Ante mortem interventions in DCD Dr Malcolm Watters Regional Clinical Lead for Organ Donation 1

Ante mortem interventions in DCD

Dr Malcolm WattersRegional Clinical Lead for Organ Donation

1

Donation and transplantation rates of organs from DBD organ donors in the UK, 1 April 2014 – 31 March 2015

0

10

20

30

40

50

60

70

80

90

100

Organs fromactual DBD

donors

Donor agecriteria met

Consent fororgan donation

Organs offeredfor donation

Organs retrievedfor transplant

Organstransplanted

Per

cent

age

Kidney Liver Pancreas Bowel Heart Lungs

% of all organs

85%82%

23%22%17%

1

3%

0

10

20

30

40

50

60

70

80

90

100

Organs fromactual DCD

donors

Donor agecriteria met

Consent fororgan donation

Organs offeredfor donation

Organs retrievedfor transplant

Organstransplanted

Per

cent

age

Kidney Liver Pancreas Lungs

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%

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

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

Potential ante-mortem interventions

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

International practice

USA Canada Australia France Belgium UK

Heparin + + ± + + -

Phentolamine ± + - -

Femoral cannulation ± - + -

Withdrawal in operating theatre

+ + + + + ±

bronchoscopy ± ±

Evidence

HeparinEstablished in DBD. Strong clinical conviction of benefit (liver, lung, paediatric heart). Reduced thrombus formation in experimental lung models

Phentolamine No evidence

Femoral cannulation

Evidence for lack of benefit in rapid cold preservation.

May be of benefit for rapid normothermic regional perfusion

Withdrawal in operating theatre

Strong clinical conviction of benefit (ischaemic cholangiopathy)

Bronchoscopy Established practice in DBD.

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

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?

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– 255 proceeding donors, 153 non-proceeding donors

• Measures– Outcome– Time to asystole– Physiological changes following treatment withdrawal

• Systemic arterial BP (systolic, mean, diastolic)

• SaO2

• Heart rate

• Respiratory rate

Time to asystole in proceeding DCD donors

0

20

40

60

80

100

120

0-10

11_2

0

21-3

0

31-4

0

41-5

0

51-6

0

61-7

0

71-8

0

81-9

0

91-1

00

101-

110

111-

120

121-

130

131-

140

141-

150

151-

160

161-

170

171-

180

181-

190

time after treatment withdrawal (minutes)

nu

mb

er

Time % asystole

10 min 18.8

20 min 61.5

30 min 74.8

52

23 2217

85 3

7

0 1 2 2 0 2 1 0 0 0 0 0 0 1 1 03

0

10

20

30

40

50

60

0 - 12 hours

13-24 hours

day 2

day 3

day 4

day 5

day 6

day 7

day 8

day 9

day 10

day 11

day 12

day 13

day 14

day 15

day 16

day 17

day 18

day 19

day 20

day 21

day 22

day 23

Hom

e

time after treatment withdrawal

nu

mb

er

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

0

50

100

150

200

250

300

0 20 40 60 80 100 120 140 160 180 200

time after treatment withdrawal (min)

syst

olic

BP

(m

mH

g)

Systolic BP in proceeding DCD donors, South West

Timings in proceeding DCD donors

Systolic BP of 50 mmHg to asystole (minutes)

Minimum Maximum

Mean 5.9 8.1

Median 5 6

Range 1 – 56

Systolic BP of 90 mmHg to asystole (minutes)

Minimum Maximum

Mean 12.8 16.2

Median 8 12

Range 1-86

Minimum: time from first recording below selected BP to asystoleMaximum: time from last recording over selected BP to asystole

0

50

100

150

200

250

300

0 20 40 60 80 100 120 140 160 180

minutes after treatment withdrawal

syst

oli

c B

P

c

Systolic BP, non-proceeding donors, n=153

0

30

60

90

120

150

180

210

240

270

300

0 20 40 60 80 100 120 140 160 180 200

time after treatment withdrawal (minutes)

sy

sto

lic B

P

died 13 hours

died 31 hours

died 8 hours

died 29 hours

died 3 hours

died 7 hours

died 4 hours

died 5 hours

died 1.5 hours

died 114 hours

died 120 hours

died 12 hours

died 7 hours

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

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

0

50

100

150

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250

300

0 20 40 60 80 100 120 140 160 180 200

time after treatment withdrawal (min)

sy

sto

lic

BP

died 8 hours

died 3 hours

died 5 hours

died 120 hours

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

Heparin

In which circumstance would you consider it acceptable for a single dose of heparin to be given to a potential DCD donor, where family consent for organ donation has been given?

All potential DCD donors at the time of treatment withdrawal

All potential DCD donors who are not at particular risk of bleeding at the time of treatment withdrawal

All potential DCD donors at the point where death is inevitable and imminent

All potential DCD donors who are not at particular risk of bleeding at the point where death is inevitable and imminent

Never

Don't know

Heparin

Would your answer be different if the patient had registered a wish to donate on the NHS Organ Donor Register? If so, what would it now be?

My answer would be the same

All potential DCD donors at the time of treatment withdrawal

All potential DCD donors who are not at particular risk of bleeding at the time of treatment withdrawal

All potential DCD donors at the point where death is inevitable and imminent

All potential DCD donors who are not at particular risk of bleeding at the point where death is inevitable and imminent

Never

Don't know

Steroids

In which circumstance would you consider it acceptable for a single dose of steroid to be given to a potential DCD donor, where family consent for organ donation has been given?

I do not think that steroids should ever be given.

I think that steroids should be given if the family agree.

I think that steroids should be given whenever they might improve transplantation.

