa-
when more data became available. 10,11 For these reasons, tional and training standards of all professionals involved.
and due to an innate bias between the appraisal of evi- We have to recognize that the safety of our patient’s and
12
dence and clinicians own past experience and beliefs, also our health-care teams is of the utmost importance.
13
orthodox medicine is often not evidence based, and However, despite recent reports on the increasing dispar-
15
anecdote is often used as to determine treatment plans. 14 ity between the supply and demand of intensive care
and on the proven effectiveness of the intervention of
Why now: the changing demographics intensive care specialists on patient care, both physi-
18
of intensive care medicine? cians 16,17 and nurses, this problem remains hidden and
unaddressed by planners of health-care systems and those
Recent years have witnessed great changes in the topology
of the human population. We are now greater in number responsible for the planning of medical education. Con-
and older in age. We are sicker and more dependent sequently, we can expect to see an increase in the impact
on prophylactic and preventive therapies. Resources are of these phenomena.
becoming scarcer and are increasingly becoming more Error in intensive care
unevenly distributed. Diseases are becoming more global. Two recent studies performed by the Health Services
Technological advancements have allowed, and been the Research and Outcomes Section of the ESICM have
stimulus for, the development of our specialty, intensive helped to bring light to this issue. In the first study,
care medicine. This specialty cares for and treats patients the sentinel events evaluation (SEE) study, Valentin
19
with acute life-threatening illnesses. The prevention, care performed an observational, 24-h cross-sectional study
and/or cure of these patients are now a global challenge, of incidents in 205 intensive care units around the
needing multiple local solutions.
world. Thirty-nine serious events were observed for every
Contrary to previous times, where almost all of the health 100 patient days. The events included medication errors
challenges could be addressed by single interventions, (136 patients), unplanned dislodgement or inappropri-
such as vaccines, antibiotics or nutritional supplements, ate disconnection of lines, catheters and drains (158),
or eventually by small packages of interventions (washing equipment failure (112), loss, obstruction or leakage of
of hands before interventional childbirth, surgery with artificial airway (47) and inappropriate turning-off of
anesthesia, prophylactic antibiotics before surgery), criti- alarms (17). The presence of organ failure, a higher
cal illness is unique in several respects: intensity in level of care and time of exposure all related
to these events. In 2009, the same group, focusing this
l in its dimensions: it is a situation in which every time on errors in the administration of parenteral drugs,
organ and many of the inter-related systems may found 74.5 events per 100 patient days in the SEE 2
be affected, either as a primary or secondary study. 20
phenomena;
l in its time-dependence: most of the diagnostic Interestingly, three quarters of the errors were classified
and therapeutic interventions must be performed as errors of omission; 1% of the study population expe-
exceptionally quickly in order to be given a chance rienced permanent harm or died because of a medication
to work; error at the administration stage. The odds ratios for the
l in its challenges: the acceptability of the practice of occurrence of at least one parenteral medication error
intensive care medicine is crucially dependent on the were raised depending on the number of organ failures,
application of the strictest ethical standards. These the use of any intravenous medication, the number
have to be maintained with the utmost respect for of parenteral administrations, typical interventions in
the patient (and their family’s) wishes and in accor- patients in intensive care, a larger intensive care unit,
dance with society’s values and expectations. These number of patients per nurse and unit occupancy rate.
may change with time and certainly change with Odds ratios for the occurrence of parenteral medication
cultural, religious and geographic demographics; errors were decreased for the presence of basic monitor-
l in its consequences: the increasing prevalence of ing, an existing critical incident reporting system, an
residual disability post-critical illness, with the con- established routine of checks at nurses’ shift change and
sequent burden on the patient, their families and on an increased ratio of patient turnover to the size of
society as a whole, has an impact for many years after the unit.
the acute illness.
