Title
Characterizing complications associated with abdominal normothermic regional perfusion in controlled DCD donors
First and Presenting author
Marta Velia Antonini MSc m.antonini@unibo.it
Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
Co-authors
Luca Bissoni MD Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
Erika Cordella MD Emilia-Romagna Transplant Reference Centre, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
Emiliano Gamberini MD Intensive Care Unit, Morgagni – Pierantoni Hospital, AUSL della Romagna, Forlì, Italy
Maria Maddalena Bitondo MD Intensive Care Unit, Infermi Hospital, AUSL della Romagna, Rimini, Italy
Luca Mezzatesta MD Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
Claudio Gecele MD Intensive Care Unit, Santa Maria delle Croci Hospital, AUSL della Romagna, Ravenna, Italy
Gianluca Zani MD Intensive Care Unit, Umberto I Hospital, AUSL della Romagna,Lugo, Italy
Vanni Agnoletti Prof Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy and Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy AND General Surgery
Alessandro Circelli MD Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
Introduction
Normothermic regional perfusion (NRP) is increasingly utilized in donors undergoing circulatory determination of death (DCDDs). NRP may shorten warm ischemia, assess/recondition the organs before procurement, and avoid the need for super rapid recovery. Complications occurring during NRP may negatively impact on its effectiveness, so on the results of procurement procedure, and potentially on feasibility and outcome of transplantation. Nevertheless, few data are available to characterize this peculiar aspect of NRP.
Methods
We designed an observational retrospective study aimed to characterized perfusion and circuit related complications in a cohort of controlled DCDDs undergoing abdominal (A) NRP. All procedures were performed by a mobile, experienced team serving a healthcare system including 5 hospitals.
Complications occurring since A-NRP initiation, and involving circuit/cannulae, regionalization strategy, and NRP physiology (i.e. drainage insufficiency or return obstruction) were meticulously analyzed.
Results
87 A-NRP procedures were included in the final analysis. During 28 A-NRP runs (32.1%) we observed at least 1 severe complication. Drainage insufficiency, a mismatch between venous return to the drainage cannula and the demands in terms of pump speed, is by far the most common problem.
A trend toward an increased rate of severe complications with increasing age was noticed. No clear trend was observed over the years. Complications and their severity did not appear to significantly raise with increased perfusion length.
Detailed analysis is included in the table, and in figure 1.
No procedure was discontinued due to the occurrence of complications occurring after cannulation, even in the setting of extreme events such as accidental decannulation or massive air entrance. Perfusion was restarted and/or maintained until required after troubleshooting.
Conclusions
Perfusion related complications may frequently occur during A-NRP, particularly in the setting of older and marginal donors, or when A-NRP is associated with lung procurement. Careful donor and circuit monitoring throughout reperfusion, enhanced coordination between team members, and focused simulation training may improve their prevention, early detection and successful management. Some NRP complications are also associated with other extracorporeal support strategies such as extracorporeal membrane oxygenation and cardiopulmonary bypass. Anyway, the physiological processes associated with the death, and regionalization strategy are NRP specific, and require a unique approach. Moreover, increased complexity and manipulation of NRP circuits may increase the risk of mechanical problems. Consistent NRP complications definitions may facilitate data collection and reporting, and support the development of standardized educational pathways.
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