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Learn more: PMC Disclaimer | PMC Copyright Notice BMJ Case Rep . 2024 Apr 16;17(4):e255348. doi: 10.1136/bcr-2023-255348 Search in PMC Search in PubMed View in NLM Catalog Add to search Tele-ICU enabled management of an organ donor in an under-resourced setting Prudhvi Dasari Prudhvi Dasari 1 Cloudphysician Healthcare Pvt Ltd, Bengaluru, India Find articles by Prudhvi Dasari 1 , Maheeja Reddy Maheeja Reddy 1 Cloudphysician Healthcare Pvt Ltd, Bengaluru, India Find articles by Maheeja Reddy 1 , Dileep Singh Parmar Dileep Singh Parmar 2 Aastha Health Care, Gandhinagar, Gujarat, India Find articles by Dileep Singh Parmar 2 , Carl Britto Carl Britto 3 Division of Critical CareDepartment of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Boston, USA Find articles by Carl Britto 3, ✉ Author information Article notes Copyright and License information 1 Cloudphysician Healthcare Pvt Ltd, Bengaluru, India 2 Aastha Health Care, Gandhinagar, Gujarat, India 3 Division of Critical CareDepartment of Anaesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Boston, USA ✉ Correspondence to Dr Carl Britto; [email protected] ✉ Corresponding author. Accepted 2024 Jan 27; Collection date 2024. © BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ. PMC Copyright notice PMCID: PMC11029231 PMID: 38627056 Abstract A man in his 30s was involved in a road traffic crash in a small town in India, not equipped to deal with cases of brainstem death. He was declared brain-dead after a few hours. The patient’s information was forwarded to organ specialists across the country, with the goal of preserving the patient’s organs for donation via a tele-ICU model. The team comprising bedside doctors and remote intensivists communicating via an indigenously developed tele-ICU platform managed the patient for 24 hours, following treatment protocols and providing critical care to ensure that the patient’s vital organs were optimally perfused. The following morning, specialist teams from a nearby city arrived at the local hospital to retrieve the patient’s organs. This fast-tracked organ retrieval and transplant process were made possible through advances in technology and the involvement of specialists from other parts of the country through this tele-ICU model. Keywords: Adult intensive care, Mechanical ventilation Background The demand for organ transplants far exceeds the current availability of organ donors. 1 Advances in modern medicine, organ preservation and transportation techniques have improved the success rate (5-year survival and rates of rejection) of organ transplants, but the demand still outpaces supply. 2–5 According to the Health Resources and Services Administration, there are over 100 000 people waiting for an organ transplant, with 17 people dying every day while waiting for a donor. 6 The process of organ transplantation requires critical care services, particularly during the brain death process and peritransplant period. 7 According to Indian guidelines, for determination of brain-stem death, a patient may only be considered for organ donation when deeply comatose secondary to a known irreversible aetiology, requires mechanical ventilatory support, is free of any form of neuromuscular blockade and all brainstem reflexes are found to be absent. 8 Two separate medically trained providers must examine the patient separately at two distinct time points at least 6 hours apart. The medically trained personnel could be the medical administrator In charge of the hospital, an authorised specialist, authorised neurologist/neurosurgeon or medical officer treating the patient. However, the THO Act (2011) states that the selection of a surgeon/physician and an anaesthetist/intensivist, in the event of the non-availability of approved neurosurgeon/neurologist is acceptable. 8 9 There must also be a demonstrable absence of respiratory movements after removal from the ventilator for sufficient duration despite a pCO2 rise above a threshold of 50–60 mm Hg (a level that stimulates spontaneous respiration). Thus, brainstem death is determined by clinical examination. Neurophysiological or imaging studies neither form part of the diagnostic requirements nor are legally required. 8 However, these tests are sometimes used when the diagnosis is equivocal. There is a shortage of critical care specialists, particularly in remote and underserved areas. 10–12 Tele-ICU technology is able to provide remote monitoring and management of critically ill patients, 13 connecting them with critical care specialists and improving access to high-quality care. Tele-ICU uses high-end cameras, electronic medical records, mobile devices and secure video conferencing to connect patients in remote areas with critical care specialists. This platform provides real-time monitoring, notifications, secure communication and high-definition video feed, allowing patients in remote areas to receive critical care monitoring and access to specialist care, at a fraction of the cost needed to train and staff remote critical care facilities. 