Although these above examples all relate to individual
The current pandemic of critical illness will spare few and patients, a bigger and less reported problem is that of
will be part of the dying process of millions of human the omission or commission of therapies for populations
beings in the forthcoming decades, with an increasing of patients. In intensive care practice this may relate to
number of patients requiring intensive care as part of the provision of appropriately sized tidal volumes during
their therapeutic plans or end of life care. Given the mechanical ventilation or the timely use of antimicrobial
narrow therapeutic margins for a significant number of therapy in septic shock. 21,22 In other clinical situations, it
the interventions belonging to our field, it is probable may relate to the patients being discharged post-acute
that a significant number of patients will be injured and myocardial infarction being prescribed appropriate doses
will suffer from the unattended consequences of medical of beta-blocker and statin therapies.

770 A P P E N D I X A W O R L D F E D E R AT I O N O F C R I T I C A L C A R E N U R S E S P O S I T I O N S TAT E M E N T S


What are the causes of an unsafe ICU and attributed to problems of communication between the
how can we improve the safety culture and physicians and nurses. Applying human factor engineer-
ing concepts to the study of the weak points of a specific
environment within our intensive care units? ICU may help to reduce the number of errors. Errors
Defining and assessing safety and quality are only one should not be considered as an incurable disease, but
side of the issue. Often in clinical practice the problem rather as preventable phenomena, if systems were
is broader than individual errors, and the whole system designed to cope and to minimize the effects and the
is at fault or at the least predisposes to an unsafe consequences of these errors. 43
environment. When assessing an ‘unsafe’ ICU, several
factors need to be understood, and these fit into two The challenges for the future
main categories: problems with the organization and Medicine in the last 200 years has changed dramati-
structure of the unit and problems with the process of cally. The nature of health and disease has altered
care used. irrevocably, pain has been conquered with anesthesia,
Perhaps the most obvious factors from the organization and infectious diseases have been fought through a
or structural point of view relate to the volume of work combination of drugs and better public health systems.
performed and outcome. This topic remains conten- At the same time our understanding of the pathophysi-
23
tious , although there is good evidence to support ological process underpinning these changes has
centralization and increased volume services in many cir- improved exponentially. Despite these advancements,
cumstances 24,25 (Nathens, 2001 no.10382). Some authors our knowledge as to how health-care systems interact
have described the relationship between patient to nurse and influence the delivery of safe and quality care are
26
ratios and nosocomial infection rates , medication poor. The recent ‘discovery’ of the epidemic of ‘medical
errors, complications and resource use after esophagec- error’ as an important cause of morbidity and mortal-
20
18
tomy or more broadly even all the aspects of safety and ity should not be a surprise.
quality in the hospital. These works lead many authors The first step to overcome this preventable epidemic is by
27
to conclude that a high-acuity nurse–patient ratio is cost- the recognition of its existence. For this reason the ESICM
28
effective , and that it is crucial to have ICUs adequately is promoting an initiative to bring together all the stake-
staffed. 29 holders who relate to our specialty in a process aimed at
The process of care relates to issues of teamwork, collabo- not only raising the profile of patient safety, but to actu-
ration and communication. These issues are far more ally improve the outcome of our patients.
difficult to quantify and are often obscure and forgotten.
In intensive care medicine they were perhaps first raised Appendix 1
by Pascale le Blanc and Wilmar Schaufeli in the EURICUS 1. We, the Leaders of the Societies representing the
studies. 30,31 They demonstrated these variables to be medical specialty of intensive care medicine, met
32
associated with increasing nosocomial infection rates. in Vienna on 11 October 2009. Together with the
Among these aspects, the issue of nurse–physician col- representatives of the main institutions and
laboration in ICUs 33-35 seems to be crucial. Also, the issue stakeholders who speak up for patient safety,
of the transmission of individual information between we declare:
36
professionals is today a critical issue , first raised by 2. We recognize that patient safety and clinical team
19
37
Donchin in 1995 and later confirmed in the SEE study. safety are of paramount importance to every prac-
Notwithstanding these issues, it is important not to forget ticing health professional and represents one of
38
the well-being of intensive care nurses or the effect of a the major challenges in modern day medicine.
