Transcript Controlled Non-heart Beating Organ Donation

Maastricht Classification of DCD
Definition
I
Where
Dead on arrival
Spain, France, Italy
II
Unsuccessful resuscitation
III
Cardiac arrest awaited after withdrawal of life
support in patients who are not brain dead
IV
Cardiac arrest after brain death
MC I, II, uncontrolled
MC III, IV: controlled
18th TPM course, November 2012
Belgium, United
Kingdom, Netherlands,
Australia, USA, New
Zealand
An Introduction to Maastricht Category III DCD
Dr Paul Murphy
National Lead for Organ Donation
NHS Blood and Transplant, UK
18th TPM course, November 2012
Controlled DCD – the donation process
Objectives for the session – to understand
• Definition of category III DCD
• Key elements of the category III DCD pathway
• Obstacles to DCD donation
– Family approach and conflict of interest
– Who can donate: prediction of asystole
– Limitation of ischaemic injury
– Diagnosis of death and post mortem
interventions
• Outcomes
– Contribution to transplantation in UK
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The pathway of controlled DCD
The retrieval of organs from patients
whose death is diagnosed on cardiorespiratory criteria and which follows
the planned withdrawal of lifesustaining treatments.
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How is end of life care changed to support DCD?
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DCD as part of end of life care
Key considerations
General overview
• Donation considered before death
• Withdrawal delayed by several hours
– Physiological instability
• Altered management of death
– ? Withdrawal in anaesthetic room
– Diagnosis of death after 5 minutes of asystole
– Rapid transfer to theatre
• Organ ischaemia and graft outcomes
• Stand down
• Substitution
18th TPM course, November 2012
We view DCD as
part of the care we
give patients when
they die – offered,
not imposed
DCD as part of end of life care
Key considerations
General overview
• Donation considered before death
• Withdrawal delayed by several hours
– Physiological instability
• Altered management of death
– ? Withdrawal in anaesthetic room
– Diagnosis of death after 5 minutes of
asystole
– Rapid transfer to theatre
• Organ ischaemia and graft outcomes
• Stand down
• Substitution
18th TPM course, November 2012
40% of DCD
retrievals in the UK
are stood down.
Family approach and conflict of interest
• Decision making around withdrawal of
treatments should be transparent and
consistent
– All ICUs and EDs should have explicit local
policies based upon national guidance
– Multi-disciplinary
• Donation should only be raised after a
family have understood and accepted their
loss
– presented as an end of life care option
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“You should be prepared to
follow any national
procedures for identifying
potential organ donors”
GMC
Ischaemic injury in category III DCD
decision re
WLST
withdrawal
asystole
cold
perfusion
warm
ischaemia
terminal
physiological decline
SBP < 50mmHg
SaO2 < 75%
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transplant
reperfusion
cold
ischaemia
Ischaemic injury
decision re
WLST
withdrawal
asystole
cold
perfusion
transplant
reperfusion
agonal
period
cold
ischaemia
SBP < 50mmHg
SaO2 < 75%
NB: timeline not to scale
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functional
warm
ischaemia
Time to asystole
56% die within 60 mins
64% die within 2 hours
72% die within 4 hours
•
•
Younger age
High respiratory
support
– High FiO2
– PEEP > 10 cmH2O
– IPPV
•
•
•
•
Inotropes
GCS 3
Terminal extubation
BMI > 30
Suntharalingam et al. AJT 2009;9:2157
18th TPM course, November 2012
Current UK guidance on DCD stand down
• 40% DCD retrievals are stood down
– Practicality (agonal period)
– Ischaemic injury (functional warm ischaemia)
• Minimum agonal period is now 3 hours
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Solutions to ischaemic injury
• Ante-mortem
– Tissue typing and virological
screening
– Steroids, heparin, vasodilators
– Femoral cannulation
• Management at time of death
– Withdrawal in theatre
t = 2 min
– Expedient diagnosis of death
• Post-mortem reperfusion
– In situ
– Ex situ
18th TPM course, November 2012
Medical Centre
University of Pittsburgh
USA
Process of treatment withdrawal
• Manner of treatment withdrawal should not be
adjusted to promote donation
• Complete withdrawal of all cardio-respiratory
treatments
– Inotropes
– Ventilation
– Endotracheal tube
• Nursed in supine position
• Pharmacological comfort cares as required
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Location of treatment withdrawal
Theatre
Critical Care
Reduces warm ischaemia
Fewer staffing issues
May give family more privacy
Stand downs easily managed
Need back up plan for stand down
Longer warm ischaemia
Creates staffing problems
Undignified rush to theatre
May create conflicts for retrieval
teams
Not ideal environments for families
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Diagnosis of Death
www.aomrc.org.uk/publications/
reports-guidance.html
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In the UK, death can be confirmed
after 5 minutes of complete and
