Implementation of a mobile ECMO team for normothermic regional perfusion as donor preservation method in Controlled Donation After Circulatory death (CDAC) in the community of Madrid
Alonso Mateos Rodriguez1,3, Fatima Davila2, Ma Jesus Segade2, Carlina Garcia2, Juan Jose Rubio2, Marina Perez2, Juan Ignacio Torres1, Esther Casado1, Francisco Jose Del Rio-Gallego1.
1Oficina Regional de Coordinacion de Trasplantes, Consejeria de Sanidada, Madrid, Spain; 2Coordinacion de Trasplantes, Hospital Puerta de Hierro Majadahonda, Majadahonda, Spain; 3Facultad De Medicina, Universidad Francisco De Vitoria, Pozuelo De Alarcon, Spain
Introduction: Normothermic regional perfusion with extracorporeal membrane oxygenation (NRP-ECMO) in controlled donation after circulatory death is becoming the preservation method of choice in CDAC. Post transplant results are excellent. This procedure requires experience and the availability of portable ECMO devices which usually are confined to third level hospitals. In order to provide support with NRP-ECMO for CADC among the different hospitals of the Community of Madrid, a mobile ECMO team was trained and formed created.
Materials and Methods: Mobile ECMO team members must be composed by: 1) an experienced surgeon for great vessels cannulation; 2) a nurse for ECMO perfusion; and 3) an intensive care specialist /transplant coordinator responsible of coordination of the whole procedure and able to check complete assessment of procedure. The mobile ECMO team would be able to attend donation procedures of CDACD in any of the 27 public hospitals of the CM distributed over its 3100.4 square miles and providing care for 6.6 million inhabitants.
Results: ECMO mobile team protocol:
Limitation of vital support is a decission that depends on attending medical team and must be done before alert ECMO – mobile team.
Donor evaluation and validation depends of procurement hospital´s transplant coordination team. Family assessment and judicial consent (if necessary), must be completed before ECMO mobile team is activated.
Cannulation: cannulation and other techniques aimed at to organ preservation that do not interfere with the dying process are permitted before LLST as long as the family consents. Usually, when using NRP-ECMO, cannulation and LLST are performed in the operating room in order to facilitate different technical aspects and to shorten recovery times, but, if the family’s wishes do not allow, it can also be done in the intensive care unit (ICU)
After the cannulae have been inserted, an aortic occlusion catheter is placed trough contralateral groin
LLTS and end-of-life care are conducted in accordance with standard practices at the procuring hospital and led by the physician in charge of the patient.
If cardiac arrest happens in the first 120´of LLST, a five-minute hands-off period after cardiac arrest is required by Spanish law before declaration of death. The second condition that has to be met to transition from eligible to actual donor is compliance with certain warm ischemia times.
After death has been declared, and if warm ischemia times are deemed appropriate, the aortic occlusion balloon is inflated upper the mesenteric artery level and the extracorporeal perfusion is started, thereby commencing the NRP-ECMO phase
1.- The creation of a mobile ECMO team is feasible,
2.- It has promoted the creation of new cDCD programs across the ACM and that it has helped hospitals lacking the technological support to provide NRP-ECMO.
3.- In the first 24 months 64 real donors have been obtained through this protocol.
4.- In this period, 146 organs valid to be transplanted have been obtained (kidneys, liver and lungs). With a specific procedure to attend this purpose, and as described in other paper, hearts also can be obtained for transplant purpose.
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