pharmacist’s and/or a nurse’s interventions on cost and This affects the lives of women, men, and children
adverse effects of drug therapy in the ICU. 39-41 in every country. Without a safe environment it is
not possible to provide the quality of care that we
The need for a multidimensional approach to the mini-
mization of error and the consequent improvement in all aspire to. This is especially true in intensive
the clinical and economical effectiveness of an ICU care medicine, given the very fragile nature of the
42
is becoming increasingly clear. When comparing the patients we care for, often in the extremes of age,
‘most efficient’ with ‘least efficient’ ICUs, Rothen and unconscious and with minimal margins for error
co-workers demonstrated that only interprofessional imposed by their deranged physiology. This global
rounds, the presence of an emergency department and problem requires a global solution.
the geographical region of the hospital were significantly 3. We believe that improving levels of safety for criti-
asso ciated with improvement in quality indicators. The cally ill patients is achievable in all units and in
adoption of electronic prescribing over handwritten pre- all countries, irrespective of the available resources.
scription has also been shown to lead to the prescrip- If the safety of our patients is increased, then the
tions being more readable and complete, with fewer quality of care that we can provide will improve.
errors. This should result in improved prescribing and 4. We strongly believe that increasing patient safety
a safer environment for the giving of drugs to our is as crucial to the development of medical prac-
patients. tice as the increase in the effectiveness of our
interventions.
In conclusion, a significant number of dangerous human 5. We have today therefore pledged to do whatever
errors occur in the ICU. Many of these errors can be is necessary to:

A P P E N D I X A W O R L D F E D E R AT I O N O F C R I T I C A L C A R E N U R S E S P O S I T I O N S TAT E M E N T S 771

l Increase the knowledge of the causes and European Federation of Critical Care Nursing
reasons for failures to provide a safe environ- Associations
ment in the intensive care unit. European Society of Anaesthesiologists
l Improve our understanding of the conse- Finnish Society of Intensive Care
quences of failure to provide a safe environ- Georgian Society of Anesthesiology and Critical Care
ment for critically ill adult and children and Medicine
the health-care professionals caring for these German Sepsis Society
patients. Hungarian Society of Anaesthesiology and Intensive
l Develop and promote criteria that can assess Care Therapy
safety in the intensive care unit. Indian Society of Critical Care Medicine
l Further our ability to translate the knowledge Indonesian Society of Intensive Care Medicine
of safety into improving the quality of care Intensive Care Society
that can be provided to our patients. International Pan-Arab Society of Intensive Care
By acting together to fulfill these pledges we will improve Medicine
the safety of intensive care practice and thereby increase Israel Society of Critical Care Medicine
the quality of care. Korean Society of Critical Care Medicine
6. Through the design and promotion of safer and Kuwait
even more efficient devices and drugs, we acknowl- Lithuanian Society of Anaesthesiology and Intensive
edge that industrial partners have a pivotal role to Care
play in improving patient safety. With the signa- Macedonia Society of Anaesthesia and Intensive Care
ture of this declaration, manufacturers of bio- Malaysian Society of Anaesthetists
medical, pharmaceutical and biotechnology Nederlandse Verenigning voor Intensive Care
companies pledge to: Osterreichische Gesellschaft fur Anaesthesiologie,
l Engage in efforts to improve the safety profile Reanimation und Intensivmedizin
of their products. Romanian Society of Anaesthesia and Intensive Care
l Provide resources to facilitate the safe use of Scandinavian Society of Anaesthesiology and Inten-
their products. sive Care
l Release, as soon as they become available, any Scottish Intensive Care Society
information related to safety concerns of their Serbian Society of Intensive Care Medicine
products to health-care professionals and reg- Slovak Society of Anaesthesiology and Intensive Care
ulatory agencies. Sociedad Espanola de Anestesiologia, Reanimacion y
7. The agreements reached today will enable us to Terapeutica del Dolor
develop safety criteria that can be used by inten- Sociedade Portuguesa de Cuidados Intensivos
sive care units around the world to improve their Sociedad Española de Medicina Intensiva, Crítica y
safe practices and increase the quality of care pro- Unidades Coronarias
vided to the benefit of all of our patients. Società Italiana Di Anestesia
Analgesia Rianimazione E Terapia Intensiva
Appendix 2 Société de Réanimation de Langue Française
Société Francaise d’Anesthésie et de Réanimation
Critical care societies who are participating in the Society of Anaesthesiologists and Reanimatologists of
initiative: Central Russia
Associação de Medicina Intensiva Brasileira (AMIB) Society of Critical Care Medicine
Asia-Pacific Association of Critical Care Medicine Sudan
Australian and New Zealand Intensive Care Society Swedish Society of Anaesthesiology and Intensive
Austrian Society of Medical and General Intensive Care Medicine
Care Medicine Swiss Society of Intensive Care Medicine
Bahrain Tunisia
Belgian Society of Intensive Care Medicine UEMS
Canadian Critical Care Society
Chinese Society of Critical Care Medicine REFERENCES
Croatian Society of Intensive Care Medicine
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und Notfallmedizin 3. Blendon RJ, DesRoches CM, Brodie M, Jm Benson, Rosen AB et al. Views of
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Egyptian Society of Critical Care and Emergency 4. Altman DE, Clancy C, Blendon RJ Improving patient safety – five years after
Medicine the IOM report. N Engl J Med 2004; 351: 2041–3.
