Department of Critical Care Medicine, Foothills Medical Center, University of Calgary, 3132 Hospital Drive N.W, Calgary, AB, T2N 5A1, Canada.
Southern Alberta Organ and Tissue Donation Program, Alberta Health Services, Calgary, AB, Canada.
Can J Anaesth. 2020 May;67(5):521-531. doi: 10.1007/s12630-020-01594-8. Epub 2020 Feb 25.
Donation after circulatory determination of death (DCD) has been performed in Canada since 2006. Numerous aspects of donor management remain controversial.
We performed a multicentre cohort study involving potential DCD donors in western Canada (2008-2017), as well as recipients of their organs, to describe donor characteristics and critical care practices, and their relation to one-year recipient and graft survival.
There were 257 patients in four provinces that underwent withdrawal of life-sustaining therapies (WLST) in anticipation of possible DCD. The proportion of patients that died within two hours of WLST ranged from 67% to 88% across provinces (P = 0.06), and was predicted by deeper coma (P = 0.01), loss of pupillary light or corneal reflexes (P = 0.02), and vasopressor use (P = 0.01). There were significant differences between provinces in time intervals from onset of hypotension to death (9-11 min; P = 0.02) and death to vascular cannulation (7-10 min; P < 0.001). There was inconsistency in pre-mortem heparin administration (82-96%; P = 0.03), including timing (before vs after WLST; P < 0.001) and dose (≥ 300 vs < 300 units·kg; P < 0.001). Donation after circulatory death provided organs for 321 kidney, 81 liver, and 50 lung transplants. One-year recipient and graft survival did not differ among provinces (range 85-90%, P = 0.45). Predictors of death or graft failure included older recipient age (odds ratio [OR] per year, 1.04; 95% confidence interval [CI],1.01 to 1.07) and male donor sex (OR, 3.35; 95% CI, 1.39 to 8.09), but not time intervals between WLST and cannulation or practices related to heparin use.
There is significant variability in critical care DCD practices in western Canada, but this has not resulted in significant differences in recipient or graft survival. Further research is required to guide optimal management of potential DCD donors.
自 2006 年以来，加拿大已经开展了循环判定死亡后的捐献（DCD）。在供者管理方面仍存在许多有争议的问题。
我们开展了一项多中心队列研究，纳入了加拿大西部的潜在 DCD 供者（2008-2017 年）以及接受其器官的受体，以描述供者特征和重症监护实践，并研究这些因素与受体和移植物 1 年存活率的关系。
在四个省有 257 例患者接受了生命支持治疗的撤机（WLST），以备可能进行 DCD。在各省，死亡发生在 WLST 后 2 小时内的患者比例范围为 67%至 88%（P = 0.06），并可通过昏迷程度更深（P = 0.01）、瞳孔或角膜反射消失（P = 0.02）和血管加压药的使用（P = 0.01）来预测。在从低血压发作到死亡的时间间隔（9-11 分钟；P = 0.02）和从死亡到血管插管的时间间隔（7-10 分钟；P < 0.001）方面，各省之间存在显著差异。在生前肝素给药方面存在差异（82%-96%；P = 0.03），包括时机（在 WLST 之前或之后；P < 0.001）和剂量（≥ 300 单位·kg 与 < 300 单位·kg；P < 0.001）。循环判定死亡后提供了 321 例肾脏、81 例肝脏和 50 例肺移植的供体器官。各省之间的受体和移植物 1 年存活率没有差异（范围 85%-90%，P = 0.45）。死亡或移植物失功的预测因素包括受体年龄较大（每年增加 1.04；95%置信区间[CI]，1.01 至 1.07）和男性供者性别（OR，3.35；95%CI，1.39 至 8.09），但 WLST 和插管之间的时间间隔或与肝素使用相关的实践不是。
在加拿大西部，重症监护 DCD 实践存在显著差异，但这并未导致受体或移植物存活率的显著差异。需要进一步研究来指导潜在 DCD 供者的最佳管理。
