A previously fit and well 45 year old man presented to the emergency department with a two-hour history of a sudden onset severe headache associated with weakness, vomiting and photophobia. He had a normal breathing pattern and oxygen saturations of 96% in air. He was hypertensive with a non-invasive blood pressure of 220/115mmHg and a pulse rate of 85 beats/minute in sinus rhythm. Neurological examination revealed a Glasgow Coma Scale (GCS) of 14/15 with a dense hemiparesis, with hemisensory neglect and dysarthria.
He deteriorated and dropped his GCS to 5/15. He was intubated and an urgent computed tomographic (CT) brain scan was performed that revealed a large right-sided intraparenchymal haemorrhage with 4mm of midline shift. Blood tests including full blood count, urea and electrolytes and clotting screen were normal.
He was discussed with the neurosurgeons who felt transfer to institute intracranial pressure monitoring or surgical intervention was not indicated. His blood pressure was managed with a labetalol infusion aiming for a target systolic blood pressure of ≤ 160mmHg. Seizure activity was managed with a 15mg/kg loading dose of phenytoin followed by a maintenance dose of 300mg once daily nasogastrically. Sodium levels were monitored closely and hypotonic fluids avoided.
By day 5 he was making spontaneous respiratory effort, and his pupils were equal and sluggishly reactive. His GCS remained 3/15. A repeat CT was performed on day 9 due to no improvement in his clinical condition and revealed extension of the intraparenchymal haemorrhage with 8mm midline shift, effacement of the ventricles and loss of sulcal definition. A discussion regarding end of life care was held with his family who raised the possibility of organ donation. In agreement with his family, end of life care was instituted and he became an organ donor after circulatory death was confirmed.
How can we facilitate Donation After Circulatory Death?
Sonya Daniel
Advances in medical care and improved life expectancy have resulted in increasing numbers of patients with end stage organ failure awaiting transplant. There is a deficiency of organs available for these patients and so donation after circulatory death (DCD) has increased in order to meet this need. DCD refers to organ retrieval for transplantation that occurs after death is confirmed using circulatory criteria.1,2,3
The Maastricht Classification categorises patients according to the circumstances under which they may meet the criteria for DCD: category 1 are brought in dead, category 2 undergo an unsuccessful resuscitation attempt, category 3 are awaiting cardiac arrest, category 4 suffer a cardiac arrest after the diagnosis of brainstem death and category 5 are hospital inpatients that suffer a cardiac arrest. Controlled DCD occurs in Maastricht category 3 or 4 patients (i.e. those in which life sustaining treatment is no longer considered in the patient’s best interests or in those who have been declared brainstem dead). Uncontrolled DCD occurs in patients who have suffered an unexpected death that has been confirmed using circulatory criteria (i.e. Maastricht category 1,2 or 5 patients). In the United Kingdom the kidneys, liver, lungs, pancreas and tissue (skin, heart valves, corneas, and bone) are retrieved for the purposes of transplantation from DCD donors.1,2,4
Patients in whom end of life care is being considered and whose subsequent death may occur quickly may be candidates for DCD and should be discussed with the local transplant coordinator. It is imperative that the decision to commence end of life care should be in the patient’s best interests and completely uninfluenced by any consideration of organ donation.1,2,3,5
Contraindications to organ donation include haematological malignancy, uncontrolled systemic sepsis, variant Creutzfeldt-Jakob disease, HIV and cancer within the last 3 years (not including non-melanomatous skin cancer and primary brain tumours).2
Until end of life care is instituted the level of support the patient has received prior to being identified as a potential organ donor should continue. The patient should not undergo any procedures or interventions that cause harm or distress. When the retrieval team is assembled in an operating theatre and the family is in agreement, the process of end of life care should commence in conformity with usual practice. The time from which systolic blood pressure falls below 50mmHg or oxygen saturations fall below 70% is noted. If more than an hour passes with these parameters organ donation may be abandoned due to a prolonged duration of warm ischaemia and end of life care continued.1,2,3
The dead donor rule states that organ retrieval may only occur when the donor is dead. Absence of circulation should be monitored for 5 minutes using an arterial line, echocardiography or asystole on the electrocardiogram trace before formal certification of death. Should cardiac or respiratory activity occur during this 5 minute period, a further observation period of 5 minutes should occur after cessation of this activity. 1,2,3,5
After death has been confirmed the relatives may spend five minutes with the patient before transfer to the operating theatre for retrieval. In theatre the organs are cooled rapidly with intravascular perfusion of cold preservation solution and application of ice, and removed quickly to limit warm ischaemic time.3
Lessons Learnt
Donation after circulatory death is an important means of increasing the availability of organs for patients awaiting transplant. It is vital that decisions regarding end of life care should be made in patients’ best interests and that the family is closely involved throughout the process.
References
- Manara A, Murphy P, O’Calaghan G. Donation After Circulatory Death. Br J Anaesth 2012; 108 (s1): 108-121.
- Dunne K, Doherty P. Donation After Cardiac Death. Contin Educ Anaesth Crit Care Pain 2011. Doi: 10.1093/bjaceaccp/mkr003
- Working Party Of The British Transplantation Society. United Kingdom Guidelines: Transplantation From Donors After Deceased Circulatory Death. March 20 http://www.bts.org.uk/Documents/FINAL%20July%202013%20DCD%20guidelines.pdf
- Kootstra G, Daemen JH, Osmen AP. Categories Of Non Heart Beating Donors. Transpl Proc 1995; 27: 2893-4
- Bernat J. The Boundaries Of Organ Donation After Circulatory Death. N Engl J Med 2008; 359: 669-671
ICM Case Summaries 