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1115–18.
ESPNIC 6. Haynes B Can it work? Does it work? Is it worth it? Br Med J 1999; 319:
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Randomization in clinical trials of titrated therapies: unintended conse- empirical relation between surgical volume and mortality. 1979. Clin Orthop
quences of using fixed treatment protocols. Crit Care Med 2007; 35: Relat Res 2007; 457: 3–9.
1509–16. 25. Stockwell DC, Slonim AD. Volume-outcome relationships: is it the individual
8. Hopewell S, Clarke M, Moher D, Wager E, Middleton P et al. CONSORT for or the team? Crit Care Med 2006; 34: 2495–7.
reporting randomized controlled trials in journal and conference abstracts: 26. Hugonnet S, Chevrolet J-C, Pittet D. The effect of workload on infection risk
explanation and elaboration. PLOS Med 2008; 5: e20. doi:10.1371/journal. in critically ill patients. Crit Care Med 2007; 35: 76–81.
pmed.0050020. 27. Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-staffing
9. GRADE working group. Grading quality of evidence and strength of recom- levels and the quality of care in hospital. N Engl J Med 2002; 346: 1715–22.
mendations. Br Med J 2004; 328: 1–8. 28. Vandijck DM, Blot SI. High acuity nurse patient ratio–is it costeffective?
10. Tinetti ME. Over-the-counter sales of statins and other drugs for asymptom- In: Kuhlen R, Moreno R, Ranieri M, Rhodes A (eds) Controversies in intensive
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11. Armitage J. The safety of statins in clinical practice. Lancet 2007; 370: p. 393–405.
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12. Grol R. Beliefs and evidence in changing clinical practice. Br Med J 1997; 315: and implications for action. Int J Qual Health Care 2003; 15: 275–7.
418–21. 30. Miranda DR, Ryan DW, Schaufeli WB, Fidler V (eds). Organization and manage-
13. Garrow JS. What to do about CAM: how much of orthodox medicine is evi- ment of intensive care: a prospective study in 12 European countries. Berlin:
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15. Kelley MA, Angus DC, Chalfin DB, Crandall ED, Ingbar D et al. The critical 32. Jain M, Miller L, Belt D, King D, Berwick DM. Decline in ICU adverse events,
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23. Jones J, Rowan K. Is there a relationship between the volume of work carried 43. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M et al. A look into the nature
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11: 762–9. 2003; 12: 143–8.

APPENDIX B1 providers and critical care clinicians on the desir-
able outcomes of critical care courses.