continuous absence of cardiorespiratory function…………
Diagnosis of Death
• Asystole is absence of mechanical
cardiac function, not electrical silence
on ECG
• It is best diagnosed by
– Invasive arterial pressure monitoring
– Echocardiography
• If invasive pressure monitoring or
echocardiography are not available,
identify on basis of isoelectric ECG
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Death can be diagnosed
after five minutes of
continuous asystole
Diagnosis of Death
• Death is confirmed by demonstrating
the absence of neurological function
(respiration, consciousness and brainstem reflexes) after 5 minutes of
continuous asystole
• Any return of cardiac or respiratory
function must prompt further 5 minutes
of observation
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Death is regarded as the
simultaneous and
irreversible loss of
consciousness and
respiration
Diagnosis of death and organ retrieval
• A clear intention not to perform cardiopulmonary resuscitation
• Confidence that the possibility of
spontaneous return of cardiac function
has passed
• An absolute prohibition on any
intervention that might restore cerebral
oxygenation
– Restoration of myocardial contractility
– Extracorporeal oxygenation
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The brain remains
responsive to restoration
of oxygenation of some
minutes
Methods of retrieval
Perfusion in situ
Intra-peritoneal cooling
Crash laparotomy
Super-rapid perfusion
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Solutions to ischaemic injury
Normothermic regional perfusion
normothermic
regional
perfusion
withdrawal
asystole
cold
perfusion
transplant
reperfusion
cold ischaemia
Normothermic reperfusion
serves to restore aerobic
conditions prior to cold
perfusion
18th TPM course, November 2012
Reversing organ ischaemia
• Laparotomy, cannulation and perfusion with
preservation solutions can begin as soon as
death has been confirmed
• Regional normothermic perfusion of
abdominal organs with oxygenated blood
can take place as soon as the cerebral
circulation has been isolated
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Lung retrieval from DCD donors
• Re-intubation can take place
as soon as death has been
confirmed
• Lungs can be re-inflated with a
single insufflation after 10
minutes
DCD donors may become the preferred
source of lungs – particularly if assessed
and re-conditioned ex-vivo
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• Cyclical mechanical ventilation
can only begin when the
cerebral circulation has been
isolated.
Deceased donation in UK, 2000-12
1200
DBD
deceased donors in UK
1000
controlled DCD
800
600
400
200
0
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
2008-2009
2009-2010
2010-2011
2011-2012
year
25% of DD transplants in the UK come from MC 3 DCD donors
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Number of patients transplanted from UK
deceased donors
1 April 2010 – 31 March 2011
DBD
Donors
DCD
637
373
1091
567
30
11
Heart, Heart+lung
134
0
Lung (single and double)
147
22
Liver
580
100
1982
700
3.1
1.9
Kidney, kidney+pancreas
Pancreas
Total transplanted patients
Transplanted patients per donor
25% of DD transplants in the UK come from MC 3 DCD donors
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Cause of death in MC III DCD donors
42.8
Intracranial haemorrhage (non traumatic)
26.3
8.0
5.6
Diagnostic categories
Other CVA (thrombotic or unclassified)
7.8
Trauma (including head injury)
3.2
27.5
25.9
Hypoxic Brain Injury
6.2
Primary Respiratory Disease
12.4
4.2
Other Medical Disease
16.2
3.5
Other Miscellaneous
Potential DCDs %
10.4
0
UK Potential Donor Audit (October 2009 – March 2012)
7504 patients referred as potential DCD donors
877 actual DCD donors
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Actual DCDs %
5
10
15
20
25
Percentage
30
35
40
45
UK kidney transplant outcomes for
DBD/DCD donors
Graft survival
DBD
DCD
90
90
% patient survival
100
% graft survival
100
80
70
60
50
40
Patient survival
80
70
60
50
0
1
2
3
4
years post-transplant
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5
40
0
1
2
3
4
years post-transplant
5
UK Liver transplant outcomes for
DBD/DCD donors
100
100
3 year transplant
survival
3 year patient
survival
90
% patient survival
% transplant survival
90
80
70
60
50
0.0
80
70
DBD
DCD
60
0.5
1.0
1.5
2.0
Years since transplant
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2.5
3.0
50
0.0
0.5
1.0
1.5
2.0
Years since transplant
2.5
3.0
UK Liver transplant outcomes for
DBD/DCD donors
100
3 year transplant
survival
% transplant survival
90
80
70
60
50
0.0
0.5
1.0
1.5
2.0
Years since transplant
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2.5
3.0
Summary
• MC 3 DCD requires
– modification to end of life care
– organ retrieval to begin within minutes of diagnosis of death
– considerable commitment from retrieval teams
• There are anxieties over ischaemic injury
– outcomes for kidney transplantation are acceptable
– Interest in restoring circulation soon after death
• MC 3 DCD accounts for almost all the increase in
deceased donation in the UK over last 5 years
18th TPM course, November 2012