- Email: [email protected]
Interhospital Transfers of a Mobile Extracorporeal Membrane Oxygenation Team for Maastricht III Donations
Interhospital Transfers of a Mobile Extracorporeal Membrane Oxygenation Team for Maastricht III Donations M. Sevilla Martineza,*, A. Iglesias Santiagoa, R. Lara Rosalesa, E.P. Fuentes Garciab, and J.M. Perez Villaresa a
Intensive Care Unit, Virgen de las Nieves Hospital, Granada, Spain; and bIntensive Care Unit, San Cecilio Hospital, Granada, Spain
ABSTRACT Objective. The objective is to describe the donations made with extracorporeal membrane oxygenation as a method of preservation to meet the characteristics of the donors and the transplants obtained. Methods. This was a retrospective descriptive study, using the donation registration data made at Virgen de las Nieves Hospital from 2010 to February 2018. Results. A total of 11 transfers occurred: 2 to the province of Jaen (Jaen Hospital, 92 km from Virgen de las Nieves Hospital; San Agustín Hospital, Linares, 136 km), 1 to Santa Ana Hospital, Motril (68 km), 1 to Poniente Hospital, El Ejido, Almeria (137 km), and 7 trips within the city of Granada. From these donations, a total of 21 kidneys, 3 livers, 10 corneal transplants, 4 extractions of osteotendinous tissue, and 1 extraction of vascular tissue were obtained. Conclusion. Extracorporeal membrane oxygenation mobile teams can enable donation in controlled donation after circulatory death with normothermic preservation in hospitals without these resources, which increases the donor group and optimizes graft results.
S
PAIN has high transplant activity, but the number of donations is insufficient to cover the needs for transplants in our population [1]. A progressive decrease in the number of brain death donors makes the number of donors insufficient. The number of patients newly listed keeps increasing, which results in 5% to 10% of patients dying or becoming too sick to be transplanted. Donation after circulatory death (DCD) is the strategy to increase the number of donors. Fortunately, since the publication of the 2012 National Consensus Document on Donation in Asystole and since Royal Decree 1723/2012 became effective back in 2013, the programs of Maastricht III in our country have grown exponentially [2]. METHODS The purpose of this study was to describe the donations made with extracorporeal membrane oxygenation (ECMO) as a method of preservation to meet the characteristics of the donors and the transplants obtained. This was a retrospective descriptive study using the donation registration data made in the Virgen de las Nieves Hospital from 2010 to February 2018. 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.08.013
3042
Thanks to the experience acquired with ECMO since 2010 with the uncontrolled DCD program and since 2013 with the controlled DCD (cDCD) program (according to current Spanish legislation and all international recommendations), we have advanced in the knowledge and experience of ECMO as a perfusion method. This allowed us to create a group of mobile ECMO in 2015 for cDCD outside our center. The ECMO device is operated by transplant coordinators who are specialists in intensive medicine.
RESULTS
Our experience consisted of 11 transfers: 2 in Jaen (Hospital Complex of Jaen, 92km from Virgen de las Nieves Hospital; San Agustin Hospital, Linares 136km), 1 to Sana Anta Hospital, Motril, 68 km; 1 to Poniente Hospital, Almeria, 137 km; and 7 in the same city. The mobile team deployed included 1 doctor from the transplant coordination team; 1 nurse from the transplant
*Address correspondence to Dr María Sevilla Martínez, Intensive Care Unit, Hospital Universitario Virgen de las Nieves, Cy Las Flores, n 3, Ático B. 18004, Granada, Spain. Tel: 660148939. E-mail: [email protected] ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 3042e3043 (2019)
EXTRACORPOREAL MEMBRANE OXYGENATION TEAM
3043
Table 1. Characteristics of the Donors and Results
DCD; it facilitates graft quality assessment prior to validation, and there is the possibility of conducing intraoperative biopsies for organ assessment [3]. The results suggest that ECMO may be the most effective method for preserving abdominal organs in DCD, especially in liver transplantation [4]. DCD is seen as the clearest way to expand the number of transplants. In 2018, it involved a total of 629 donors, which represents an increase of 10% with respect to the previous year. More than 100 hospitals across the country, in 16 autonomous communities, are already accredited for this type of donation. Despite the advantages it offers, the use of normothermic regional perfusion cannot be extended to all hospitals due to its high complexity, so it is proposed that ECMO mobile teams transfer to hospitals with possible Maastricht III donors and fewer resources. In our experience, the ECMO mobile teams may enable cDCD donation with normothermic preservation in hospitals without these resources, which increases the group of donors and optimizes graft results. In the last years, DCD have become the most important way to increase the number of organ donations in our country, and the role played by intensivists with bioethics, management of life support systems, and organ donation formation is essential.