ACCCN POSITION STATEMENT (2006) 7. Graduates of postgraduate courses in critical care
ON THE PROVISION OF CRITICAL must be able to demonstrate clinical competence
CARE NURSING EDUCATION as well as a sound theoretical knowledge base. A
strong emphasis on the application of theory to
The Australian College of Critical Care Nurse Limited practice, and the assessment of clinical compe-
(ACCCN) considers that appropriate preparation of spe- tence should be an integral component of post-
cialist critical care nurses is a vital component for the graduate critical care courses.
provision of quality care to patients and their families. 8. The provision of appropriate experience to facili-
This position statement outlines the recommendations of tate the development of clinical competence
ACCCN regarding the provision of critical care nursing should be a collaborative responsibility between
education. Where possible these recommendations are education and healthcare providers. Critical care
based on evidence from research in critical care nursing students should have access to support and guid-
and allied fields. In areas where current research-based ance from appropriately experienced staff such as
evidence is not available, these recommendations are clinical teachers and nurse preceptors.
based on the opinion of expert nurses in the field of 9. Clinical teachers and nurse preceptors for post-
critical care nursing in Australia.
graduate critical care students should be appro-
1. Programs preparing critical care nurses to func- priately supported in their role by both education
tion at a specialist level of practice should be and healthcare providers.
provided at a postgraduate level and conducted 10. Close collaboration between the healthcare and
by a higher education provider (for example, a higher education sectors is important in order
university or equivalent provider). that postgraduate critical care nursing education
2. The curricula of Australian critical care nursing is provided at a standard that meets the expecta-
postgraduate courses must provide an appropri- tions of both sectors.
ate theoretical and clinical experience to prepare 11. Critical care education providers should have in
nurses to meet the challenges of clinical practice place policies and processes for recognition of
effectively. prior learning and alternative flexible entry path-
3. ACCCN considers the Competency Standards for ways into postgraduate specialist courses.
Specialist Critical Care Nurses developed by ACCCN 12. Healthcare and higher education providers should
could be utilised to inform critical care curricu- establish strategies to reduce the significant finan-
lum development and assessment of clinical cial burden faced by nurses undertaking post-
practice. graduate critical care courses.
4. ACCCN endorses the recommendations of the 13. Healthcare providers and health departments
2005 Declaration of Madrid on the preparation of should implement suitable strategies that provide
critical care nurses in relation to curriculum financial or career incentives that will encourage
content. critical care nurses to complete postgraduate criti-
5. Postgraduate courses for critical care nurses must cal care courses.
provide a balance between clinically oriented 14. Education providers should implement educa-
content and broader generic content that enables tional strategies to facilitate flexible access to post-
the specialist nurse to contribute to the profession graduate critical care courses for nurses from a
through processes such as research, practice devel- range of geographical locations.
opment and leadership. 15. Innovative strategies need to be implemented to
6. There is a pressing need for the establishment of address the deficit of qualified critical care nurses.
consensus among education providers, healthcare Such strategies may include comprehensive criti-
cal care workforce planning, innovative retention
strategies, refresher or re-entry critical care educa-
tion, professional development programs and the

774 A P P E N D I X B A U S T R A L I A N C O L L E G E O F C R I T I C A L C A R E N U R S E S ( A C C C N ) P O S I T I O N S TAT E M E N T S

provision of greater support for nurses undertak- l illnesses and alterations of vital body functions
ing postgraduate critical care courses. l legal and ethical issues
16. Providers of short critical care training courses l plans of care and nursing interventions
should seek credit transfer within the higher edu- l professional nursing roles in critical care, including
cation sector for nurses completing these courses. clinical teaching strategies, team leadership and
As a minimum, the critical care dimensions of the follow- management issues
ing subject areas should be included in critical care educa- l medical indications and prescriptions, with result-
tion programs to prepare critical care nurses. ing nursing care responsibilities
l anatomy and physiology l use of current research findings to deliver evidence
l psychosocial aspects, including cultural and spiri- based multidisciplinary care
tual beliefs l responding to clinical emergencies
l pathophysiology l global critical care perspectives
l technology applications REFERENCES
l pharmacology
l caring for the carer, including debriefing, stress Australian College of Critical Care Nurses Ltd. Competency standards for specialist
management and peer support critical care nurses, 2002.
l clinical assessment (including diagnostic and labo- Australian College of Critical Care Nurses Ltd Position statement on postgraduate critical
care nursing education, 1999.
