Background
- Donation After Circulatory Death (DCD) Has Been Reintroduced Due to the Shorten of Organs for Transplant
- DCD was Historically the First Method of Organ Procurement that was Used: DCD was used to harvest the first heart used for transplant
- DCD Contrasts with Organ Procurement by Standard Means (Namely, Donation After Brain Death (see Brain Death, [[Brain Death]])
- DCD May Be Used for Procurement of Kidneys, as Well as Organs with a Lower Tolerance for Warm Ischemia (Such as the Liver, Pancreas, and Lungs)
- Common Diagnoses of Patients Undergoing DCD
- Intracranial/Intracerebral Hemorrhage (see Intracerebral Hemorrhage, [[Intracerebral Hemorrhage]]): 45% of cases
- Hypoxic-Ischemic Brain Injury (see Hypoxic-Ischemic Brain Injury, [[Hypoxic-Ischemic Brain Injury]]): 25% of cases
- Traumatic Brain Injury (TBI) (see Traumatic Brain Injury, [[Traumatic Brain Injury]]): 11.3% of cases
- Respiratory Disease: 5% of cases
- Cardiac Arrest (see Cardiac Arrest, [[Cardiac Arrest]]): 1.5% of cases
- Other: 4.9% of cases
Technique
Definitions
- Organ Harvest After Death is Confirmed by Circulatory Criteria
Modified Maastricht Classification of Donation After Circulatory Death (Transplant Proc, 1995) [MEDLINE]
- Type I
- Description: Dead on Arrival
- Type of DCD: Uncontrolled DCD
- Location: ED in a Transplant Center
- Type II
- Description: Unsuccessful Resuscitation
- Type of DCD: Uncontrolled DCD
- Location: ED in a Transplant Center
- Type III
- Description: Anticipated Cardiac Arrest
- Type of DCD: Controlled DCD
- Location: ICU and ED
- Type IV
- Description: Cardiac Arrest in a Brain Dead Donor
- Type of DCD: Controlled DCD
- Location: ICU and ED
- Type V
- Description: Unexpected Arrest in ICU Patient
- Type of DCD: Uncontrolled DCD
- Location: ICU in a Transplant Center
Warm Ischemic Injury in Controlled DCD
- Organs from DCD Donors are Exposed to a Longer Duration of Warm Ischemia than Organs from Donation After Brain Death Donors
- Warm Ischemia Occurs to Some Extent During Preceding Phase of Cardiovascular Collapse: which precedes asystole
- Warm Ischemia Occurs to the Greatest Degree Between the Onset of Asystole and the Establishment of Cold Organ Perfusion
- “Functional Warm Ischemia Time”: begins when the systolic blood pressure falls below 50 mm Hg and/or the SaO2 falls below 70% and ends with cold perfusion
- There is a Defined Interval Between Withdrawal of Care (Most Commonly Reduction/Withdrawal of Ventilation or Extubation) and the Onset of Asystole
- While Not Universally Agreed Upon, Many Criteria Specify that Death Can Be Confirmed After 5 min of Continuous Cardiopulmonary Arrest (Including Asystole)
- Ischemic Injury
- Increases the Risk of Primary Graft Failure
- Increases Other Complications: such as biliary stricture, etc
- Interventions Which Might Prevent/Reverse Ischemic Injury
- Ante-Mortem Interventions
- Corticosteroids
- Heparin
- Vasodilators
- Consistent Application of Published Schedules for the Prompt Identification of Death
- Decrease in Time Interval Between Diagnosis of Death and Organ Retrieval: therefore, withdrawal of treatment in the operating room is commonly practiced
- Post-Mortem Reperfusion of Particularly Vulnerable Organs (Liver, etc)
- Early Tissue Typing to Allow Prompt Identification and Mobilization of Suitable Recipients
- Ante-Mortem Interventions
Clinical Outcomes
- Kidneys Harvested by DCD Have the Same Outcome than Those Harvested by Donation After Brain Death