Maintaining the permanence principle of death during normothermic regional perfusion in controlled donation after the circulatory determination of death: Results of a prospective clinical study

American Journal of Transplantation, Год журнала: 2023, Номер 24(2), С. 213 - 221

Опубликована: Сен. 21, 2023

Язык: Английский

---

The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols

The American Journal of Bioethics, Год журнала: 2024, Номер 24(6), С. 4 - 15

Опубликована: Июнь 2, 2024

Organ donation after the circulatory determination of death requires permanent cessation circulation while organ brain irreversible functions. The unified brain-based connects and criteria for in as follows: systemic causes which perfusion function. relevant that must cease is to brain. Eliminating from donor ECMO circuit thoracoabdominal NRP protocols satisfies but only if complete can be proved. Despite its medical physiologic rationale, remains inconsistent with Uniform Determination Death Act.

Язык: Английский

---

Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion

Transplantation, Год журнала: 2023, Номер 107(8), С. 1650 - 1654

Опубликована: Май 12, 2023

The brain-based determination of death ("brain death") is now widely accepted throughout the world. It states that irreversible cessation brain functions fundamental criterion for human death. recent World Brain Death Project provided a comprehensive cataloguing all aspects including its medical and legal acceptance world.1 Organ donation after (DBDD) currently accounts majority multiorgan donations internationally. circulatory (DCDD) has grown worldwide since Institute Medicine United States endorsed practice controlled DCDD in 20002 US national conference on 2005 standardized practice.3 are expanding but remain fewer than number DBDD donations. donor requires permanent absence systemic circulation. When circulation absent, ceases. essential feature unified concept produces neuronal perfusion resulting functions. Thus, by criteria consistent with neurologic criteria. In situ normothermic regional (NRP) emerging as component organ recovery procedures DCDD. Controlled practiced hospitalized patients planned withdrawal life-sustaining therapy (WLST). NRP uses extracorporeal membrane oxygenation to reestablish specific regions body following determination. reestablished may be restricted abdominal cavity (A-NRP) or also include thoracic (TA-NRP). reportedly improves utilization recipient outcomes comparable those organs from donors,4,5 it raises complex medical, ethical, questions must resolved.6-8 protocols This situation principal question NRP: if resumption contradicts conditions declaration, how can declared dead circulation? use resolves dilemma clarifying relevant cease brain.9,10 If effectively ensure no brain, thereby preventing function, fulfills requirements respects rule. Ensuring ceased permanently will not restarted allows donors based despite restoration abdomen thorax. DEATH DETERMINATION IN DONATION AFTER CIRCULATORY OF Under current protocols, declaration determining potential donor's permanently. Three establish circulation: (1) completely, evidenced intra-arterial pressure monitoring, electrocardiography, echocardiography; (2) persists beyond time interval during which autoresuscitation been reported occur; (3) intervention made restore declared.11 these met, permanence fulfilled, validly dead, subsequent donated does violate rule.11 Although standards differ among jurisdictions, physicians who follow confident they acting accordance around world have long equated circulation.8 minimum 5 min absent establishes heart restart spontaneously permanent. standard was recommended Medicine2 common most European countries.12 5-min confirmed large prospective observational study autoresuscitation, determined WLST, longest between asystole 4 24 s.13 THE UNIFIED BRAIN-BASED There widespread basis functions, defined loss capacity consciousness, breathe, stem reflexes.1,14 caused primary pathology, such traumatic head injury, stroke, meningitis, hypoxic–ischemic damage secondary arrest. provides when function results arrest, applying DCDD, initially causes cease. Permanent perfusion, that, leads functions.9,10 Physiologic studies dying WLST show activity closely correlates electroencephalogram becomes isoelectric within 30 s cardiac arrest brain15 occur even sooner followed severe hypotension hypoxemia before arrest.16,17 Cessation triggers physiologic cascade: leading function. After