ratory results) World Federation of Critical Care Nurses. Declaration of Madrid on the preparation
l patient and family education of critical care nurses. 2005. Available from: www.wfccn.org

A P P E N D I X B A U S T R A L I A N C O L L E G E O F C R I T I C A L C A R E N U R S E S ( A C C C N ) P O S I T I O N S TAT E M E N T S 775

APPENDIX B2 The ratio of ACCESS nurses required per unit/
ACCCN ICU STAFFING POSITION per shift will depend on the average level of skill
and expertise of the total team. As a fair measure
STATEMENT (2003) ON INTENSIVE of an individual unit’s need for ACCESS nurses,
CARE NURSING STAFFING ACCCN have linked the required ratio of ACCESS
nurses to the overall percentage of qualified criti-
The Australian College of Critical Care Nurses Ltd cal care nurses available on the roster. Therefore:
(ACCCN) is the peak professional nursing association
representing critical care nurses throughout Australia. l Units with < 50% qual. ICU nurses – 1 : 4.
This position statement outlines the appropriate nursing i.e. one ACCESS nurse for every 4 patients/
staffing standards in Australia for Intensive Care Units, shift.
taking into account accepted minimum national stan- l Units with 50–75% qual. ICU nurses –
dards, best practice evidence and a rational economic 1 : 6. i.e. one ACCESS nurse for every 6
health and government environment. patients/shift.
l Units with >75% qual. ICU nurses – 1 : 8.
ACCCN recommends the following 10 key points and i.e. one ACCESS nurse for every 8 patients/
principles to meet the expected standards of critical care shift.
nursing in Australia. These standards articulate with those
guidelines outlined by both the Australian Council ACCCN acknowledges the crucial support
1
of Healthcare Standards (ACHS) and the Joint Faculty of agency/casual nursing staff provide, however,
Intensive Care Medicine (ANZCA/RACP). 2 agency/casual staff require additional orientation,
support and guidance further emphasising the
1. ICU patients (clinically determined) – require a need for ACCESS nurse positions.
standard nurse : patient ratio of at least 1 : 1. ACCCN acknowledges that a combination of
2. High-dependency patients (clinically determined) both suitable critical care experience and a post-
– require a standard nurse : patient ratio of at graduate specialist qualification, provide the
least 1 : 2 optimal critical care nursing preparation.
3. Clinical Coordinator (team leader) – there must Idiosyncrasies and special needs: In units
be a designated critical care qualified senior nurse which have idiosyncratic needs such as retrieval
per shift who is supernumerary and whose services, large teaching courses, dedicated equip-
primary role is responsibility for the logistical ment nurses and major research projects, addi-
management of patients, staff, service provision tional nursing requirements will need to be
and resource utilisation during a shift. This factored into the total establishment in addition
includes coordinating staff, ensuring compliance to that which is described above.
with hospital policy and procedures, liaison with 5. At least one designated Nursing Manager (NUM/
medical and allied staff to formulate patient clini- CNC/NPC/CNM or equivalent title) is required
cal management plans, monitor appropriateness per ICU who is formally recognised as the unit
and effectiveness of clinical care, and ensure a nurse leader. In certain circumstances, (e.g. large
safe conducive environment is maintained. This units of 20+ beds) alternative supports will be
nurse should be guaranteed to be supernumerary required, and these need to be planned indepen-
for the entire shift. dently and in addition to the ratios described
4. ACCESS nurses – these nurses are in addition to above.
bedside nurses, clinical coordinator, unit manager, 6. At least one designated Clinical Nurse Educator
educators and non-nursing support staff. The (CNE) should be available in each unit. The rec-
ACCESS nurses provide ‘on-the-floor’ Assistance, ommended ratio is one FTE CNE for every 50
Coordination, Contingency (for a late admission nurses on the ICU roster, with additional educa-
on the shift, or staff sick mid-shift), Education tors to run and manage tertiary-based critical care
(of junior staff, relatives, and others), Supervision nursing courses. The ICU Clinical Nurse Educator
and Support. The ACCESS nurse would reduce is for unit-based education and staff development
entry block to ICU for emergency admissions. activities only and must be located in the ICU
ACCCN acknowledges that similar positions have itself. The role of Clinical Nurse Consultant differs
varying names and descriptions in units all over between states, ranging from unit management to
Australia (e.g. float nurses, ‘bay nurse’, admission providing a global critical care resource, educa-
nurses) tion and leadership to specific units, hospital and
The role of the ACCESS nurse may be incorpo- area-wide services and to the tertiary education
rated into the Clinical Coordinator’s role; however, sector.
