Clinical paperOrgan donation in cardiac arrest patients treated with extracorporeal CPR: A single centre observational study☆
Introduction
Cardiac arrest (CA) is a catastrophic event with a high mortality rate. In more severe cases, while the circulation could be supported by extracorporeal CPR (eCPR: extracorporeal cardiopulmonary resuscitation), a devastating anoxic brain injury could develop [1], [2], [3]. This condition might evolve to brain death (BD) and, potentially, to organ donation [4]. A recently published systematic review on BD after CPR [2] described an overall prevalence of 8.9% [7.0–11.0], with higher rates in patients treated with eCPR (21.9% [16.6–27.5]). Given this potential for organ donation, CA patients resuscitated using eCPR should be carefully screened in the first days after CA for BD, in line with the suggestion of the European Resuscitation Council Guidelines for Resuscitation 2015 [5]. The actual rate of organ donation from BD patients after CA is up to 41% in very selected series [2]. In fact, this cohort represented an important niche for organ donation, with similar success rate as organs retrieved from patients deceased from other causes [6].
In our institution, eCPR, accordingly to a defined protocol [7], is a standard of care in selected refractory CA with relative good outcomes [8]. In this setting, once the Italian BD criteria have been fulfilled, organ donation has been considered and some preliminary results have been already reported [8]. Despite that eCPR gained popularity over last decades, organ donation from BD patients after CA and supported with V-A ECMO (veno-arterial extracorporeal membrane oxygenation) is not the current policy in many centres. Only small series are published on this topic, with a total of 11 eCPR donors [9].
Aim of the study is to describe the incidence of BD in a large consecutive cohort of refractory CA treated with eCPR and to investigate variables related to evolution to BD. Eligibility and determinants of organ donation will be described and the short-term follow-up results of the transplanted organs will be reported.
Section snippets
Methods
The Institutional Ethical Committee approved this retrospective cohort study of prospectively collected data. We included:
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All consecutive in-hospital and out-of-hospital cardiac arrest (IHCA/OHCA) patients with refractory CA, defined as delivery of more than 30 min of CPR without recovery of spontaneous circulation,
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eCPR support. In our institution eCPR support, available 24/24 7/7, is a standard of care in refractory CA, accordingly to a defined protocol. Eligible patients have the following
Results
During the study period, 112 patients received eCPR (52.1% of the 215 CA patients admitted to the Cardiac Intensive Care Unit in the study period) and the general characteristics of this population are summarised in Table 1. The mean age was 57.8 ± 11.1 years, with a high prevalence of male (82.1%). The main cause of CA was acute coronary syndrome (74.1%) and the main rhythm of presentation was ventricular tachycardia/fibrillation (58.9%). OHCA were prevalent (65.2%) and presented a more than
Discussion
The huge discrepancy between organ availability for transplantation and organ need still remains a major medical priority. Intensivists could implement strategies for reducing this gap improving the identification of potential organ donors. Brain death in eCPR patients is a possible condition where organ donation might be explored, as suggested also by the European Resuscitation Council Guidelines for Resuscitation 2015 [5]. We evaluated in a consecutive cohort of BD subject during eCPR our
Conclusion
In this study on post-CA patients resuscitated with eCPR, the prevalence of BD in this population is higher than 20% and this should be considered when further treatment is judged futile, to avoid early withdrawal of life supporting therapies. These patients have a good potential for organ donation, with a similar success rate as organs retrieved from patients deceased from other causes.
Authors’ contribution
G.C. contributed to conception and design of the study. M.C.C, A.C, A.V., J.V. contributed to acquisition and analysis of data for the work. M.R. and M.C.C. performed the statistical analysis. M.C.C. and G.C. wrote the first draft of the manuscript, with input from all the co-authors.
Funding
No external funding has been obtained for this research.
The first analysis of this study has been partially presented at the ISICEM 2017.
Conflict of interest
The authors declare no conflict of interest for this manuscript.
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A Spanish translated version of the abstract of this article appears as Appendixi n the final online version at http://dx.doi.org/10.1016/j.resuscitation.2017.06.001