Time to Cardiac Death After Withdrawal of Life-Sustaining Treatment in Potential Organ Donors

Abstract

Organ donation after cardiac death (DCD) is increas-

Outcomes of simultaneous pancreas–kidney transplantation from brain-dead and controlled circulatory death donors

“…These uncertainties limit the use of DCD pancreas, with just 32 grafts implanted in the USA in 2008 11 . In addition, potential DCD donors may place a considerable strain on procurement services owing to the difficulty in predicting donor death and the need for prolonged waiting periods to increase organ recovery rates 9,12 .…”

A few realistic questions raised by organ retrieval in the intensive care unit

“…It is not the duration per se but rather the hemodynamic profile during the withdrawal period that determines the consequences of warm ischemia on organ viability (26). However, a long withdrawal period often results in severe ischemic damage, compromising organ usability for transplantation (26,28). This period may range from a few minutes to many hours or days, depending on the level of life support engaged at the time of the decision for WhWd, and how withdrawal is achieved.…”

“…This period may range from a few minutes to many hours or days, depending on the level of life support engaged at the time of the decision for WhWd, and how withdrawal is achieved. Because circulatory arrest must occur after a short period, only the withdrawal of life-sustaining cardiopulmonary support for highly-dependent patients [high inspired oxygen fraction (FiO 2 ), non-triggered modes of ventilation, inotrope/vasoactive drug use] is compatible with post-mortem organ donation (26,(28)(29)(30)(31)(32). Any patient in whom the elective WhWd measure is not withdrawal of life-sustaining treatment should therefore be definitively excluded from any intention to retrieve organs.…”

“…Such a procedure could even become intolerable for relatives and caregiving staff if the eventuality (still possible) of a prolonged agonal period making organ donation impossible has not been explicitly addressed beforehand. It is thus essential to accurately predict time to circulatory arrest after withdrawal of life-sustaining treatment (28,29,31,33,34). When death is the most likely outcome, withdrawal of life-sustaining treatments usually involves disconnection of mechanical ventilation (with or without removal of the endotracheal tube) and cessation of vasoactive drugs.…”

“…Removal of the endotracheal tube (extubation) is more often associated with progression to organ donation than terminal weaning without extubation (12). Death within one or two hour(s) of withdrawal usually correlates with severe brain injuries (low Glasgow Coma Scale, absence of brainstem reflexes) (30)(31)(32)(35)(36)(37)(38), high dependence on mechanical ventilation (non-triggered mode, high FiO 2 , high positive expiratory pressure) (28-32,36,38,39), use of inotrope drugs (29,30,35,39), young age (28,35,40), underlying diseases (37,39), and physiological anomalies (high severity index scores, low blood pressure, low pH on arterial blood gas analysis) (37,38,40,41). Under Maastricht III conditions, the removal of organs must be scheduled before withholding/ withdrawal implementation and starts as soon as death is certified.…”