14 15 By improving access to critical care services, tele-ICU may be able to play a crucial role in increasing the pool of potential organ donors. Case presentation A healthy man in his late 30s without known comorbidities was involved in a high-impact road traffic crash in a rural area of India, at approximately 11:00 hours. He was found unresponsive by first responders and was taken to a nearby health facility before being transferred to a level II ICU hospital within 2 hours of the crash. The patient was evaluated and resuscitated on arrival to the ICU. An initial evaluation was performed by the bedside team (comprising a doctor with basic skills but no formal critical care training, a bedside nurse and a pharmacist), along Advanced Trauma Life Support guidelines with the assistance of remote critical care specialists via a unique tele-ICU model. As detailed in figure 1 , the operational ‘hub-and-spoke’ model of this tele-ICU uses a unique, indigenously developed tele-ICU platform. From the time of admission until disposition, the patient was monitored by a critical care specialist remotely who coordinates care with staff at the patient’s bedside. The monitoring system uses a high-resolution pan-zoom camera and embed artificial intelligence technology that alerts staff to deteriorating trends on monitors and ventilators. This tele-ICU system allows the clinical monitoring of a wide range of entities. Live continuous video feed avoids any middleware (a software programme/device that provides services to applications installed on the operating system) needed to connect bedside monitors to central computers. The high-definition pan-tilt-zoom cameras installed in this ICU (set up by the hardware team) provide a 360° view of the patient using computer vision technology. Endotracheal tube markings, ventilator waveforms, pupillary changes, superficial breaks in skin and breathing movements are some of the clinical features that can be appreciated remotely. The real time visual data are complemented by a proprietary Tele-ICU Management Platform (TMP; Cloudphysician Healthcare, Bengaluru, India) to correlate clinical data with visual inspection findings. The TMP is used for clinical data entry, notes, escalations and communication. A mobile application that can run on low-cost android phones also allows for monitoring to be provided easily and enables communication through a secure chat feature. Ventilator and vital sign parameters are recorded by the bedside nurse and subsequently validated by the ‘hub’-side nurse. Figure 1. Open in a new tab Workflow of the tele-ICU model in the context of organ perfusion in a brain-dead patient ‘created by CB’. At the ‘hub’, the team uses the transmitted information to advise on initial resuscitation steps and medication orders. The hub (remote) team also participates in daily rounds, monitors the patient and recommends best practices for the ‘spoke’ ICU team, based on their observations and clinical trends. The patient had a Glasgow Coma Score of 3/15, agonal breaths and a heart rate of 60 beats per minute with a palpable central pulse. The remote critical care team advised intubation and mechanical ventilation to secure his airway, along with placement of a cervical collar on suspicion of cervical cord injury. The patient was resuscitated with 1 L of Ringer’s lactate after recording the admission blood pressure of 86/56 mm Hg and norepinephrine was started at 0.03 µg/kg/min and titrated to target mean arterial pressure greater than or equal to 65 mm Hg while the Ringer’s lactate was continued at 75 mL per hour. Norepinephrine was the vasopressor used to achieve the target mean arterial pressure. By 24 hours of admission, the patient’s requirement of noradrenalin increased (0.15 µg/kg/min) and the second vasopressor, vasopressin at a dose of 0.04 IU/min was added to target mean arterial pressure of 65 mm Hg. The patient was sent for long bone X-rays and CT of the head, chest, abdomen and pelvis after initial haemodynamic stabilisation with intravenous fluids and inotropes. Initial imaging studies confirmed that polytrauma was complicated by severe traumatic brain injury. There were also bilateral lung contusions and atelectasis but no trauma or signs of injury on imaging of the abdominal viscera. The liver was normal in size and density, there was no evidence of any focal or diffuse lesions seen that would preclude transplant. Both kidneys were normal in size, shape and position with no gross abnormalities. They also showed prompt excretion of the contrast with no evidence of calculus or hydronephrosis. Thus, both kidneys were suitable for transplantation. Both ureters were normal in course and calibre. The CT findings revealed haemorrhagic contusions in the cerebral parenchyma, subdural haematoma, diffuse cerebral and cerebellar oedema, tonsillar herniation, and displaced fractures in the frontal, occipital, parietal bones and left sphenoid sinus. There were no cervical spine injuries. ECG showed non-specific ST-T changes in the V1 and V2 leads with a sinus rhythm. Two-dimensional echocardiography revealed a normal left ventricular (LV) size and function with an LV ejection fraction of 60%. The overall impression was of a structurally normal heart with normal biventricular function. A detailed neurological examination was performed a few hours later and revealed absent brain stem reflexes (non-reactive pupils, absent corneal and oculocephalic reflexes, absent facial movements, no motor response to noxious stimuli, and no gag and cough reflexes.) The patient was kept nil per oral and received gastric ulcer prophylaxis, anticonvulsants and analgesics. Preliminary laboratory results showed leucocytosis, mild acute kidney injury with hypokalaemia, elevated uric acid levels, elevated transaminase liver enzymes, and a respiratory and metabolic acidosis. The patient was maintained on volume-controlled ventilation (fractional inspired oxygen 70%, tidal volume 420 (6 mL/kg), PEEP 8 and a respiratory rate