1. DCD challenges
SNOD course

2. DCD today DCD DONATION represents 40% of all transplants
Increase complications due to increase in warm ischaemic time (WIT).
1% occurrence of ischaemic cholangiopathy with DBD liver.
28% occurrence of ischaemic cholangiopathy with DCD liver.
Increase of primary non function x 2.
Increase discard rate
(27% DCD livers transplanted vs 83% DBD).
Decrease in number of organs/donor: DCD:2.6 vs DBD:4)
Increase in organ injury at time of retrieval
(surgical haste in attempt to reduce WIT).

3. Organ utilisation from DCD donors

4. Aims Increase retrieval of organs Improve quality of organs retrieved
DCD heart
DCD lung
Improve quality of organs retrieved
Reduce WIT (withdrawal in anaesthetic room)
Normothermic regional perfusion

5. DCD hearts
Feb 2015 – April 2016 there have been 22 DCD heart retrievals and 20 successful transplants, from a small pool of donor hospitals within London, South East and Eastern area
DCD heart retrieval and transplantation is safe in terms of patient outcomes.

6. DCD heart retrieval Papworth, Harefield and Wythenshawe
Two models of procurement
Direct (Papworth, Harefield and Wythenshawe)
Normothermic regional perfusion (Papworth, only in three centres)
Hearts re-started on OCS and transferred to implanting unit
30 transplants since February 2015
12 NRP (no deaths, but adverse impact on retrieval of other organs)
18 direct procurement (2 deaths)
Business case being considered by Health Departments
If we stick with hearts, let’s move onto DCD heart retrieval, which is now supported by three retrieval centres
2 methods of procurement
OCS technology used to ‘revitalise’ heart for transport to implanting centre
Excellent outcomes, although donors and recipients selected subgroups
OCS technology expensive and business case being considered by DH

7. DCD Heart Retrieval: Sequence of events
Papworth Hospital
NHS Foundation Trust
NHS
DCD Heart Retrieval: Sequence of events
sBP
<50mmHg
Circulatory
Arrest
Diagnosis
of death
WLS
KTS
FWIT 27 min.
DPP
7 min.
Heart
reperfusion
NRP
7 min.
Time (min.)
FWIT 18 min.

8. DCD heart retrieval The ask of us
Agreement in principle
Specifics
Pre-withdrawal transthoracic echo
Cross-match and albumin solution (to prime OCS circuit)
Withdrawal in theatre / very close by
What does it need from us.
Minimise warm ischaemia.
Most importantly, withdrawal in theatre or very close to it
The heart in a box

9. DCD lung
What is required for successful lung donation after circulatory death?
Confirmation of Death
Protection of the airway to prevent aspiration of stomach contents
Early inflation of the lungs with oxygen

10. The confirmation of death after cardiorespiratory arrest
Three vital caveats (from page 12)
There will be no cardio-pulmonary resuscitation
Five minutes is based on the evidence that after this time, spontaneous restoration of the heart and circulation will NOT occur.
“It is obviously inappropriate to initiate any intervention that has the potential to restore cerebral perfusion after death has been confirmed
Early inflation of the lungs with oxygen

11. Protection of the airway to prevent aspiration of stomach contents
Lung DCD
Confirmation of Death
Protection of the airway to prevent aspiration of stomach contents
Early inflation of the lungs with oxygen
2010

12. Lung DCD
Confirmation of Death
Protection of the airway to prevent aspiration of stomach contents
Early inflation of the lungs with oxygen
A cuffed breathing tube can be placed in the airway any time after death has been confirmed
if necessary
planned
by someone appropriately experienced

13. Lung DCD
Confirmation of Death
Protection of the airway to prevent aspiration of stomach contents
Early inflation of the lungs with oxygen
Inflation of the lungs
Minimum wait of 10 minutes after the onset of asystole
Single recruitment maneuver
Followed by CPAP 5cm H2O

