Donation
As A said I am going to give you a quick run through the challenges a clinician faces during the process of donation from the circulatory death pathway
http://internal-acceptance-movement.tumblr.com/post/411436202
Heroes in the world of donation
Dr Joseph Murray pioneered the field of organ transplantation performing the first kidney transplant in 1954 on an identical twin. (1) and then performed the 1st successful cadaveric kidney transplant in 1963. He was awarded the Nobel prize in physiology or medicine in 1990. (1st allograft as well)
Dr Thomas Starzl performed the first human liver transplant in 1963. It was only in 1967 when the first successful transplant occurred with survival up to a year.
James Hardy performed the first lung transplant in 1963 and the first animal to human heart transpant (chimpanzee heart lasted 90mins).
Barnard 1967 – 1st human heart transplant in 1967 with the recipient lasting 18 days.
Harvard definition of brain death 1968
What is not well known is that these were Non heart beating donations
In those days, the surgical team brought a brain-dead donor into the operating room with the recipient for the removal; the respirator was then stopped, and everyone waited for the donor’s heart to cease to beat. Technically, therefore, these donors were donation after cardiac death (DCD) donors
DCD abandoned since adoption of BD criteria, Organs from BD donors had better survival options. Dissatisfaction with the process.
Re-focus on DCD with increased demand, shortage of organs and improved surgical and preservation techniques.
DCD is now back in vogue.
“Donation should not cause or hasten death”
Dead donor rule offers protection to the clinicians involved in organ donation and transplantation from prosecution for assault or even murder, and protects the community support for donation and transplantation.
DDR must be upheld to maintain public trust in the organ-transplantation enterprise.
Organ procurement should not cause the death of the donor and satisfies general prohibition on killing innocent victims
Graveyard shift
The ‘Maastricht’ categories for DCD have been developed as a way to categorise potential donors on a clinical basis and are widely accepted internationally.
Category I. Dead on arrival. Tissue (corneas, heart valves, skin, bone, etc.) can be recovered from category I donors or any individuals who die in a manner not suitable for solid organ recovery. Since there are no immediate time constraints to minimise tissue injury, there is no requirement for a precisely timed approach to tissue recovery.
Category II. Unsuccessful resuscitation (CPR). These are patients who suffer a witnessed cardiac arrest outside the hospital and undergo unsuccessful cardiopulmonary resuscitation (CPR). When CPR fails in a medically suitable organ donor, uncontrolled organ donation is an option.
Category III. Awaiting cardiac arrest following withdrawal of care. With the permission of the donor or donor family, organs may be recovered after death is declared from patients with irreversible brain injury or respiratory failure and in whom treatment is withdrawn. Death is declared after a predetermined period of circulatory arrest.
Category IV. Cardiac arrest after brain death. Rarely, a consented brain dead donor has a cardiac arrest before scheduled organ recovery. Such category IV donors should either proceed as for a normal multi-organ retrieval - if this has already started- or should be managed as a category III donor as appropriate to the circumstances of cardiac arrest.
Category V. Cardiac arrest in a hospital patient. This category is made up of category II donors that originate in-hospital.
S Pelletier MD, Uni of Michigan
In uncontrolled donors, ISP with the double-balloon, triple-lumen catheter or the Gillot catheter is used. In the two countries with the largest numbers of uncontrolled donors (Spain and France), extracorporeal membrane oxygenation with either hypothermic or normothermic perfusion is used as the preservation method of choice.
http://www.clodlog.com/log/files/feed.xml
Controlled DCD Type 3
How certain are you as a clinician that a neurogical outcome will be as predicted?
Prior to ever inititating a conversation wregarding organ donation we should be certain that the patient in question is either going to die or be in such an impaired state that under no circumstance would this be an acceptable outcome for the patinet or their family.
This is “as good as you can get prognostic certainty” accepting that in some situations there will be a glimmer of doubt and at times there will be case in which it is acceptable not to raise organ donation.
Disabilty a fate worse than death??
University of Wisconsin DCD evaluation tool score – AGE, BMI, O2 sats, method of intbation(ETT or trache), level of spont resp or requirement of vasopressors.
An accurate and relevant scoring system which is relevant to local practise will help predict the likelihood of death within a given time period will be welcome.
Reducing the no of stood down donations will reduce family stress and reduce the burden on hard pressed ICU staff and also enable more efficient use of scarce retrieval capacity
Your time starts now
Withdrawal phase.
Acirculatory Phase
Amelia Earhart
Elvis
Lord Lukin
2 minutes – The limited data available suggests that circulation does not spontaneously return after it has stopped for 2 minutes.
DeVita MA. The death watch: certifying death using cardiac criteria. Prog Transplant 2001;2:58-66
To avoid conflicts of interest neither the surgeon who recovers the organs nor any other personel involved in transplantation can participate in end of life care or the declaration of death.