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NHBD_2010 pdf

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Kidney transplant function using organs from non-heart-beating donorsmaintained by mechanical chest compressions
Alonso Mateos-Rodríguez
, Luis Pardillos-Ferrer
, José María Navalpotro-Pascual
,Carlos Barba-Alonso
, María Eugenia Martin-Maldonado
, Amado Andrés-Belmonte
Servicio de Urgencias Médicas de Madrid SUMMA112, Spain
Coordinación de trasplantes, Hospital Universitario 12 de Octubre, Madrid, Spain
a r t i c l e i n f o
 Article history:
Received 10 February 2010Received in revised form 12 April 2010Accepted 28 April 2010
Non-heart beating donorsEmergency medical servicesTransplantation
a b s t r a c t
Thisstudyaimstodeterminethefailurerateoftransplantedkidneygraftsinrecipientsoforgansfrom non-heart beating donors (NHBDs) who have had mechanical chest compressions to maintain acirculation before organ retrieval.
Aretrospectiveobservationalstudybasedonreviewoftheemergencymedicalservicedatabaseand case histories of NHBDs, and information periodically sent by transplant units about donors andorgans. The following variables were studied: age, sex, transfer hospital, time to arrival on the scene of cardiopulmonaryarrest,timetoarrivalinhospital,numberandtypeoforgansretrieved,useofmechan-ical chest compression devices, and kidney function in graft recipients. The study covered the periodbetween January 2008 and November 2009. During 2008 standard manual chest compressions wereused and during 2009 mechanical chest compression devices were used.
In39transplantedkidneysfromdonorsreceivingmechanicalchestcompressionsprimaryfailurewasdocumentedinrecipientsontwooccasions(5.1%).Kidneystransplantedfromdonorswhohadman-ual chest compressions resulted in three primary failures in recipients (9.1%). The difference betweenthe two groups was not significant (
=0.5). Three patients achieved successful return of spontaneouscirculation in the mechanical chest compression group after initiation of the NHBD donor protocol.
Wehavedescribedourexperienceandprotocolfornon-heartbeatingdonationusingvictimsofout-of-hospitalcardiacarrestinwhomcardiopulmonaryresuscitationhasbeenunsuccessfulasdonors.Primary kidney graft failure rates in organs from non-heart beating donors is similar when manual ormechanical chest compression devices are used during cardiopulmonary resuscitation.© 2010 Elsevier Ireland Ltd. All rights reserved.
1. Introduction
Non-heart-beating donors (NHBDs) have to meet predefinedcriteria for organ donation
including death from irreversible ces-sation of the beating heart. In 1995 the Maastricht conference
defined four NHBD categories to differentiate their viability, andprovide ethical and legal support.
Type I donors (admitted to thecentre after death) and type II donors (resulting from unsuccessfulcardiopulmonary resuscitation (CPR) attempts) are referred to as
donors, since the precise duration of warm ischaemiais not known in these donors. In Spain, NHBDs who originate fromthe out-hospital setting correspond to type II donors. These are
A Spanish translated version of the abstract of this article appears as Appendixin the final online version atdoi:10.1016/j.resuscitation.2010.04.024.
Corresponding author at: C/ Antracita 2 bis, 28045 Madrid, Spain.Tel.: +34 607110309.
E-mail address:
amateo.summa@salud.madrid.org(A. Mateos-Rodríguez).
patients who have suffered a cardiac arrest outside hospital, andafter failed CPR attempts are then transferred with continued CPRto hospital for organ donation.MobileEmergencyUnitdoctorsarelegallyandethicallyenabledto diagnose (but not certify) the death of the patient and activatethe donor protocol. In Spain all individuals whose views on organdonation are not known are considered as organ donors.
In spiteof this family permission is also obtained. This is regulated by theRoyal Decree 2070/1999 relating to the donation and transplanta-tion of organs and tissues.
This allows the diagnosis of death aftercardiorespiratory arrest according to the following:
The unequivocal confirmation of the absence of a heart beat,diagnosedbytheabsenceofacentralpulseorasystoleontheelec-trocardiogram,andtheabsenceofspontaneousbreathing—beingobserved for a period of at least 5min.
The irreversibility of the cessation of cardiorespiratory functionmustbeconfirmedafteranadequateperiodofadvancedCPR.Thisperiod,andCPRinterventionsshouldbeappropriatefortheageof 
0300-9572/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2010.04.024
 A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907 
theindividualandthecircumstancesleadingtocardiorespiratoryarrest.Atalltimescurrentadvancedlifesupportguidelinesmustbe followed.
If the cardiac arrest victim’s body temperature is less than 32
C,thevictimshouldbewarmedbeforeestablishingtheirreversibil-ity of cardiac arrest, and thus the diagnosis of death.This study describes the role of mechanical chest compressiondevices in our service and determines if recipients of organsfrom NHBDs who have had mechanical chest compressions haveimproved kidney graft function compared with those recipientsfrom NHBDs who have had manual chest compressions.