Age Case (y)
LTE
Organ and Tissues
2 kidneys, 1 bone tissue, 1 vascular tissue 2 kidneys, 2 corneal, 1 bone tissue 2 kidneys 2 kidneys, 2 corneal 1 liver, 1 kidney, 2 corneal 1 liver, 2 kidneys, 1 bone tissue, 2 corneal 2 kidneys
1
53
Anoxic encephalopathy
2
56
Anoxic encephalopathy
3 4 5
57 60 56
Anoxic encephalopathy Anoxic encephalopathy Anoxic encephalopathy
6
56
Anoxic encephalopathy
7
56
8
57
Unfavorable respiratory pathology Stroke
9 10
35 61
11
58
12
43
Anoxic encephalopathy Unfavorable respiratory pathology Unfavorable respiratory pathology Anoxic encephalopathy
2 kidneys, 2 corneal, 1 bone tissue 1 liver, 2 kidneys 1 kidney 1 kidney 2 kidney, 1 bone tissue
Abbreviation: LTE, limitation of therapeutic effort.
coordination team; 1 vascular surgeon (for cannulation); and a team of surgeons for organ extraction. The portable equipment included cannulation material and the ECMO device. The donors were hospitalized in the intensive care units and included 10 men and 2 women with an average age of 54 years (35-61 years). The reason for limitation of therapeutic effort was anoxic encephalopathy in 8 cases, stroke in 1 case, and respiratory pathologies with unfavorable evolution and prognosis in 3 cases. The average time from intensive care unit admission until limitation of therapeutic effort was 10 days (Table 1). Twenty-one renal transplants, 3 livers, 10 corneal transplants, 5 extractions of bone tissue, and 1 extraction of vascular tissue were obtained. DISCUSSION
The normothermic regional perfusion with ECMO has been the most widely used preservation method for the last few years due to a wide experience using it in uncontrolled
REFERENCES [1] Organización Nacional de Trasplantes. Donación en asistolia en España: situación actual y recomendaciones [Consensus Document]. http://www.ont.es/infesp/DocumentosDeConsenso/DO NACIÓN%20EN%20ASISTOLIA%20EN%20ESPAÑA.%20SIT UACIÓN%20ACTUAL%20Y%20RECOMENDACIONES.pdf/; 2012. [Accessed 01.17; in Spanish]. [2] Pérez-Villares JM, Lara-Rosales R. Interhospital transfers of a mobile team for organ preservation with extracorporeal membrane oxygenation in controlled donors after circulatory death. Med Intensiva. 2018;42:131e3. [3] Pérez-Villares JM, Lara-Rosales R, Fernández-Carmona A, Fuentes-García P, Burgos-Fuentes M, Baquedano-Fernández B. Mobile ECMO team for controlled donation after circulatory death. Am J Transplant. 2018;18:1293e4. [4] Miñambres E, Suberviola B, Domínguez-Gil B, et al. Improving the outcomes of organs obtained from controlled donation after circulatory death donors using abdominal normothermic regional perfusion. Am J Transplant. 2017;17:2165e72.
Intensive Care Unit, Virgen de las Nieves Hospital, Granada, Spain; and bIntensive Care Unit, San Cecilio Hospital, Granada, Spain
ABSTRACT Objective. The objective is to describe the donations made with extracorporeal membrane oxygenation as a method of preservation to meet the characteristics of the donors and the transplants obtained. Methods. This was a retrospective descriptive study, using the donation registration data made at Virgen de las Nieves Hospital from 2010 to February 2018. Results. A total of 11 transfers occurred: 2 to the province of Jaen (Jaen Hospital, 92 km from Virgen de las Nieves Hospital; San Agustín Hospital, Linares, 136 km), 1 to Santa Ana Hospital, Motril (68 km), 1 to Poniente Hospital, El Ejido, Almeria (137 km), and 7 trips within the city of Granada. From these donations, a total of 21 kidneys, 3 livers, 10 corneal transplants, 4 extractions of osteotendinous tissue, and 1 extraction of vascular tissue were obtained. Conclusion. Extracorporeal membrane oxygenation mobile teams can enable donation in controlled donation after circulatory death with normothermic preservation in hospitals without these resources, which increases the donor group and optimizes graft results.
S
PAIN has high transplant activity, but the number of donations is insufficient to cover the needs for transplants in our population [1]. A progressive decrease in the number of brain death donors makes the number of donors insufficient. The number of patients newly listed keeps increasing, which results in 5% to 10% of patients dying or becoming too sick to be transplanted. Donation after circulatory death (DCD) is the strategy to increase the number of donors. Fortunately, since the publication of the 2012 National Consensus Document on Donation in Asystole and since Royal Decree 1723/2012 became effective back in 2013, the programs of Maastricht III in our country have grown exponentially [2]. METHODS The purpose of this study was to describe the donations made with extracorporeal membrane oxygenation (ECMO) as a method of preservation to meet the characteristics of the donors and the transplants obtained. This was a retrospective descriptive study using the donation registration data made in the Virgen de las Nieves Hospital from 2010 to February 2018. 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.08.013
3042
Thanks to the experience acquired with ECMO since 2010 with the uncontrolled DCD program and since 2013 with the controlled DCD (cDCD) program (according to current Spanish legislation and all international recommendations), we have advanced in the knowledge and experience of ECMO as a perfusion method. This allowed us to create a group of mobile ECMO in 2015 for cDCD outside our center. The ECMO device is operated by transplant coordinators who are specialists in intensive medicine.
