Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures.

BACKGROUND: The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied. METHODS: We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity. RESULTS: A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients. CONCLUSIONS: After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness. (Funded by the Canadian Institutes for Health Research and others.).

Determination of death after circulatory arrest by intensive care physicians: A survey of current practice in the Netherlands.

PURPOSE: Determination of death is an essential part of donation after circulatory death (DCD). We studied the current practices of determination of death after circulatory arrest by intensive care physicians in the Netherlands, the availability of guidelines, and the occurrence of the phenomenon of autoresuscitation. METHODS: The Determination of Cardiac Death Practices in Intensive Care Survey was sent to all intensive care physicians. RESULTS: Fifty-five percent of 568 Dutch intensive care physicians responded. Most respondents learned death determination from clinical practice. The most commonly used tests for death determination were flat arterial line tracing, flat electrocardiogram (standard 3-lead electrocardiogram), and fixed and dilated pupils. Rarely used tests were absence pulse by echo Doppler, absent blood pressure by noninvasive monitoring, and unresponsiveness to painful stimulus. No diagnostic test or procedure was uniformly performed, but 80% of respondents perceived a need for standardization of death determination. Autoresuscitation was witnessed by 37%, after withdrawal of treatment or after unsuccessful resuscitation. CONCLUSIONS: Extensive variability in the practice of determining death after circulatory arrest exists, and a need for guidelines and standardization, especially if organ donation follows death, is reported. Autoresuscitation is reported; this observation requires attention in further prospective observational studies.

Variability in protocols on donation after circulatory death in Europe.

INTRODUCTION: Organ donation after circulatory death (DCD) has become an accepted strategy to reduce the shortage of organs for transplantation in many European countries. The use and number of DCD donors varies between countries. The purpose of this study was to evaluate the available protocols for DCD in Europe. METHODS: We contacted national transplant societies and responsible transplant co-ordinators in the countries that perform DCD to obtain DCD protocols. We compared information on the protocols and additional data including: inclusion and exclusion criteria for donation, legislation, determination of death and preservation methods. RESULTS: In ten European countries DCD is performed, eight of which describe the methods in protocols. There are large differences in used DCD categories, legislation and the way death is determined. Protocols differ in the detail in which DCD procedures are described and the way methods are supported by additional consensus statements and ethical frameworks. CONCLUSIONS: Although DCD is an established strategy to enlarge the donor pool and to contribute to the reduction of the waiting list for transplantation, its potential has not been fully utilized yet. To further promote DCD transplantation, it is important to share expertise and obtain consensus, so that this can be translated into more uniform and solid protocols supported by the competent authorities, transplant and intensive care professionals, which may eventually result in a further promotion of DCD transplantation in Europe.

Transplantation of kidneys from paediatric DCD donors: a comparison with DBD donors.

BACKGROUND: Although acceptable outcomes have been reported in kidney transplantation from donation after cardiac death (DCD), little is known about kidney transplantation from paediatric DCD. The objective of this study was to compare the outcome of kidney transplantation using paediatric DCD with the outcome of paediatric donation after brain death (DBD). METHODS: Recipients from DCD and DBD donors <18 years of age transplanted in the Netherlands between January 1981 and July 2006 were included in this study. Ninety-one patients were transplanted with kidneys from paediatric DCD donors and 405 patients received grafts from paediatric DBD donors. RESULTS: Grafts from DCD donors were associated with higher percentage of primary non-function (9 versus 2%, P < 0.01) and delayed graft function (48 versus 8%, P < 0.001) compared with DBD donor grafts. Estimated glomerular filtration rate did not differ between groups (57 ± 17 versus 58 ± 21 mL/min at 1 year and 62 ± 14 versus 57 ± 22 mL/min at 5 years, respectively). After correction for confounding variables, the risk of graft failure was higher in the DCD group [hazard ratio 2.440 (95% confidence interval (CI) 1.280-4.650; P = 0.007]. Patient survival, however, was similar between groups [hazard ratio 1.559 (95% CI 0.848-2.867; P = 0.153)]. CONCLUSIONS: Paediatric DCD kidneys represent a valuable source of donor kidneys that has not been fully utilized. Although transplantation of paediatric DCD kidneys is associated with a higher risk of graft failure than transplantation of paediatric DBD kidneys, results are comparable with adult donors. We therefore conclude that paediatric DCD kidneys can be safely added to the donor pool.

Higher organ donation consent rates by relatives of potential uncontrolled donors versus potential controlled donors after death.