2. Material and methods
 2.1. Study setting 
Madrid, Spain has 6 million inhabitants. The emergency medi-cal service (EMS) is the Service of Medical Emergencies of Madrid,SUMMA112. This provides a comprehensive service including theuse of two helicopters, 26 mobile intensive care units, 17 rapidintervention vehicles, a truck for major incidents, and anotherfor special situations. Emergency vehicles have emergency traineddoctors and nurses—and one or two emergency care technicians.During 2008 the service received about one million calls andattended 400,000 incidents including 78,000 by emergency carevehicle.
 2.2. Resuscitation and donor protocol
The inclusion criteria for the NHBD protocol of the MadridEmergency Medical Service SUMMA112 are: absence of neoplas-tic,systemicortransmissiblediseases(includingnoHIVinfection);an age of between 1 and 55 years; a known time of cardiac arrest;a time interval from cardiac arrest to the start of advanced CPR of lessthan15min;hospitalarrivalinlessthan90minaftercardiopul-monary arrest; a known or easily diagnosable cause of death, withno suspected abdominal or chest bleeding, and a healthy externalappearance.When the EMS attends a cardiac arrest they begin CPR. If after30min of advanced CPR, there is no return of spontaneous cir-culation the victim is assessed as a potential NHBD. If the victimfulfills the NHBD criteria the protocol is activated, and ventilationand chest compressions (but not drugs) are continued while thepatient is transferred to the transplant hospital. Resuscitation isnot stopped during this assessment process. Death is diagnosedand certified after hospital arrival by a doctor who is not a mem-ber of the transplant team. This is usually an ICU doctor. CPR isstopped and the patient is assessed and the signs of death must beobserved for at least 5min to confirm death. The transplant sur-gical team than connect the donor to an extracorporeal circulation(bypass)machinetomaintainacirculation.Theprocessandtimingsare summarized inTable 1.There are two public hospitals in this programme: San CarlosUniversityClinicHospitalandDocedeOctubreHospital.Atpresent,thefollowingorgansareretrievedfortransplantationfromNHBDsidentified by this program: kidneys, lungs, liver, corneas and bonetissue.Wereportheredatafromoneofthesetwocentres(DocedeOctubre Hospital).The study covered the period from January 2008 to Novem-ber 2009. During the first year of the study mechanical chestcompression devices were not used. Since 2009 mechanical chestcompression devices have been included in the protocol. Specif-ically, use has been made of the Lucas©(Physio-Control) andAutopulse©(Zoll) compression devices (Fig. 1).In the case of heli-
Fig. 1.
Mechanical cardiac compressors used in the program, Lucas©from Physio-Control and Autopulse©from Zoll.
copter transfer, where the Autopulse©was used. The analysis waslimited to those cases in which one or two kidneys were retrievedand transplanted.
 2.3. Data collection
A retrospective observational study based on review of emer-gency medical service database, case histories of NHBDs, andinformation provided by transplant units on the validity of donorsand organs. The following variables were entered into a database:age,sex,transferhospital,timetoarrivalonthesceneofcardiopul-monary arrest, time to arrival in hospital, number and type of organsretrieved,useofmechanicalchestcompressiondevices,andkidney function in graft recipients.
 2.4. Statistical analysis
The SPSS©version 16.0 was used for statistical analysis. Quan-titative variables are expressed as the mean
standard deviation(SD).Qualitativevariablesarereportedaspercentages.Forthecom-parison of qualitative variables, the Chi-squared test or its Fisher
correction was used. Comparison of quantitative variables wasmade with the Student’s
3. Results
During 2009, 28 NHBD candidates were transferred to the Docede Octubre Hospital with the use of one of the mechanical chestcompression devices. Of these 28 cases, 85% were males, with amean age of 39
10 years. The mean time for EMS arrival to thesceneofthecardiopulmonaryarrestwas12
8min,andtheinter-val from the initial alert for the cardiac arrest and hospital arrivalwas 97
53min. There was no significant difference with the datafrom 2008 when manual chest compressions were used (Table 2).The cause of death in the 28 patients who had mechanical chestcompressionswas:cardiacarrest(15cases),neurological(5cases),respiratory (1 case) and unknown (information missing from clin-ical record in 7 cases).Thirty-nine kidneys were transplanted from the 28 NHBDs in2009,representing70%ofthetotalpotentialkidneys.Kidneyswerenot transplanted because of: legal objection in one case (two kid-neys), family refusal in three cases (6 kidneys), failure to establishan extracorporeal circulation in 1 case (two kidneys) and micro-scopic and macroscopic defects in 7 kidneys.During the manual chest compression period in 2008, 33 kid-neys were transplanted from 20 NHBDs (83% of the potentialorgans).Thedifferencebetweenbothgroupsinproportionofdonorkidneys transplanted was not significant (
A. Mateos-Rodríguez et al. / Resuscitation 81 (2010) 904–907 
 Table 1
Timing and interventions for out-hospital NHBD program.Pre-hospital setting Hospital setting Legal actions015min Arrive at scene and start CPR15–30min If no ROSC and fulfill NHBD criteriaactived protocol30–90min NHBD alert and transfer to hospitalwith CPR on going (manual ormechanical compressiions)Hospital organ retrieval team alerted Diagnosis of death and certification byhospital doctor on arrivalLegal request for catheterization forpreservation purposes90120min Extracorporeal bypass circulation120240min Ask family if they agree with organdonationLegal request for organ retrievalROSC=return of spontaneous circulation. NHBD=non-heart beating donor.