of 20 breaths per minute), saturating at 99% with no A-a gradient. Neurology and neurosurgical consults were also obtained prior to brainstem-death declaration to ensure there were no other reversible causes, and to ensure congruence in the ultimate prognosis of the patient. Brainstem death was declared 12 hours after admission based on the aforementioned tests performed 6 hours apart by a physician and neurologist separately and the family consented to organ donation. While the patient’s family was being counselled on the options of organ donation, the tele-ICU team continued to carefully titrate treatment through the bedside team to maintain optimal organ perfusion. Mechanical ventilation was continued to preserve respiration and blood gas levels. The objective was to keep an oxygen saturation level of at least 94% and a blood pH between 7.35 and 7.45. Haemodynamic support entailed preservation of the heart rate and blood pressure of the patient within specific physiological limits to guarantee adequate blood flow to the organs. To avoid organ damage, the body temperature target of the patient was kept between 36.5°C and 37.5°C. This was achieved through warmed intravenous fluids and surface warming blankets. Electrolyte imbalances impact organ function, so preserving the patient’s electrolyte levels within normal limits was a priority. This was achieved through the use of intravenous fluids, electrolyte supplementation and correction of any underlying metabolic conditions that may have caused the imbalance. Electrolytes and blood gases were measured every 6 hours. Strict glucose control was maintained with appropriate glucose concentration in intravenous fluids with a glucose infusion rate maintained within physiological parameters. All of these interventions took place in a remote region, not ordinarily equipped to deal with brainstem death or organ donation. The remote team did not have the expertise to manage a brainstem dead patient on the ventilator for over 12 hours, titrate pressors for optimal physiology, assess clinical changes and manage acid-base disorders appropriately. After 24 hours in ICU, a transplant team arrived and transported the patient to a nearby city for organ retrieval and subsequent transplantation. Organ procurement was performed for both kidneys, liver and heart; however, the heart was not used for transplantation due to atherosclerotic changes. Global health problem list Shortage of organs for transplantation. Challenges in coordinating organ retrieval, preservation and transportation to the recipient. Shortage of trained healthcare professionals in remote areas for organ donation and transplantation processes. Limited resources and funding for developing and maintaining tele-ICU technology. Global health problem analysis The primary goal of intensive care of a brainstem dead patient is to maintain organ perfusion until the organs may be procured for transplantation. 16 Mechanical ventilation, haemodynamic support with vasopressors, electrolyte monitoring and fluid balance management are some measures employed to maintain adequate oxygenation, gas exchange, blood pressure and organ perfusion. Careful continuous monitoring of the patient’s clinical status is imperative for favourable outcomes and requires a highly skilled team. Any changes in the patient’s condition must be promptly addressed, and appropriate interventions made to maintain organ perfusion until transplantation. This tele-ICU model was refined during the COVID-19 pandemic and has since been adapted to efficiently treat patients requiring ICU level of care across a spectrum of complex conditions. 14 In India, there is a disproportionately low number of ICU beds (2.3/100 000 population) with the disproportion most pronounced in rural regions. 17 This statistic has a direct impact on organ donation and organ transplant as ICU expertise is crucial to the process of organ transplantation both at donor and recipient levels. While a large number of solid organ transplants, particularly kidney and liver, are now increasingly being performed from live donors, cadaveric/brainstem death transplants are still an important source of organs. 6 Access to critical care services and expertise even in rural areas, therefore, assumes great importance as patients who have been declared brainstem dead and potential organ donors need to be managed carefully with adequate organ perfusion, until a disposition regarding organ procurement can be made. In most developed regions, there is a well-developed operational system of critical care transport where unstable patients who are invasively ventilated, on pressors and even supported by extracorporeal life support can be transported to an organ transplant centre for procurement of organs. 18 19 Even when patient transport cannot take place, systems exist for transportation of the organs after procurement in a manner that maintains the viability of the organ enroute to the recipient. In India, these systems are lacking and poorly operational. The global health challenges are at multiple levels. First, there are very few options for transport of critically ill patients. While the public system maintains ambulances through the National Health Mission, only the advanced life support ambulances are equipped with ventilators. 