the Clinical Coordinator should not be the only 7. ACHS guidelines state that ICUs must have a
1
contingency nurse available for emergency admis- minimum 50% qualified Critical Care Nurses.
sions. That is, where a unit has the number of ACCCN supports this as a minimum standard,
beds/qualified staff to justify only one ACCESS however, we assume that the optimum qualified
nurse, a supernumerary Clinical Coordinator Critical Care Nurse ratio should be 75%. (Units
must also be rostered on duty. with less than 50% qualified staff will need

776 A P P E N D I X B A U S T R A L I A N C O L L E G E O F C R I T I C A L C A R E N U R S E S ( A C C C N ) P O S I T I O N S TAT E M E N T S

additional ACCESS nurses as described in 4 and cleaning purposes except on very few occa-
above.) To ensure at least 50% of ICU nursing sions when the nature of such work is specialised
staff are qualified (optimally 75%), ACCCN rec- and requires educated or professional knowledge
ommends that nursing staff without postgraduate and skill.
qualifications should receive financial assistance 10. Senior nursing staff (e.g. CNS) should work
and study leave to complete a recognised critical towards becoming an Australian Credentialled
care nursing course and that such support is fac- Critical Care Nurse for which they must be remu-
tored into the unit budget each year. nerated to a significantly higher level than that of
8. Resources are allocated to support nursing time the base grade award.
and costs associated with quality assurance activi-
ties, nursing and multidisciplinary research and REFERENCES
conference attendance.
9. Intensive Care Units are provided with adequate 1. Australian Council on Healthcare Standards. Guidelines for Intensive Care Units.
Sydney: Australian Council on Healthcare Standards, 1997.
administrative staff, ward assistants, manual han- 2. Joint Faculty of Intensive Care Medicine. Minimum Standards for Intensive Care
dling assistance/equipment, cleaning and other Units. IC-1. Melbourne, 2003.
support staff to ensure that such tasks are not the 3. Australian Institute of Health & Welfare. Nursing Labour Force Series, Canberra,
Australia, 1998.
responsibility of nursing personnel. ACCCN 4. Williams G, Clarke T. A consensus driven method to measure the required
believes that the value and cost of ICU nurses number of intensive care nurses in Australia. Australian Critical Care, 2001;
does not support their time being used for clerical 14(3): 106–115.

A P P E N D I X B A U S T R A L I A N C O L L E G E O F C R I T I C A L C A R E N U R S E S ( A C C C N ) P O S I T I O N S TAT E M E N T S 777

APPENDIX B3 healthcare worker. This concept fails to recognise the
POSITION STATEMENT (2006) expertise and knowledge of the Division 1* RN (espe-
ON THE USE OF HEALTHCARE cially those with a postgraduate qualification) that has
been demonstrated to decrease the risk of adverse patient
WORKERS OTHER THAN outcomes. 4,5
DIVISION 1* REGISTERED NURSES The use of Division 2 RNs/ENs** and unlicensed health-
IN INTENSIVE CARE care workers in the intensive care setting has been exam-
ined in North America and the United Kingdom, with a
ACCCN acknowledges the important contribution of number of studies identifying a relationship between low
Enrolled Nurses (ENs) (Division 2 RN)** in many roles Division 1* RN staffing levels, higher patient mortality
and settings, and is supportive of all nurses who wish to rates and increased adverse events. 6-12 Other studies
enhance their skills and knowledge to enable them provide evidence that the number of Division 1* RN
to work in specialist areas. ACCCN believes the best way hours per patient per day influences the quality of
to achieve the appropriate skill level for specialist areas patient care. 13-15
is through a formal postgraduate program in that
specialty. The British Association of Critical Care Nurses (BACCN)
performed a critical appraisal of the literature to inform
This position statement is based on current evidence their position statement on nurse : patient ratios within
regarding the effect of healthcare workers other than Divi- intensive care16; included in this review was an examina-
sion 1* Registered Nurses on patient outcomes in the tion of the use of staff other than (Division 1*) Registered
intensive care environment. It is also supported by the Nurses. The BACCN position statement states that it is
ACCCN ‘Position Statement on Intensive Care Nurse the right of intensive care patients to be cared for by a
1
Staffing’ , the Joint Faculty of Intensive Care Medicine (Division 1*) Registered Nurse, and that the acuity of the
2
(JFICM) ‘Minimum Standards for Intensive Care Units’ , intensive care patient should be the determining factor
and the Australian Council of Healthcare Standards when matching their needs with the knowledge and skills
3
‘Guidelines for Intensive Care Units’ . 16
of the Registered Nurse delivering their care.