I don’t know

None of the above. I think that:

Steroids



I do not think that steroids should ever be given.

I think that steroids should be given if the family agree.

I think that steroids should be given whenever they might improve transplantation.

I don’t know


Phentolamine

In which circumstance would you consider it acceptable for a single dose of phentolamine to be given to a potential DCD donor, where family consent for organ donation has been given?

I do not think that phentolamine should ever be given.

I think that phentolamine should be given if the family agree.

I think that phentolamine should be given whenever it might improve transplantation.

I don’t know


Phentolamine


My answer would be the same.

I do not think that phentolamine should ever be given.

I think that phentolamine should be given if the family agree.

I think that phentolamine should be given whenever it might improve transplantation.

I don’t know


Additional non-invasive testsTrans-thoracic echocardiography

Trans-thoracic echocardiography may become part of the ante-mortem assessment of potential DCD heart donors. How do you feel about this?

I think that the scan should be carried out whenever it is needed to assess whether a person can donate their heart for transplant.

I think that doctors can do the scan as long as the family agree to it.

I don’t think that the scan should ever be done, even if this means that heart transplantation cannot happen.

I don't know.

None of these. I think ……….

Additional non-invasive testsTrans-thoracic echocardiography




I think that doctors can do the scan as long as his family agree to it.

I don’t think that the scan should ever be done, even if this means that a heart transplant cannot happen.

I don't know.


Additional invasive testsTrans-oesophageal echocardiography

Trans-oesophageal echocardiography may become part of the ante-mortem assessment of potential DCD heart donors. How do you feel about this?


I think that doctors can do the scan as long as the family agree to it.

I don’t think that the scan should ever be done, even if this means that heart transplantation cannot happen.

I don't know.


Additional invasive testsTrans-oesophageal echocardiography




I think that doctors can do the scan as long as his family agree to it.

I don’t think that the scan should ever be done, even if this means that a heart transplant cannot happen.

I don't know.


Additional invasive testsBronchoscopy

Bronchoscopy may assist in the assessment of potential DCD lung donors. The patient would receive appropriate sedation for the procedure. How do you feel about a bronchoscopy being carried out?

I think that a bronchoscopy should be carried out whenever it is needed to assess whether a person can donate their lungs for transplant.

I think that the bronchoscopy can be performed as long as the family agrees.

I don’t think that a bronchoscopy should ever be done, even if this means that a lung transplant cannot happen.

I don't know.


Additional invasive testsBronchoscopy



I think that a bronchoscopy should be carried out whenever it is needed to assess whether a person can donate their lungs for transplant.

I think that the bronchoscopy can be performed as long as the family agrees.

I don’t think that a bronchoscopy should ever be done, even if this means that a lung transplant cannot happen.

I don't know.


Intubation and ventilation

What do you think about a dying patient, in whom donation would be possible, being intubated and ventilated in order to facilitate organ donation.

I think that a dying patient should be intubated and ventilated whenever organ donation is a possibility.

I think that a dying patient should be intubated and ventilated whenever organ donation is a possibility, but only if the next of kin agree to it.

I don’t think that a dying patient should ever be intubated and ventilated just for the purposes of organ donation.

I don’t know.

None of these. I think …………..

Intubation and ventilation



I think that a dying patient should be intubated and ventilated whenever organ donation is a possibility.

I think that a dying patient should be intubated and ventilated whenever organ donation is a possibility, but only if the next of kin agree to it.

I don’t think that a dying patient should ever be intubated and ventilated just for the purposes of organ donation.

I don’t know.


Emergency resuscitation

A potential DCD donor suffers a cardiac arrest before the retrieval team are ready for treatment withdrawal. What do you think about cardiac resuscitation in such circumstances?

I think that resuscitation should begin immediately.

I think that resuscitation should begin as soon as the family have given permission for it.

I don’t think that resuscitation should be instituted in any circumstances. The patient should be allowed to die.

I don’t know.





I think that resuscitation should begin immediately.

I think that resuscitation should begin as soon as the family have given permission for it.

I don’t think that resuscitation should be instituted in any circumstances. The patient should be allowed to die.

I don’t know.


Changing how treatments are withdrawn

Donation may be more likely if treatment withdrawal includes terminal extubation. How would you feel about a potential DCD donor being extubated if this is not something normally done when withdrawing treatments?

I think that if it has been decided that donation should go ahead, treatments should be withdrawn in a way that makes this most likely to happen.

I think that if it has been decided that donation should go ahead, medical staff should discuss with the family about how best to withdraw treatments.

I do not think that there should ever be any change to how treatments are withdrawn to make donation more likely to happen.

I don’t know.

None of these. I think that……

Changing how treatments are withdrawn



I think that if it has been decided that donation should go ahead, treatments should be withdrawn in a way that makes this most likely to happen.

I think that if it has been decided that donation should go ahead, medical staff should discuss with the family about how best to withdraw treatments.

I do not think that there should ever be any change to how treatments are withdrawn to make donation more likely to happen, even if the person wanted to be a donor.

I don’t know.

None of these. I think that……

Overview

Which interventions would you be willing to undertake or allow when caring for a potential DCD donor within the current professional, ethical and legal framework of practice for DCD in the UK?

Drug therapy - heparin

Drug therap - steroids

Drug therapy - phentolamine

Trans-thoracic echocardiogram

Trans-oesophageal echocardiogram

Bronchoscopy

Elective intubation and ventilation


Changing how treatments are withdrawn (extubation of the airway)

Documents

Ante mortem interventions in DCD Dr Malcolm Watters Regional Clinical Lead for Organ Donation 1