complete circulation, grounds and, therefore, Permanence established elapsed resuscitative attempted. A ceases irreversibly means cannot restored. restored.18 From inception, testing enables formal retrospective assessment had previously (they restored). (real time) only According unifying death, valid because (see Figure 1). true endpoint consequence brain.FIGURE 1.: dependent brain.After permanently, direct would ideal method prove absence. But technical reasons, electrophysiological feasible donor, particularly Therefore, used surrogate justified strict causal relationship exists ceases: continue However, mere presence measurable necessarily imply detected blood flow achieve necessary threshold allow Yet, indicates possible. These precise thresholds unknown. GOAL TA-NRP IS TO RESTORE CIRCULATION THORACIC AND ABDOMINAL ORGANS added an preservation strategy reperfuse organs, reduce warm ischemic damage, better assessed being recovered transplantation. A-NRP, aorta clamped blocked restrict whereas stapling aortic arch vessels. purpose vessel clamping exclude initiated, mechanical ventilation restarted. transplantation suitability sinus rhythm contractions. perfuse opportunity assess heart's functional do techniques succeed totally excluding POTENTIAL INADEQUACIES CLAMPING AORTIC ARCH VESSELS completely excluded collateral arterial dynamics autoregulation. robust system arteries distributed aorta. Blood proceeds through carotid vertebral ultimately form Circle Willis. At level medulla, give off branches merge anterior spinal artery. artery distributes cord supply derived cervical (C1–T3), (T4–T8), lumbar (T9 conus medullaris) via Adamkiewicz. That cephalad toward along impaired major routes flow. Clamping brain's main stimulate cerebral autoregulation generated NRP.19 Current data insufficient assure zero NRP, although animal models reassuring.20 experiment small sample pigs found vessels prevented electroencephalogram, evoked potentials, flow, oxygen uptake.21 uncertainty vessels, Kingdom Spain step severing distal clamps draining aspirating ends severed while exposed atmospheric pressure.22 maneuver intended divert any possible away brain. For restored other means. Animal performed reassure eliminated incorporated into protocols. could inform best methods clinical monitoring TA-NRP. To resolve over restoring studies, Spain, should conducted TA-NRP, example, contrast angiography. Given sufficiently sensitive detect functioning, areas difficult examine, like stem, one assume functioning. RECOMMENDATIONS DEVELOP AN INTERNATIONAL CONSENSUS ON CONCEPT WHEN IMPLEMENTED International Professional Societies Develop Medical Standards Should Work Achieve Consensus Unified Brain-based Concept applicable both distinct. achieved brain.23 Determining outside context donation.1 continue. Establishing international professional consensus provide framework policy practice, promoting public trust addressing barriers opportunities Such accomplished expert collaboratives solid scientific evidence.1,14,24 Future laboratory research determine residual exceeds restrictive vascular blocking implemented. Protocols Recovery, Especially With Situ Preservation Using Must Ensure Absence Circulation validated assurance stop experimentally proven clinically effective. Programs using validation available consider implementing reassurance continued TA-NRP–assisted recovery.25 Surgical Recovery Maneuvers Used Prevent During Be Legally, Ethically, Socially Acceptable Discussions qualified professionals families information about aims, methods, maneuvers sufficient family members surrogates make informed decisions authorizing donation. Transparency conversations ensures Some commentators emphasized desirability pursuing ex avoids ethical issues providing many benefits.26 this alternative associated substantially higher costs own limits countries where legislation observation period longer support development practices communicating families, hospital personnel explore their attitudes understanding We encouraged efforts Canadian panel adopted guideline functions.27 Their rationale recommendations serve model worldwide, Alignment prevailing clinical, remains necessary.7,8

Язык: Английский

---

Ex-situ oxygenated hypothermic machine perfusion in donation after circulatory death heart transplantation following either direct procurement or in-situ normothermic regional perfusion

The Journal of Heart and Lung Transplantation, Год журнала: 2023, Номер 42(6), С. 730 - 740