BACKGROUND: Refusal to consent to organ donation is an important cause of the persisting gap between the number of potential organ donors and effectuated donors. In the Netherlands, organ donors include both uncontrolled donors: donors who die unexpectedly after cardiac death (DCD), after failed resuscitation and donors in whom death can be expected and donors after brain death, and controlled DCD donors: those who die after the withdrawal of treatment. Different donor type implies a different setting in which relatives are requested to consent to organ donation. It is unknown whether the setting influences the eventual decision for donation or not. Therefore, we compared the consent rate in potential donors who died unexpectedly (UD group) and in whom death was expected. METHODS: A total of 523 potential organ donors between 2003 and 2011 in the 715-bed Maastricht University Medical Centre, the Netherlands were included. Both the patients' registration in the national donor register (DR) and the relatives' refusal rate in the two groups were retrospectively assessed using data from the donation application database. RESULTS: There were 109 unexpected and 414 expected potential donors The potential donors in the UD group were younger (mean age 52 versus 55 years, P = 0.032) and more often male (68 versus 52%, P = 0.003). There were no significant differences in registration in the DR between the groups. The relatives' consent rate in non-registered potential donors, or those who mandated the relatives for that decision, was higher in the UD group (53 versus 29%, P < 0.001). CONCLUSIONS: Less than 50% of the potential donors were registered in the national DR. Therefore, the relatives have an important role in the choice for organ donation. The relatives of potential donors who died unexpectedly consented more often to donation than those in whom death was expected.

Prediction of time of death after withdrawal of life-sustaining treatment in potential donors after cardiac death*.

OBJECTIVE: Organ donation after cardiac death increases the number of donor organs. In controlled donation after cardiac death donors, the period between withdrawal of life-sustaining treatment and cardiac arrest is one of the parameters used to assess whether organs are suitable for transplantation. The objective of this study was to identify donation after cardiac death donor characteristics that affect the interval between withdrawal of life-sustaining treatment and cardiac death. DESIGN: Prospective multicenter study of observational data. PATIENTS: All potential donation after cardiac death donors in The Netherlands between May 2007 and June 2009 were identified. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 242 potential donation after cardiac death donors, 211 entered analysis, 76% of them died within 60 mins, and 83% died within 120 mins after withdrawal of life-sustaining treatment. The median time to death was 20 mins (range 1 min to 3.8 days). Controlled mechanical ventilation, use of norepinephrine, absence of reflexes, neurologic deficit as cause of death, and absence of cardiovascular comorbidity were associated with death within 60 and 120 mins. The use of analgesics, sedatives, or extubation did not significantly influence the moment of death. In the multivariable logistic regression analysis, controlled mechanical ventilation remained a risk factor for death within 60 mins, and norepinephrine administration and absence of cardiovascular comorbidity remained risk factors for death within 120 mins. The clinical judgment of the intensivist predicted death within 60 and 120 mins with a sensitivity of 73% and 89%, respectively, and a specificity of 56% and 25%, respectively. CONCLUSION: Despite the identification of risk factors for early death and the additional value of the clinical judgment by the intensivist, it is not possible to reliably identify potential donation after cardiac death donors who will die within 1 or 2 hrs after life-sustaining treatment has been withdrawn. Consequently, a donation procedure should be initiated in every potential donor.

Preservation techniques for donors after cardiac death kidneys.

PURPOSE OF REVIEW: The purpose of the present review is to describe the techniques currently used to preserve kidneys from donors after cardiac death. RECENT FINDINGS: Automated chest compression devices may be used to improve organ perfusion between cardiac death and preservation measures. Normothermic extracorporeal membrane oxygenation reduces warm ischemic injury and has the ability to improve organ viability in donors after cardiac death. SUMMARY: Kidneys from donors after cardiac death expand the donor pool but are inevitably subjected to a period of warm ischemia. Reduction of warm ischemic injury to the organs improves transplant outcome. To reduce this injury in organs from donors after cardiac death, different preservation techniques are used. Automated chest compression devices improve organ perfusion between cardiac death and the start of organ preservation. In-situ preservation with double-balloon triple-lumen catheter is an easy technique to preserve organs in uncontrolled donors and is used in many centers to cool and flush the organs. In controlled donors, organs can also be flushed after laparotomy and direct cannulation of the aorta. Extracorporeal membrane oxygenation reduces warm ischemic injury and the use of normothermic perfusion seems promising. Optimal preservation is essential to improve the viability of kidneys from donors after cardiac death, to fully utilize this large donor pool.