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Ante mortem interventions in DCD

Ante mortem interventions in DCD. Dr Paul Murphy National Clinical Lead for Organ Donation NHS Blood and Transplant. 1. 100. 90. 80. 70. 60. Percentage. 50. 40. 30. 20. 10. Kidney. Liver. Pancreas. Bowel. Heart. Lungs. 0. Organs from. Donor age. Consent for.

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Ante mortem interventions in DCD

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  1. Ante mortem interventions in DCD Dr Paul Murphy National Clinical Lead for Organ Donation NHS Blood and Transplant 1

  2. 100 90 80 70 60 Percentage 50 40 30 20 10 Kidney Liver Pancreas Bowel Heart Lungs 0 Organs from Donor age Consent for Organs offered Organs retrieved Organs actual DBD criteria met organ donation for donation for transplant transplanted donors Donation and transplantation rates of organs from DBD organ donors in the UK, 1 April 2014 – 31 March 2015 % of all organs 85% 82% 23% 22% 17% 3% 1

  3. 100 90 80 70 60 Percentage 50 40 30 20 10 Kidney Liver Pancreas Lungs 0 Organs from Donor age Consent for Organs offered Organs retrieved Organs actual DCD criteria met organ donation for donation for transplant transplanted donors Donation and transplantation rates of organs from DCD organ donors in the UK, 1 April 2014 – 31 March 2015 % of all organs 80% 35% 12% 7%

  4. Background • Legal guidance issued in 2009 - 11 • Conservative • Effective prohibition on ante-mortem heparin • Call for revision in 2012 / 2013 by UK DEC • Generic overarching guidance • Separate documents covering specific interventions (e.g. heparin, extubation) • Specific recommendations regarding heparin • Further evidence required by Department of Health • Risks and benefits • Clinical and public acceptability • NHSBT asked to conduct this review

  5. Review deliverables • Literature review of risks and benefits of ante-mortem interventions • Description of international practices • Better understanding of physiological changes following treatment withdrawal • Public and professional survey of acceptability of ante-mortem interventions • Expert workshop • Focus groups • On-line survey • Recommendations to the Department of Health

  6. Interventions to assess organs Trans thoracic echocardiography Trans-oesophageal echocardiography Bronchoscopy Interventions to preserve organs Heparin, steroid, phentolamine Femoral cannulation Elective intubation and ventilation Emergency resuscitation Terminal extubation Potential ante-mortem interventions

  7. International practice

  8. Evidence

  9. Avoiding harm? • Can heparin be given after treatment withdrawal? • Does the patient always die if BP goes below a certain level? • Does donation always happen if BP goes below a certain level? • Is there time to give heparin once point of no return is identified for it to have a systemic effect? • Do all potential DCD donors die following treatment withdrawal? • Lessens the risk of ante mortem interventions carried out before treatment withdrawal

  10. Physiological changes following treatment withdrawal • Can a point of ‘no-return’ be identified following treatment withdrawal? • Does the patient always die if BP goes below a certain level? • Does donation always happen if BP goes below a certain level? • Is there time to give heparin once point of no return is identified for it to have a systemic effect? • What happens to non-proceeding DCD donors? • Do all potential DCD donors die following treatment withdrawal?

  11. Time to asystole in proceeding DCD donors

  12. Methodology • Review of SN-OD records of proceeding and non-proceeding DCD donors • April – Dec 2013 • Yorkshire, South Central, South West, Northern, Midlands, Scotland, Northern Ireland, South Wales • Physiological changes following treatment withdrawal • Systemic arterial BP (systolic, mean, diastolic) • SaO2 • Heart rate • Respiratory rate • 255 proceeding donors, 153 non-proceeding donors

  13. Systolic BP in proceeding DCD donors, South West

  14. Timings in proceeding DCD donors Minimum: time from first recording below selected BP to asystole Maximum: time from last recording over selected BP to asystole

  15. Systolic BP, non-proceeding donors, n=153

  16. Non-proceeding DCD donors with one or more SBP < 90 mmHg (n=13)

  17. Non-proceeding DCD donors with one or more SBP < 50 mmHg (n=4)

  18. Time to death in non-proceeding DCD donors (n=153, data on three patients missing)

  19. Conclusions • Most but not all potential DCD donors die following treatment withdrawal • 3 / 408 patients discharged from hospital • All patients die if BP falls below 90 mmHg • Donation does not always happen • Limited time to give heparin • Systolic BP 50 mmHg: 5-6 minutes • Systolic BP 90 mmHg: 8–12 minutes

  20. Heparin

  21. Heparin

  22. Steroids

  23. Steroids

  24. Phentolamine

  25. Phentolamine

  26. Additional non-invasive testsTrans-thoracic echocardiography

  27. Additional non-invasive testsTrans-thoracic echocardiography

  28. Additional invasive testsTrans-oesophageal echocardiography

  29. Additional invasive testsTrans-oesophageal echocardiography

  30. Additional invasive testsBronchoscopy

  31. Additional invasive testsBronchoscopy

  32. Intubation and ventilation

  33. Intubation and ventilation

  34. Emergency resuscitation

  35. Emergency resuscitation

  36. Changing how treatments are withdrawn

  37. Changing how treatments are withdrawn

  38. Overview

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