Опубликована: Фев. 7, 2023

Heart transplantation in donation after circulatory death (DCD) relies on warm perfusion using either situ normothermic regional (NRP) or ex machine perfusion. In this study, we explore an alternative: oxygenated hypothermic (HMP) a novel clinically applicable system, which is compared to NRP with static cold storage (SCS).In porcine model, DCD setting was simulated, followed by (1) and SCS (2) HMP the XVIVO preservation system (3) direct procurement (DPP) HMP. After preservation, heart (HTX) performed. weaning from cardiopulmonary bypass (CPB), biventricular function assessed admittance Swan-Ganz catheters.Only transplanted hearts groups showed significantly increased contractility (end-systole elastance) 2 hour post-CPB (left ventricle absolute change: HMP: +1.8 ± 0.56, p = 0.047, DPP +1.5 0.43, 0.045 SCS: +0.97 0.47 mmHg/ml, 0.21; right +0.50 0.12, 0.025, +0.82 0.23, 0.039 +0.28 0.26, 0.52) while receiving less dobutamine maintain cardiac output >4l/min SCS. Diastolic preserved all groups. Post-HTX, both increments plasma troponin T SCS.In HTX, post-HTX only observed addition, need for inotropic support signs of myocardial damage were lower HTX can be successfully performed preclinical setting.

Язык: Английский

---

Restoring the Organism as a Whole: Does NRP Resurrect the Dead?

The American Journal of Bioethics, Год журнала: 2024, Номер 24(6), С. 27 - 33

Опубликована: Июнь 2, 2024

The introduction of normothermic regional perfusion (NRP) in controlled donation after circulatory determination death (cDCDD) protocols is by some regarded as controversial and ethically troublesome. One the main concerns that opponents have about introducing NRP cDCDD reestablishing circulation will negate criteria, potentially resuscitating donor. In this article, I argue not case. If we take a closer look at concept underlying criterion for death, find purpose to show whether organism whole has died. fulfilled protocols, applying does or resuscitate

Язык: Английский

---

Normothermic Regional Perfusion—The Next Frontier in Organ Transplants?

JAMA, Год журнала: 2023, Номер 329(24), С. 2123 - 2123

Опубликована: Июнь 2, 2023

This Viewpoint examines an approach known as normothermic regional perfusion, involving use of ECMO to restore perfusion internal organs in situ before they are removed from a deceased donor.

Язык: Английский

---

Normothermic Regional Perfusion in Controlled Donation After the Circulatory Determination of Death: Understanding Where the Benefit Lies

Transplantation, Год журнала: 2024, Номер unknown

Опубликована: Июль 25, 2024

Controlled donation after the circulatory determination of death (cDCDD) has emerged as a strategy to increase availability organs for clinical use. Traditionally, from cDCDD donors have been subject standard rapid recovery (SRR) with poor posttransplant outcomes abdominal organs, particularly liver, and limited organ utilization. Normothermic regional perfusion (NRP), based on use extracorporeal membrane oxygenation devices, consists in situ that will be transplantation oxygenated blood under normothermic conditions declaration before recovery. NRP is potential solution address limitations traditional methods. It become normal practice several European countries recently introduced United States. The increased occurred result growing body evidence its association improved utilization compared SRR. However, expansion precluded by obstacles an organizational, legal, ethical nature. This article details technique both thoracoabdominal NRP. Based available evidence, it describes benefits terms thoracic addresses cost-effectiveness aspects NRP, well logistical limit implementation this innovative preservation strategy.

Язык: Английский

---

Normothermic regional perfusion in paediatric donation after circulatory determination of death—the Oxford position statement from ELPAT

Frontiers in Transplantation, Год журнала: 2024, Номер 3

Опубликована: Янв. 29, 2024

OPINION article Front. Transplant., 29 January 2024Sec. Organ and Tissue Preservation Volume 3 - 2024 | https://doi.org/10.3389/frtra.2024.1320783

Язык: Английский

---

A Scintigraphic Look at the Dead Donor Rule in DCDD with the use of Normothermic Regional Perfusion: a single-center interventional trial

American Journal of Transplantation, Год журнала: 2025, Номер unknown

Опубликована: Март 1, 2025

Язык: Английский

---

Normothermic Regional Perfusion Requires Careful Ethical Analysis Before Adoption Into Donation After Circulatory Determination of Death

Critical Care Medicine, Год журнала: 2022, Номер 50(11), С. 1644 - 1648

Опубликована: Окт. 13, 2022

Peled, Harry MD; Mathews, Sajen Rhodes, David Bernat, James L. MD Author Information

Язык: Английский

---