maastricht classification of dcd

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18 th TPM course, November 2012 Maastricht Classification of DCD Definition Where I 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 Belgium, United Kingdom, Netherlands, Australia, USA, New Zealand IV Cardiac arrest after brain death MC I, II, uncontrolled MC III, IV: controlled

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Maastricht Classification of DCD. MC I, II, uncontrolled MC III, IV: controlled. An Introduction to Maastricht Category III DCD. Dr Paul Murphy National Lead for Organ Donation NHS Blood and Transplant, UK. Controlled DCD – the donation process. Objectives for the session – to understand. - PowerPoint PPT Presentation

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Page 1: Maastricht Classification of DCD

18th TPM course, November 2012

Maastricht Classification of DCD

Definition Where

I Dead on arrivalSpain, France, Italy

II Unsuccessful resuscitation

III Cardiac arrest awaited after withdrawal of life support in patients who are not brain dead

Belgium, United Kingdom, Netherlands, Australia, USA, New ZealandIV Cardiac arrest after brain death

MC I, II, uncontrolled

MC III, IV: controlled

Page 2: Maastricht Classification of DCD

18th TPM course, November 2012

An Introduction to Maastricht Category III DCD

Dr Paul MurphyNational Lead for Organ Donation

NHS Blood and Transplant, UK

Page 3: Maastricht Classification of DCD

18th 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

Page 4: Maastricht Classification of DCD

18th 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.

Page 5: Maastricht Classification of DCD

18th TPM course, November 2012

How is end of life care changed to support DCD?

Page 6: Maastricht Classification of DCD

18th TPM course, November 2012

General overview

DCD as part of end of life careKey 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

Page 7: Maastricht Classification of DCD

18th TPM course, November 2012

General overview

DCD as part of end of life careKey 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.

Page 8: Maastricht Classification of DCD

18th 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

Page 9: Maastricht Classification of DCD

18th TPM course, November 2012

Ischaemic injury in category III DCD

asystole coldperfusion

transplantreperfusion

withdrawal

cold ischaemia

decision reWLST

warm ischaemia

terminal physiological decline

SBP < 50mmHgSaO2 < 75%

Page 10: Maastricht Classification of DCD

18th TPM course, November 2012

Ischaemic injury

asystole coldperfusion

transplantreperfusion

withdrawal

cold ischaemia

decision reWLST

functional warm

ischaemia

NB: timeline not to scale

agonalperiod

SBP < 50mmHgSaO2 < 75%

Page 11: Maastricht Classification of DCD

18th TPM course, November 2012

Time to asystole

56% die within 60 mins64% die within 2 hours72% die within 4 hours

Suntharalingam et al. AJT 2009;9:2157

• Younger age• High respiratory support

– High FiO2

– PEEP > 10 cmH2O– IPPV

• Inotropes• GCS 3• Terminal extubation• BMI > 30

Page 12: Maastricht Classification of DCD

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

Page 13: Maastricht Classification of DCD

18th TPM course, November 2012

Solutions to ischaemic injury

t = 2 min

Medical CentreUniversity 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

Page 14: Maastricht Classification of DCD

18th 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

Page 15: Maastricht Classification of DCD

18th TPM course, November 2012

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 teamsNot ideal environments for families

Page 16: Maastricht Classification of DCD

18th TPM course, November 2012

Diagnosis of Death

www.aomrc.org.uk/publications/reports-guidance.html

In the UK, death can be confirmed after 5 minutes of complete and continuous absence of cardio-respiratory function…………

Page 17: Maastricht Classification of DCD

18th 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

Page 18: Maastricht Classification of DCD

18th 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

Page 19: Maastricht Classification of DCD

18th 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

Page 20: Maastricht Classification of DCD

18th TPM course, November 2012

Methods of retrieval

Perfusion in situIntra-peritoneal cooling

Crash laparotomySuper-rapid perfusion

Page 21: Maastricht Classification of DCD

18th TPM course, November 2012

asystole coldperfusion

transplantreperfusionwithdrawal

cold ischaemia

Solutions to ischaemic injuryNormothermic regional perfusion

normothermicregional

perfusion

Normothermic reperfusion serves to restore aerobic conditions prior to cold

perfusion

Page 22: Maastricht Classification of DCD

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

Page 23: Maastricht Classification of DCD

18th 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

Page 24: Maastricht Classification of DCD

18th TPM course, November 2012

Deceased donation in UK, 2000-12

0

200

400

600

800

1000

1200

2002-2003 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011 2011-2012

year

dece

ased

don

ors

in U

K

DBD controlled DCD

25% of DD transplants in the UK come from MC 3 DCD donors

Page 25: Maastricht Classification of DCD

18th TPM course, November 2012

Number of patients transplanted from UK deceased donors

1 April 2010 – 31 March 2011

DBD DCDDonors 637 373

Kidney, kidney+pancreas 1091 567

Pancreas 30 11

Heart, Heart+lung 134 0

Lung (single and double) 147 22

Liver 580 100

Total transplanted patients 1982 700

Transplanted patients per donor 3.1 1.9

25% of DD transplants in the UK come from MC 3 DCD donors

Page 26: Maastricht Classification of DCD

18th TPM course, November 2012

Cause of death in MC III DCD donors

10.4

16.2

12.4

25.9

3.2

5.6

26.3

3.5

4.2

6.2

27.5

7.8

8.0

42.8

0 5 10 15 20 25 30 35 40 45

Other Miscellaneous

Other Medical Disease

Primary Respiratory Disease

Hypoxic Brain Injury

Trauma (including head injury)

Other CVA (thrombotic or unclassified)

Intracranial haemorrhage (non traumatic)

Dia

gnos

tic c

ateg

orie

s

Percentage

Actual DCDs %

Potential DCDs %

UK Potential Donor Audit (October 2009 – March 2012)7504 patients referred as potential DCD donors877 actual DCD donors

Page 27: Maastricht Classification of DCD

18th TPM course, November 2012

UK kidney transplant outcomes for DBD/DCD donors

Graft survival

% g

raft

surv

ival

40

50

60

70

80

90

100

years post-transplant0 1 2 3 4 5

% p

atie

nt s

urvi

val

40

50

60

70

80

90

100

years post-transplant0 1 2 3 4 5

DCDDBD Patient survival

Page 28: Maastricht Classification of DCD

18th TPM course, November 2012

DBDDCD

3 year patient survival

% p

atie

nt s

urviv

al50

60

70

80

90

100

Years since transplant0.0 0.5 1.0 1.5 2.0 2.5 3.0

3 year transplant survival

% tr

ansp

lant

sur

vival

50

60

70

80

90

100

Years since transplant0.0 0.5 1.0 1.5 2.0 2.5 3.0

UK Liver transplant outcomes for DBD/DCD donors

Page 29: Maastricht Classification of DCD

18th TPM course, November 2012

3 year transplant survival

% tr

ansp

lant

sur

vival

50

60

70

80

90

100

Years since transplant0.0 0.5 1.0 1.5 2.0 2.5 3.0

UK Liver transplant outcomes for DBD/DCD donors

Page 30: Maastricht Classification of DCD

18th 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