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INTRODUCTION

  • Interest in donation after cardiac death (DCD) was renewed in the early 1990s as a means to partially overcome the shortage of donation after brain death (DBD).

  • DCD donors have a significant contribution to the potential donor pool.1

  • In Middle Eastern countries and in Asia, DCD has become an increasingly frequent procedure.

  • In 1995 the first consensus was published in Maastricht classifying DCD into 4 categories (Table 51-1).

  • The length of warm ischemia during DCD varies.

  • Uncontrolled DCD: Organs procured after an unexpected cardiopulmonary arrest.

    • Variable period of ischemic damage due to cardiac standstill followed by cardiac resuscitation.7

  • Controlled DCD: Cardiocirculatory arrest is a consequence of a planned and timed withdrawal of ventilator and organ-perfusion support (minimal warm ischemia).7

TABLE 51-1Maastricht Categories of DCD2–6

ORGAN PROCUREMENT IN DCD

  • DCD organs suffer from a period of hypotension and hypoxia before the cardiac arrest.

  • Outcomes are generally inferior when compared to DBD.

  • Length of warm ischemic time correlates with organ postimplantation function and recovery.

  • Failure of DCD donors to progress to circulatory arrest within a specified time frame (usually one hour) precludes procurement. In these instances the donor is returned to the intensive care unit (ICU) or transferred to palliative care.

DEFINITION OF CARDIAC DEATH

  • “Irreversible cessation of circulatory and respiratory functions.7

  • Diagnosed by the cessation of heartbeat and/or blood circulation.

  • Assessed by electrocardiography, monitoring of arterial pulses, and/or invasive arterial pressure readings.

TIMELINE OF ORGAN DONATION IN CONTROLLED DCD (CATEGORY III-IV)8 (FIG. 51-1)

  • The transplant team should be contacted and present before vital life support is withdrawn.

FIGURE 51-1

* No touch period: A minimum time lapse (usually 2 to 5 minutes) to ensure that death after cardiac standstill has become irreversible.

POTENTIAL DCD CANDIDATE SELECTION7

  • Medically appropriate for donation.

  • Brain death criteria not met. Potential donor is still alive, and procurement should not take place until death has been pronounced. Some donors may progress to brain death prior to procurement.

  • No expectation of meaningful survival, as determined by the patient’s treating physician.

    • Withdrawal of ventilator and organ perfusion support approved by the patient’s legal decision maker(s).

  • Informed consent obtained from the patient’s legal decision maker(s).

    • Requested prior to becoming a potential DCD donor.

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