18 These ambulances are not always available on an emergent basis. Next, the staff managing the ambulances are not trained in the management of patients with complex critical care needs and cannot maintain continuous communication with critical care providers or trouble shoot in the case of sudden deterioration. Finally, there is no way to coordinate transfers on an emergent basis. A small rural centre referring a patient who is brainstem dead to a large healthcare facility does not know if there is a transplant surgeon available and may not be able to discuss the case in detail. The large referral healthcare facility will only receive a written summary of the patient and is not made aware of the patient’s arrival in advance. There are multiple layers of disconnect during referrals, which make emergent transfer of brainstem dead patients from a rural hospital to a large referral centre extremely difficult. This tele-ICU model offers a temporising solution to stabilise patients in order to maintain perfusion of vital organs while the logistics of transfer and organ procurement are organised. Tele-ICU models have been shown to be efficacious in a number of scenarios including resource-constrained settings. 12 14 15 20 21 The immediate post-trauma stage, particularly in the context of brainstem death is extremely important in maintaining the viability of organs as well as providing resources and information to the family in helping them make decisions about organ donation. 22 It should be noted that most of the population in India do not have a preference regarding organ donation and general awareness is lacking. 23–26 It is, therefore, a very daunting task for a healthcare provider to counsel the family about organ donation, particularly when the healthcare provider is not well versed in the process or management—which is the case for most doctors working in rural regions of the country. The tele-ICU model enables critical care experts to take part in the discussions with the family and answer nuanced questions regarding the procedure, criteria and outcome. Tele-ICU models facilitate skill transfer and capacity building through real-time remote consultation and support. 20 27 One way that tele-ICU models facilitate skill transfer is through virtual training and best practice education. 13 14 Tele-ICU models were instrumental in improving patient outcomes, reducing costs and addressing the shortage of critical care providers during the pandemic. 14 20 This can also help to improve the overall coordination and communication between remote and specialised healthcare providers, which can lead to better patient outcomes. The legal basis for operations is per the Tele-Health Guidelines of the Government of India that works on a model of registered medical practitioner to registered medical practitioner (RMP-RMP) where the bedside team takes responsibility for clinical decisions and consults the tele-ICU team as needed. 9 As in this case, the tele-ICU team provided input for the bedside team to follow. The input is grounded in adherence to protocols and known clinical training. The ground reality and resource constraints of the local ICUs are important considerations when providing tele-ICU input. To scale up the tele-ICU model, several factors are important—the expansion of the tele-ICU network, partnerships with local hospitals to provide remote monitoring and the organisation of support services. Investing in technology and infrastructure, such as high-speed internet connectivity, telemedicine equipment and trained information technology personnel is also crucial. While tele-ICU is one small part of the improvement needed in Indian critical care service provision, until rural infrastructure, medical training and staffing can be improved, tele-ICU has a potentially important role to play in the provision of rural critical care. Learning points. The demand for organ transplants exceeds the current availability of organ donors. Tele-ICU technology provides remote monitoring and management for critically ill patients via high-end cameras, electronic medical records, mobile devices and video conferencing to connect patients with critical care specialists. Improving access to critical care services through tele-ICU can increase the provision of critical care in rural areas. Footnotes Contributors: The following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: PD, DSP and CB. The following authors gave final approval of the manuscript: PD, DSP and CB. Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy. Competing interests: Prudhvi Dasari and Maheeja Reddy are employees of Cloudphysician Pvt India Ltd that owns the intellectual property to RADAR, the tele-ICU platform used for patient care in this case report. The authors hold no formal affiliation to Cloudphysician Pvt India Ltd. Provenance and peer review: Not commissioned; externally peer reviewed. Ethics statements Patient consent for publication Consent obtained from next of kin. References 1. Platt JL, Cascalho M. New and old technologies for organ replacement. 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Int J Environ Res Public Health 2022;19:5101. 10.3390/ijerph19095101 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Articles from BMJ Case Reports are provided here courtesy of BMJ Publishing Group ACTIONS View on publisher site PDF (301.1 KB) Cite Collections Permalink PERMALINK Copy RESOURCES Similar articles Cited by other articles Links to NCBI Databases Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM Add to Collections Create a new collection Add to an existing collection Name your collection * Choose a collection Unable to load your collection due to an error Please try again Add Cancel Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top