Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death

Summary

The protocol combines a lung cooling rapid recovery technique with abdominal normothermic regional perfusion for abdominal graft procurement in controlled asystole donors, which is a safe and useful method to expand the donor pool.

Abstract

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years confirm that the outcomes after lung transplantation from cDCD are similar to those from brain death donors; however, the utilization of lungs from asystole donors remains low. Several reasons may be involved: different legal frameworks among countries and centers with different premortem interventions, inadequate lung donor care before procurement, or even poor experience with cDCD procedures and protocols.

Initially, the rapid recovery technique was commonly employed for the procurement of thoracic and abdominal organs in cDCD, but, in the last decade, abdominal normothermic regional perfusion (ANRP) with extracorporeal membrane oxygenation devices has become a useful method to restore blood flow to abdominal organs, allowing their quality improvement and their functional assessment prior to transplantation. This makes the donation procedure more complex and generates doubts about injury to the grafts due to dual temperature.

The aim of this article is to describe a protocol based on a single center experience with Maastricht III donors combining lung cooling rapid recovery in the thorax and abdominal normothermic regional perfusion. Tips and tricks focused on premortem interventions and lung procurement procedure techniques are explained. This may help to minimize the reluctance among professionals to use this combined technique and encourage other donor centers to use it, despite the increased complexity of the procedure.

Introduction

Donation after circulatory death (DCD) started in Spain with uncontrolled donors. In 1996, the first national consensus document on DCD was published as a guide for the practice of uncontrolled donation after circulatory death¹ (uDCD), also setting a moratorium on controlled donation after circulatory death (cDCD). In 2012, a new consensus emerged establishing the basis and the legislative framework for the practice of both uDCD and cDCD². Currently, Spain is one of the most active countries in DCD, reaching the highest rate of donors after circulatory death in the world³. This type of donor repre....

Protocol

These interventions are undertaken at the bedside in the intensive care unit (ICU). This protocol follows the guidelines of the University Hospital Marqués de Valdecilla ethics committee and is in accordance with the Spanish legal framework regarding donation procedures. Informed consent was obtained from next of kin for video recording of the procedures for research. cDCD is considered in patients with catastrophic brain damage or a terminal heart or a neurodegenerative disease for whom the decision to withdraw life-sustaining therapy (WSLT) has been made. Exclusion criteria and lung evaluation are the same as with brain death donors (Table 1).<....

Results

We performed a descriptive analysis of 30 lung transplants performed at University Hospital Marqués de Valdecilla with lungs obtained from cDCD donors in the last 2 years, 2020 and 2021. Donor and recipient demographic characteristics, technical data, postoperative outcomes, and short-term results are presented here. These results are presented as absolute numbers and percentages for categorical variables and as measures of central tendency and dispersion for continuous variables. The Kolmogorov-Smirnov test was use.......

Discussion

Though the use of simultaneous lung cold perfusion with ARNP in cDCD was first published in 2014, very few experiences have been described for this^25,26,29. Moreover, the utilization of cDCD lungs, regardless of the technique used, remains low in most countries.

The critical steps within this protocol are the use of premortem interventions; a specific methodology to ensure coronary and cerebral perfus.......