RESULTS
Our experience consisted of 11 transfers: 2 in Jaen (Hospital Complex of Jaen, 92km from Virgen de las Nieves Hospital; San Agustin Hospital, Linares 136km), 1 to Sana Anta Hospital, Motril, 68 km; 1 to Poniente Hospital, Almeria, 137 km; and 7 in the same city. The mobile team deployed included 1 doctor from the transplant coordination team; 1 nurse from the transplant
*Address correspondence to Dr María Sevilla Martínez, Intensive Care Unit, Hospital Universitario Virgen de las Nieves, Cy Las Flores, n 3, Ático B. 18004, Granada, Spain. Tel: 660148939. E-mail: [email protected] ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 3042e3043 (2019)
EXTRACORPOREAL MEMBRANE OXYGENATION TEAM
3043
Table 1. Characteristics of the Donors and Results
DCD; it facilitates graft quality assessment prior to validation, and there is the possibility of conducing intraoperative biopsies for organ assessment [3]. The results suggest that ECMO may be the most effective method for preserving abdominal organs in DCD, especially in liver transplantation [4]. DCD is seen as the clearest way to expand the number of transplants. In 2018, it involved a total of 629 donors, which represents an increase of 10% with respect to the previous year. More than 100 hospitals across the country, in 16 autonomous communities, are already accredited for this type of donation. Despite the advantages it offers, the use of normothermic regional perfusion cannot be extended to all hospitals due to its high complexity, so it is proposed that ECMO mobile teams transfer to hospitals with possible Maastricht III donors and fewer resources. In our experience, the ECMO mobile teams may enable cDCD donation with normothermic preservation in hospitals without these resources, which increases the group of donors and optimizes graft results. In the last years, DCD have become the most important way to increase the number of organ donations in our country, and the role played by intensivists with bioethics, management of life support systems, and organ donation formation is essential.
Age Case (y)
LTE
Organ and Tissues
2 kidneys, 1 bone tissue, 1 vascular tissue 2 kidneys, 2 corneal, 1 bone tissue 2 kidneys 2 kidneys, 2 corneal 1 liver, 1 kidney, 2 corneal 1 liver, 2 kidneys, 1 bone tissue, 2 corneal 2 kidneys
1
53
Anoxic encephalopathy
2
56
Anoxic encephalopathy
3 4 5
57 60 56
Anoxic encephalopathy Anoxic encephalopathy Anoxic encephalopathy
6
56
Anoxic encephalopathy
7
56
8
57
Unfavorable respiratory pathology Stroke
9 10
35 61
11
58
12
43
Anoxic encephalopathy Unfavorable respiratory pathology Unfavorable respiratory pathology Anoxic encephalopathy
2 kidneys, 2 corneal, 1 bone tissue 1 liver, 2 kidneys 1 kidney 1 kidney 2 kidney, 1 bone tissue
Abbreviation: LTE, limitation of therapeutic effort.
coordination team; 1 vascular surgeon (for cannulation); and a team of surgeons for organ extraction. The portable equipment included cannulation material and the ECMO device. The donors were hospitalized in the intensive care units and included 10 men and 2 women with an average age of 54 years (35-61 years). The reason for limitation of therapeutic effort was anoxic encephalopathy in 8 cases, stroke in 1 case, and respiratory pathologies with unfavorable evolution and prognosis in 3 cases. The average time from intensive care unit admission until limitation of therapeutic effort was 10 days (Table 1). Twenty-one renal transplants, 3 livers, 10 corneal transplants, 5 extractions of bone tissue, and 1 extraction of vascular tissue were obtained. DISCUSSION
The normothermic regional perfusion with ECMO has been the most widely used preservation method for the last few years due to a wide experience using it in uncontrolled
REFERENCES [1] Organización Nacional de Trasplantes. Donación en asistolia en España: situación actual y recomendaciones [Consensus Document]. http://www.ont.es/infesp/DocumentosDeConsenso/DO NACIÓN%20EN%20ASISTOLIA%20EN%20ESPAÑA.%20SIT UACIÓN%20ACTUAL%20Y%20RECOMENDACIONES.pdf/; 2012. [Accessed 01.17; in Spanish]. [2] Pérez-Villares JM, Lara-Rosales R. Interhospital transfers of a mobile team for organ preservation with extracorporeal membrane oxygenation in controlled donors after circulatory death. Med Intensiva. 2018;42:131e3. [3] Pérez-Villares JM, Lara-Rosales R, Fernández-Carmona A, Fuentes-García P, Burgos-Fuentes M, Baquedano-Fernández B. Mobile ECMO team for controlled donation after circulatory death. Am J Transplant. 2018;18:1293e4. [4] Miñambres E, Suberviola B, Domínguez-Gil B, et al. Improving the outcomes of organs obtained from controlled donation after circulatory death donors using abdominal normothermic regional perfusion. Am J Transplant. 2017;17:2165e72.