Transesophageal Ultrasound-Guided Normothermic Regional Perfusion in Controlled Donors After Cardiocirculatory Determination of Death.

Programs of donation after cardiocirculatory determination of death (DCD) are increasingly established in many countries to increase the availability of organs for transplantation. The use of abdominal normothermic regional reperfusion (A-NRP), shortening total warm ischemia time (tWIT), has been recently recommended by the European Society for Organ Transplantation (ESOT) to decrease the risk potentially associated with transplantation of grafts from DCD donors. We aimed to describe our transesophageal ultrasound (TEU)-guided technique to implement A-NRP in controlled DCD (cDCD) donors through femorofemoral venoarterial extracorporeal support, preventing coronary and cerebral reperfusion occluding the aorta with a balloon. After assessment of the central vascular structures, the use of TEU in real time guides the insertion of the guidewires and the balloon. Moreover, TEU allows us to verify the proper positioning of a venous cannula and aortic balloon. The entire procedure may be performed without the need for fluoroscopic or radiographic evaluation, or limiting the need for fluoroscopic or radiology assistance to a selected scenario of difficult or expected difficult cannulation and/or balloon insertion. The distribution of interventions as antemortem and postmortem reflects the scenario imposed by Italian laws regulating organ procurement in DCD donors.

cDCD organ donation pathway of Romagna Local Health Authority: strategic planning, organizational management, and results.

The introduction of pathways to enrol deceased donors after cardio-circulatory confirmation of death (donation after circulatory death, DCD) is expanding in many countries to face the shortage of organs for transplantation. The implementation of normothermic regional reperfusion (NRP) with warm oxygenated blood is a strategy to manage in-situ the organs of DCD donors. This approach, an alternative to in-situ cold preservation, and followed by prompt retrieval and cold static storage and/or ex-vivo machine perfusion (EVMP), could be limited to abdominal organs (A-NRP) or extended to the thorax (thoraco-abdominal, TA-NRP. NRP is also referred to as extracorporeal interval support for organ retrieval (EISOR). The use of EISOR is increasing in Europe, even if variably regulated. A-NRP has been demonstrated to be effective in decreasing the risk associated with transplantation of abdominal organs from DCD donors, and was recommended by the European Society for Organ Transplantation (ESOT) in a recent consensus document. We aim to explain how we select the candidates for DCD, to describe our regionalized model for implementing EISOR provision, and to introduce the health care professionals involved in this complex process, with their strictly defined roles, responsibilities, and boundaries. Finally, we report the results of our program, recruiting cDCD donors over a large network of hospitals, all pertaining to a Local Health Authority (Azienda Unità Sanitaria Locale, AUSL) in Romagna, Italy.

EISOR Delivery: Regional experience with sharing equipe, equipment & expertise to increase cDCD donor pool in time of pandemic.

Donation after circulatory death (DCD) programs are expanding in Europe, in the attempt to expand donors pool. Even in controlled DCD donors, however, a protracted warm ischemia time occurring in the perimortem period might damage organs, making these unsuitable for transplantation. Implementing a strategy of extracorporeal interval support for organ retrieval (EISOR), a regional reperfusion with normothermic, oxygenated blood provides a physiologic environment allowing extensive assessment of potential grafts, and potentially promotes recovery of native function. Here we report the results of a multi-center retrospective cohort study including 29 Maastricht Category III controlled DCD donors undergoing extracorporeal support in a regional DCD/EISOR Training Center, and in the network of referring In-Training Centers, under the liaison of the regional Transplant Coordination Center during COVID-19 pandemic, between March 2020 and November 2021. The study aims to understand whether a mobile, experienced EISOR team implementing a consistent technique and sharing its equipe, expertise and equipment in a regional network of hospitals, might be effective and efficient in implementing the regional DCD program activity even in a highly stressed healthcare system.

Trauma and donation after circulatory death: a case series from a major trauma center.

Even with encouraging recipient outcomes, transplantation using donation after circulatory death (DCD) is still limited. A major barrier to this type of transplantation is the consequences of warm ischemia on graft survival; however, preservation techniques may reduce the consequences of cardiac arrest and provide better organ conservation. Furthermore, DCD in trauma patients could further expand organ donation. We present five cases in which organs were retrieved and transplanted successfully using normothermic regional perfusion (NRP) in trauma patients. Prompt critical care support and surgical treatment allowed us to overcome the acute phase. Unfortunately, owing to the severity of their injuries, all of the donors died. However, the advanced and continuous organ-specific supportive treatment allowed the maintenance of general clinical stability and organ preservation. Consequently, it was possible to retrieve and transplant the donors' organs. Death was ascertained in accordance with cardio-circulatory criteria, which was followed by NRP. We consider that DCD in trauma patients may represent an important source of organs.

At the heart of organ donation. Case reports of organ donation after cardiac death in two patients with successfully repaired AAST grade V cardiac injuries.

Background: Trauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries. Case presentation: The first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards. Conclusions: The outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors.

Chest ultrasonography in the ICU.

Chest diagnostic imaging is essential when dealing with a critically ill patient. At present, direct visualization of the lung parenchyma is performed with a chest x-ray and computed tomography with the patient in the supine position. The relative ease of bedside ultrasound examination and the availability of user-friendly, inexpensive, portable equipment have made chest ultrasonography an interesting and alternative method in various situations, because it offers accurate information that is of therapeutic and diagnostic relevance. We describe equipment and examination technique, normal findings, and chest ultrasonography signs detected in some pathological situations, such as pneumothorax, consolidations, pleural effusions, ARDS, and pulmonary edema.

Using sonography to assess lung recruitment in patients with acute respiratory distress syndrome.

The purpose of managing acute respiratory distress syndrome (ARDS) is "to open a closed lung" by increasing the airway pressure or changing the patient's position. Assessment of recruitment of atelectatic lung regions is necessary to have a correct management of mechanical ventilation and to be sure of positive end-expiratory pressure or prone position efficacy before their application. In fact, both of them could have collateral effects. Sonographic approach allows a dynamic evaluation of lung recruitment in patients affected by ARDS and it is easy to perform bedside. In particular, it is useful for patients too unstable to be moved to the CT room. Sonography is fast, cheap, and radiation free; thus, it can be repeated in order to monitor the evolution of ARDS. To our knowledge, the use of this technique in the setting of ARDS was never reported before.