 Table 2
Description of the cases studied.Manual chest compressions(
=20 patients)Mechanical chestcompressions (
=28 patients)Age
SD (years) 41
9 39
=0.38Males (%) 85% 95%Time to arrival on scene of cardiopulmonary arrest (min) 15
7 12
=0.19Cardiac arrest alert to hospital arrival interval (min) 99
24 97
=0.89Kidneys transplanted (% versus potential number) 33 (82%) 39 (70%)
=0.23Primary graft failure in recipient 3 (9.1%) 2 (5.1%)
Among the 39 transplanted kidneys from NHBDs who hadmechanical chest compressions in 2009, primary graft failure wasdocumented in recipients on two occasions (5.1%). In the manualchest compression period there were three primary graft failuresin recipients of the 33 kidneys (9.1%). The difference between thetwo groups was not significant (
=0.62).We were also made aware of a further three cases who hadmechanicalchestcompressionsaspartoftheNHBDprotocolwherethere was a return of spontaneous circulation during transport tothetransplantcentre.Oneofthesecasesmadeagoodrecoverywithneurological function.
4. Discussion
Mechanicalchestcompressiondevicesareafeasiblealternativeto manual compressions during transport of patients in whom ourNHBD protocol is activated. The program was started in the year2004,andsincethenover500organsfrom170patientstransferredto the transplant units have been transplanted.Thenon-primaryfunctionrateinkidneyrecipientsfromdonorsof this kind is about 10%.
Although larger studies are neededto confirm this, our observational study shows that the use of mechanical chest compression devices used to maintain a cir-culation during transport of patients who have had a failedCPR attempt does not significantly improve the primary graftfunction of donated kidneys. Graft function is dependent on alarge number of factors, and cannot be established by improvedperfusion in the context of cardiopulmonary arrest alone. Pri-mary kidney graft failure is usually due to microcoagulationwithin the renal parenchyma, and this phenomenon is difficultto resolve and even more difficult to detect prior to transplan-tation. Mechanical chest compression devices likewise do notseem to offer an important improvement in the number of viableorgans for transplantation, though here again further studies areneeded.Mechanical chest compression devices do make patient trans-port easier for the medical team, decreasing the physical workrequired for manual chest compressions and minimizing injuriesto rescuers from performing chest compressions during ambu-lance during transfer. Also, while these devices have not shownimprovementinthesurvivalofpatientssufferingcardiopulmonaryarrest,
the devices do improve brain perfusion and also help min-imize interruptions in chest compressions.
We are currentlystudying injuries to donor organs caused by chest compres-sions.Themostfrequentcauseofdeathinourserieswasprimarycar-diac arrest. Trauma patients who have suffered cardiopulmonaryarrest are often not good donor candidates as they have injuries tomajorvesselsandestablishinganextracorporealcirculationcanbedifficult.We also identified three patients who were entered into theNHBD protocol and received mechanical chest compressions whohadareturnofspontaneouscirculationduringtransfertothetrans-plant hospital. If these individuals had not been included in theNHBDprotocol,resuscitationwouldhavestoppedafter30minandthe patients would not have survived. We are investigating thesecases in more detail. Ensuring that the guidance for diagnosingdeathisstrictlyfollowedonarrivalatthetransplantcentreensuresthat only those patients who have died become NHBDs.Family refusal for organ donation in this group of NHBDs is lowin comparison to heart beating donors who have been diagnosedbrain dead.
We do not know the cause of this difference. OnereasonmaybetherelativespeedoftheNHBDprocessasopposedtoasking family members who may have been at the bedside of theirsick relative for a number of days in the case of brain dead donors.Awareness and support for organ donation in Spain is generallygood.
5. Conclusions
We have described our experience and protocol for non-heartbeating donation using victims of out-of-hospital cardiac arrestin whom cardiopulmonary resuscitation has been unsuccessful asdonors.Primarykidneygraftfailureratesinorgansfromnon-heartbeating donors is similar when manual or mechanical chest com-pression devices are used during cardiopulmonary resuscitation.
Conflict of interest statement
None to declare.

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