18 th TPM course, November 2012 Maastricht Classification of DCD DefinitionWhere IDead on arrival Spain, France, Italy IIUnsuccessful resuscitation III Cardiac arrest awaited after withdrawal of life support in patients who are not brain dead Belgium, United Kingdom, Netherlands, Australia, USA, New Zealand IVCardiac arrest after brain death MC I, II, uncontrolled MC III, IV: controlled

18 th TPM course, November 2012 An Introduction to Maastricht Category III DCD Dr Paul Murphy National Lead for Organ Donation NHS Blood and Transplant, UK

18 th TPM course, November 2012 Controlled DCD – the donation process 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 Objectives for the session – to understand

18 th TPM course, November 2012 The pathway of controlled DCD The retrieval of organs from patients whose death is diagnosed on cardio- respiratory criteria and which follows the planned withdrawal of life- sustaining treatments.

18 th TPM course, November 2012 How is end of life care changed to support DCD?

18 th TPM course, November 2012 General overview DCD as part of end of life care Key considerations We view DCD as part of the care we give patients when they die – offered, not imposed 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

18 th TPM course, November 2012 General overview DCD as part of end of life care Key considerations 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 40% of DCD retrievals in the UK are stood down.

18 th TPM course, November 2012 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 Family approach and conflict of interest “You should be prepared to follow any national procedures for identifying potential organ donors” GMC

18 th TPM course, November 2012 Ischaemic injury in category III DCD asystole cold perfusion transplant reperfusion withdrawal cold ischaemia decision re WLST warm ischaemia terminal physiological decline SBP < 50mmHg SaO 2 < 75%

18 th TPM course, November 2012 Ischaemic injury asystole cold perfusion transplant reperfusion withdrawal cold ischaemia decision re WLST functional warm ischaemia NB: timeline not to scale agonal period SBP < 50mmHg SaO 2 < 75%

18 th TPM course, November 2012 Time to asystole 56% die within 60 mins 64% die within 2 hours 72% die within 4 hours Suntharalingam et al. AJT 2009;9:2157 Younger age High respiratory support –High FiO 2 –PEEP > 10 cmH 2 O –IPPV Inotropes GCS 3 Terminal extubation BMI > 30

18 th 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

18 th TPM course, November 2012 Solutions to ischaemic injury t = 2 min Medical Centre University of Pittsburgh USA Ante-mortem –Tissue typing and virological screening –Steroids, heparin, vasodilators –Femoral cannulation Management at time of death –Withdrawal in theatre –Expedient diagnosis of death Post-mortem reperfusion –In situ –Ex situ

18 th TPM course, November 2012 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 Process of treatment withdrawal

18 th TPM course, November 2012 Location of treatment withdrawal TheatreCritical Care Reduces warm ischaemiaFewer staffing issues May give family more privacyStand downs easily managed Need back up plan for stand downLonger warm ischaemia Creates staffing problemsUndignified rush to theatre May create conflicts for retrieval teams Not ideal environments for families

18 th TPM course, November 2012 Diagnosis of Death reports-guidance.html In the UK, death can be confirmed after 5 minutes of complete and continuous absence of cardio- respiratory function…………

18 th TPM course, November 2012 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 Death can be diagnosed after five minutes of continuous asystole

18 th TPM course, November 2012 Diagnosis of Death Death is confirmed by demonstrating the absence of neurological function (respiration, consciousness and brain- stem reflexes) after 5 minutes of continuous asystole Any return of cardiac or respiratory function must prompt further 5 minutes of observation Death is regarded as the simultaneous and irreversible loss of consciousness and respiration

18 th TPM course, November 2012 Diagnosis of death and organ retrieval A clear intention not to perform cardio- pulmonary 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 The brain remains responsive to restoration of oxygenation of some minutes

18 th TPM course, November 2012 Methods of retrieval Perfusion in situ Intra-peritoneal cooling Crash laparotomy Super-rapid perfusion

18 th TPM course, November 2012 asystole cold perfusion transplant reperfusion withdrawal cold ischaemia Solutions to ischaemic injury Normothermic regional perfusion normothermic regional perfusion Normothermic reperfusion serves to restore aerobic conditions prior to cold perfusion

18 th 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

18 th TPM course, November 2012 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 Cyclical mechanical ventilation can only begin when the cerebral circulation has been isolated. DCD donors may become the preferred source of lungs – particularly if assessed and re-conditioned ex-vivo

18 th TPM course, November 2012 Deceased donation in UK, % of DD transplants in the UK come from MC 3 DCD donors

18 th TPM course, November 2012 Number of patients transplanted from UK deceased donors 1 April 2010 – 31 March 2011 DBDDCD Donors Kidney, kidney+pancreas Pancreas3011 Heart, Heart+lung1340 Lung (single and double)14722 Liver Total transplanted patients Transplanted patients per donor % of DD transplants in the UK come from MC 3 DCD donors

18 th TPM course, November 2012 Cause of death in MC III DCD donors UK Potential Donor Audit (October 2009 – March 2012) 7504 patients referred as potential DCD donors 877 actual DCD donors

18 th TPM course, November 2012 UK kidney transplant outcomes for DBD/DCD donors Graft survival DCD DBD Patient survival

18 th TPM course, November year patient survival 3 year transplant survival UK Liver transplant outcomes for DBD/DCD donors

18 th TPM course, November year transplant survival UK Liver transplant outcomes for DBD/DCD donors

18 th TPM course, November 2012 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