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


An Introduction to Maastricht Category III DCD

Dr Paul MurphyNational Lead for Organ Donation

NHS Blood and Transplant, UK


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


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.


How is end of life care changed to support DCD?


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


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.


• 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


Ischaemic injury in category III DCD

asystole coldperfusion

transplantreperfusion

withdrawal

cold ischaemia

decision reWLST

warm ischaemia

terminal physiological decline

SBP < 50mmHgSaO2 < 75%


Ischaemic injury


transplantreperfusion

withdrawal

cold ischaemia

decision reWLST

functional warm

ischaemia

NB: timeline not to scale

agonalperiod

SBP < 50mmHgSaO2 < 75%


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


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


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


• 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


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


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…………


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


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


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


Methods of retrieval

Perfusion in situIntra-peritoneal cooling

Crash laparotomySuper-rapid perfusion



transplantreperfusionwithdrawal

cold ischaemia

Solutions to ischaemic injuryNormothermic regional perfusion

normothermicregional

perfusion

Normothermic reperfusion serves to restore aerobic conditions prior to cold

perfusion


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


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


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


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


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


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


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


UK Liver transplant outcomes for DBD/DCD donors


3 year transplant survival

% tr

ansp

lant

sur

vival

50

60

70

80

90

100


UK Liver transplant outcomes for DBD/DCD donors


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

maastricht classification of dcd

Documents

dcd retrievals

ukcontrolled dcd

dcd pathwayobstacles

planned withdrawal of

withdrawal of treatments

dcd donationfamily approach

donationcomplete withdrawal

dcd stand down40