14. Lung DCD

15. Optimisation of DCD liver retrieval
Risk of adverse outcome compared with the DBD liver transplantation
DCD overall
ICU
(WIT 26 min) OT
(WIT 18 min) OR p P
Graft survival
1.72
<0.001
1.98
0.02
1.65
0.006
Patient survival
1.36
0.01
2.15
1.20
0.29
Ischaemic cholangiopathy
16.48
19.68
<0.0001
13.73
Meta-analysis of DCD liver tx studies examining impact of location of WLST
Overall DCD is associated with higher risk of death, graft failure and biliary complications when compared to DBD liver tx.
However WLST in ICU lengthens WIT and this is associated with an even greater risk of these complications compared to WLST in OT.

16. Abdominal Normothermic Regional Perfusion (ANRP)
WHAT IS NRP?
Restores circulation of oxygenated blood to all abdominal organs.
Implemented after circulatory arrest in DCD donors. Organ procurement then proceeds in similar manner to DBD donation

17. The descending aorta and supra-hepatic cava is cross clamped to ensure no return of circulation to the chest or brain.
Establishing a localised, abdominal perfusion circuit

18. Uses extracorporeal membrane oxygenation (ECMO) technology.
Keeps organs at normal temperatures (37°C).
NRP lasts 2 hours.

19. Blood passes through organs continuously
Cells are fully nourished with oxygen and nutrients until organ preservation with cold UW
Cellular ATP is at normal levels
WHAT we achieve?
IF CELLS RUN OUT OF ATP
They BURST.
Before this happens calcium builds up in the mitochondria
Mitochondria are damaged
Cells look OK but they will not recover- Primary Non Function
DCD DONATION represents 40% of all transplants
Increase complications due to increase in warm ischaemic time (WIT).
1% occurrence of ischaemic cholangiopathy with DBD liver.
28% occurrence of ischaemic cholangiopathy with DCD liver.
Increase of primary non function x 2.
Increase discard rate (27% DCD livers transplanted V 83% DBD).
Decrease in number of organs/donor.
( National Ave: DCD/2.6 V DBD/4).
Increase in organ injury at time of retrieval (surgical haste in attempt to reduce WIT).
Cells take in water and sodium all the time- They pump it out all the time
90% of ATP is used to keep the cell water balance constant

20. WHAT HAPPENS IN CELLS DURING DBD ORGAN RETRIEVAL?
ATP
is continuously produced
is continuously consumed
Chilling the cells with UW
Stops making ATP
Keeps consuming ATP but at a slower rate
Late onset of cell death

21. WHAT HAPPENS IN CELLS DURING DCD ORGAN RETRIEVAL?
Loss of circulation causes ATP to fall rapidly.
Cold perfusion slows ATP loss
ATP levels fall to lethal levels sooner
in DCD

22. WHAT HAPPENS IN CELLS DURING NRP?

23. BENEFITS OF NRP Replenishes the ATP reserves.
Potentially can reduce ischaemic (reperfusion) injury.
Allows for macroscopic assessment
- Appearance
- Bile duct blood flow
- Portal Vein/Hepatic Artery flows
- Small bowel appearance
Enables a dynamic assessment of organ quality (using biochemical and blood gas analysis).
Less hasty retrieval-converts DCD to DBD type retrieval reducing the incidence of organ injury.
Gradual expansion of organ acceptance criteria.

24. SO WHAT DO I NEED TO KNOW? Are they planning on retrieving using NRP?
Do they have a machine perfusionist – what will be expected of you?
How many units of blood will this require?
Are they bringing a portable blood analyser?
How long will this likely extend the theatre time by?

25. SNODs will not be required to carry out any tasks involved in actual NRP sampling. The NORS team bring the NRP bags and will take the samples.
If the SNOD is attending an NRP and QUOD proceeding donor the SNODs role in facillitating QUOD does not change.
The QUOD box is handed over to the NORS team in theatre as per SOP4044.

26. EQUIPMENT REVIEW Edinburgh Cambridge Newcastle Oxford Birmingham
Royal Free