l All intensive care patients must have a Division 1*
Registered Nurse allocated exclusively for their care The Canadian Association of Critical Care Nurses
17
l High-dependency or stepdown patients (within inten- (CACCN) position statement on the use of non-
sive care) who require a nurse to patient ratio of 1 : 2, regulated health personnel in intensive care areas identi-
should have a Division 1* Registered Nurse allocated fies how critical-thinking is both invaluable and essential
exclusively to their care in the provision of care to critically ill patients. They also
l Enrolled Nurses (Division 2 RNs**) may be allocated assert the process involved in the delivery of nursing care
duties to assist the Division 1* Registered Nurse; to this specific population of patients represents a com-
however, any activities which involve direct contact plex integration of knowledge, judgement, organisation
with the patient, must always be performed in the and evaluation. While CACCN do not unequivocally rule
immediate presence of the Division 1* Registered out the use of these personnel in this setting, they believe
Nurse the quality of patient care would be compromised with
l Unlicensed personnel should only be used to assist their use, and they do not endorse the use of non-regu-
the Division 1* Registered Nurse perform direct lated personnel in direct patient care roles in intensive
15
patient care for specific duties such as manual han- care areas.
dling. Otherwise their duties should be confined to In Australia, while there has not been a formal examina-
non-nursing duties, housekeeping, etc. tion of the use of Division 2 RNs/ENs** within the inten-
sive care setting, two publications that inform this debate
Discussion come from the Australian Incident Monitoring Survey.
Many factors that result in decreased recruitment and The first paper examined 3600 reports which identified
retention are causing the current worldwide nursing 89 incidents related to nursing staff shortages; 373 inci-
shortage. One idea that has been promulgated as a poten- dents related to nursing staff shortages being a contribut-
tial solution to the shortage of nurses in intensive care is ing factor in the incident, and 81% of the adverse events
the use of personnel other than Division 1* Registered reported resulted from inappropriate numbers of nursing
Nurses. This idea suggests the issue is one of ‘workload’, staff or inappropriate skill mix. 18
i.e. a group of tasks that can easily be delegated to any
The second paper from this group examined 735 reports
which identified 1472 incidents relating to nursing staff
inexperience. Of the 1472 incidents, 20% led to adverse
*Division 1 Registered Nurse is the term used in Victoria for nurses who are
referred to as Registered Nurses in all other states of Australia. RNs in all states outcomes for the patient. The authors believe that nursing
must undertake a 3 year undergraduate degree. care without appropriate expertise poses a potential
increased risk of harm to the patient. They concluded that
**Division 2 Registered Nurse is the term used in Victoria for nurses who are
referred to as Enrolled Nurses in other states of Australia. The educational prepara- the rate of errors made by experienced intensive care
tion varies between states, but is primarily conducted in the vocational sector; it nurses was likely to increase during periods of staffing
ranges from a 12-month certificate to an 18-month diploma. One of the most shortages, when inexperienced nurses required super-
contentious differences between jurisdictions and educational preparation is the 15
inclusion of medication administration. vision and assistance. Another Australian study also