Materials

Name	Company	Catalog Number	Comments
Vial 5 mL Heparin 1000 UI/mL	ROVI		For donor heparinization
ECMO KIT (MATERIALS FOR CANNULATION)
Artery pressure lines	BEXEN MEDICAL	137.15	Artery pressure line por radial artery and femoral cannula
Bandage scissors	SURGIMEDIC	BC-881R	Shear to cut ECMO lines
Bio-medicus Venous cannula 21 Fr (7.0 mm) x 27.5 in (69.9 cm)	MEDTRONIC	96670-121	Venous cannula
Clhorhexidine solution 2%			Disinfectant solution
ECMO device Maquet Rotaflow	Maquet, Rasttat, Germany		ECMO system
Electrocautery handle	DEXTRO	SW12200
EndoReturn Arterial Cannula Kit  21-23F	Edwards Lifesciences	ER21B, ER23B	Arterial cannula with a doble lumen to ECMO connection and to introduce aortic oclussion balloon
Ethicon LigaClip med/short 20 titanium medium	ETHICON	MCS30	Ligaclips for control bleeding during groin dissection
Ethicon LigaClip med/short 20 titanium small	ETHICON	MCS20	Ligaclips for control bleeding during groin dissection
Insertion Kit Bio-medicus 180cm	MEDTRONIC	96551	Insertion Kit for ECMO cannulas, with catheter, metal wire guide and dilators
Irrigation pear	MEDLINE	DYNDE 20125	Pear to be filled with saline and purge ECMO lines at the site of connection with cannulas
Luer cone syringe 50cc	CARDIONATUR	60ML	Syringe filled with saline to fill occlusion balloon
Mersilk no 1, LR-60 CONV , 75 cm	ETHICON	W562H	Silk curved suture for ECMO cannulas fixation
Prolene 4/0	ETHICON	W8355	polypropylene suture for purse string in femoral vessels or vascular suture
Prolene 5/0 , 60 cm	ETHICON	8325	polypropylene suture for vascular suture
Prolene 5/0, 90 cm	ETHICON	8720	polypropylene suture for vascular suture
Reliant Stent Graft Balloon Catheter 12F	Medtronic, Ireland	AB46	Aortic occlusion balloon introduced through femoral artery. It is used as an endoclamp
Scalpel blade no 11	INTRAVEN	150011
Scapel blade no 23	INTRAVEN	150023
Silicone tube	IBERHOSPITEX	0027224-P	Silicone tube to connect suction system
Sofsilk braided silk no 1 strands	COVIDIEN	L-12	Silk strand for ligation or bleeding control
Sofsilk braided silk no 3 strands	COVIDIEN	L-115	Silk strand for ligation or bleeding control
straight connector 3/8"x3/8" with Luer lock	ANDOCOR	04CS0022	Piece to connect arterial cannula with ECMO line and the three way stop-cock for pressure line and blood sampling
Surgical pads pack	TEXPOL	146500
Surgical stapler	COVIDIEN	8886803712	Stapler to close surgical wound
Three-way stopcock	BD CONNECTA	394501	Three way stop-cock to connect farterial cannula with pressure line
Vessel loop large	MEDLINE	VLMAXR	Vascular loop to embrace femoral artery and vein for bleeding control.
Vessel loop small	MEDLINE	VLMINR	Vascular loop to embrace femoral artery and vein for bleeding control.
Yankauer suction terminal 50 V	DEXTROMEDICA	349701	Suction terminal for suction while surgical dissection
SURGICAL TOOLS FOR CANNULATION
Adson retractor 20 cm adn 33 cm
Aortic clamp
Boyd Scissors 18 cm
Dissection forceps without jaws 21 cm
Farabeuf retractor small
Mayo scissors straight 14 cm and 16 cm
Metzembaum scissors 18 cm, 20 cm and 23 cm
Mosquito forceps straigth and curved
Needle holder 18 cm and 23 cm
Russ dissection forceps 15 cm
Scalpel handle no 23 and no 21,  21 cm
Surgical Dissector 23 cm
MATERIALS FOR LUNG PROCUREMENT
10 cc syringe	BD DISCARDIT	309110
Alprostadil 500 mcgs injectable solution	PFIZER		Prostaglandin injected with lung preservation solution
Disposable GIA cartridge Steril 6/Ca	MEDTRONIC	1141634
Disposable GIA stapler 60/3.8 3/Ca	MEDTRONIC	2802122	Stapler for trachea and bronquial division
Foley catheter 18 Ch Folysil	Folysil, Coloplast	AA6118	urinary catheter employed to canulated pulmonary veins for retrograde perfusion
Lung preservation solution Perfadex 1000 mL	Medisan, Uppsala, Sweeden	19811 ( box of 10 units)	Lung preservation solution
Mersilk no 1, LR-60 CONV , 75 cm	ETHICON	W562H	Silk curved suture for pericardium sutures
Paediatric Venous cannula	SORIN GROUP	V132-12	Cannula used for pulmonary artery cannulation
Prolene 4/0	ETHICON	W8355	polypropylene suture for purse string in pulmonary artery
Scalpel blade no 11	INTRAVEN	150011
Sofsilk braided silk no 1 strands	COVIDIEN	L-12	Silk strand to fix arterial cannula with the tourniquet
Sofsilk braided silk no 3 strands	COVIDIEN	L-115	Silk strand for vessel ligation
Sterile bags			To keep and store lungs.
Straigth connector 1,4"/1,4" with luer lock	ANDOCOR	04CS0032	Piece to connect pulmonary artery arterial cannula with preservation line and the three way stop-cock for prostaglandin
Three-way stopcock	BD CONNECTA	394501	Three way stop-cock to connect farterial cannula with pressure line
Uromatic set for irrigation double lead	MEDISAVE	TRC4007N	Irrigation system for lung preservation solution
Uromatic set for irrigation single lead	MEDISAVE	TRC4002	Irrigation system for lung preservation solution
SURGICAL TOOLS FOR LUNG PROCUREMENT
Aortic cross- clamp
Battery-powered surgical saw
Cooley vascular clamp
Dissecting forceps 18 cm and 27,9 cm
Finochietto sternal retractor
Metzembaum scissors 20 cm and 23 cm
Mosquito forceps curved 12,5 cm
Vascular clamps
SURGICAL TOOLS FOR ABDOMINAL ORGAN PROCUREMENT
Adson articulated retractors
Allis forceps 16 cm
Aortic cross-clamps
Boyd scissors 17 cm
Castroviejo needle holder
Cooley Vascular clamps
Crile forceps curved 18 cm
Davis retractor 24.5 cm
DeBakey dissecting forceps 19.7 cm adn 24.1 cm
DeBakey vascular clamps
Dissecting forceps 18 cm and 27.9 cm
Duval forceps 23 cm
Farabeuf retractors
Kidney Trays 300 cc and 500 cc
Kocher forceps straigth 18 cm
Langenbeck retractors 21 cm and 23 cm
Mayo scissors straigth and curved , 17 cm
Mosquito forceps straigth and curved, 12.5 cm
Needle holders 15 cm, 18 cm, 23 cm and 23 cm.
Pean forceps 16 cm
Potts scissors 19cm
Rochester forceps curved 24 cm
Rochester forceps straigth 24 cm
Russ dissection forceps 15 cm and 20 cm
Scalpel handles
Senn-mueller retractor 16 cm