UNCONTROLLED DONATION AFTER CIRCULATORY DEATH: A NEW LOCAL PROTOCOL AND A TWO-CASE REPORT

IntroductionUncontrolled Donation after Cardiac Death (uDCD) is a donation path following cardiac arrest (CA) without further indications for resuscitation efforts . This represents a unique opportunity for organ procurement since incidence of brain death is decreasing. Despite its potential, this procedure is limited nowadays due to its logistic and relational complexity and the concern regarding organs’ function after long warm ischemia time (WIT)., We developed a local decision protocol to assign patients with CA to three possible different pathways:1) Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR), 2) normothermic regional perfusion (NRP), 3) standard Advanced Life Support (ALS) (Figure 1). Here we present the first two cases of uDCD happened in Legnano, Milan, Italy in January 2023, after the protocol introduction.MethodsTwo patients, aged 66 and 61, reported witnessed out-of-hospital cardiac arrests (OHCA) but no bystander Cardio-Pulmonary Resuscitation (CPR) was performed. The Emergency Medical System (EMS) started ALS procedures with mechanical CPR (mech-CPR) during transport to the hospital; according to the protocol both patients were deemed ineligible for E-CPR due to the long no flow time. When resuscitation efforts were no longer indicated, clinical conditions, prognosis and all the care performed were reported to the closest relatives.The Italian Transplant Information System (SIT) for Living Will was consulted but no records were found. After that, they were informed about the possibility of organ donation through uDCD protocol and they declared no opposition. Before interruption of mech-CPR small sheath introducers were placed in femoral vessels and full dose heparin was given. According to the Italian law 20 minutes of isoelectric EKG was recorded. After cardiac death declaration, cannulation procedure was performed. Aortic occlusion balloon was inflated to exclude upper circulation and NRP started to recondition abdominal organs.ResultsThe process of organ retrieval began after 6 and 6.5 hours of NRP, respectively. Figure 2 presents the timeline of the two cases: patients' WIT were 147 and 164 minutes. Overcoming the WIT limits illustrated in the protocol, in these two uDCD cases, the livers were successfully transplanted in both cases, while kidneys in one of them.DiscussionDespite the difficulties, this simple protocol permits managing and triaging patients undergoing refractory CA in three different pathways (ECPR, uDCD, ALS), depending on CA timing and patient features. Long WIT, known difficulty in uDCD, did not prevent the successful transplanted organs outcome. These results suggest the need for further research about organ WIT, in order to potentially increase organs availability through DCD path.