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1 Good afternoon everyone, Dr Faucher would like to apologize not to be here today due to personal medical reasons (she is actually pregnant). I have been asked to talk you about udcd. I haven t practiced my English for several years now, so I would also like to apologize for it. Although udcd seems to have promising results in terms of graft survival, it brings several medical, ethical, legal, economic, and logistic challenges on topics such as cardiac arrest, resuscitation, organ donation and preservation. Currently, there is no gold-standard protocols. From one country to another, there are many procedures that are used in clinical practice but, we don t know much about the efficiency of each dedicated protocols. Is Barcelona protocol more valuable than Paris or Maastricht ones? 1

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5 For those who would like to implement a new protocole in their area, and for those who are implementing but would like to improve or adapt it, I will try to answer this question: When should udcd be considered? Many questions that came to me when preparing this lecture. Most of them are covered in the new udcd recommendations issued recently in transplant international, and I first want to thank their authors for this remarquable work. 5

6 For those who would answer «never» - but I m sure there s no one in this room-, I will tell them: «But udcd works!» I ve chosen deliberately this «ten years old» paper, just to show you that it already worked 10 years ago, and since then many improvements have been done on this topic. Although PNF rates appear to be higher in udcd kidneys (but under 3%, which is acceptable), there s no significant difference in graft and patient survival when compared to cdcd or DBD. With nearly 2000 udcd donors in the 3 main countries, in less than 25 local programmes, the donor pool seems to be considerable. In France, Spain and the Netherlands, udcd donors account for a significant number of deceased-donor transplants. Others countries such as Austria, Belgium, Italy, and recently Russia, have developed udcd programs. 6

7 Then should we? or rather could we? propose it for all cardiac arrests when there s no return of a spontaneous circulation? The 2015 international guidelines for CPR recommend that patients who would otherwise have termination of efforts after an unsuccessful resuscitation may be considered candidates for organ donation. acpr exhausted according to national protocols, aligned with international standards, must be a prerequisite. acpr is identically applied, regardless of whether the person could be considered a potential donor or not. But we can t hide that during this early stage, even experimented teams often face a strong dilemna: how to achieve an optimized and complete resuscitation, and in the meantime try to identify as soon as possible the potential donors. 7

8 The time constraints are indeed really tight, as emergency teams are very busy. The international recommandations advocate an acpr of at least 30, but if we wait these 30 before thinking to udcd, it s most of the time already to late. Within the first 15 must the emergency team: - Get information on the past and present medical history of the patient, - Have an idea of the cause of the cardiac arrest - Evaluate timings (exact time of the CA, time acpr was started, time of transfer to the hospital) - And know to which hospital they must refer to. Combined with classical tasks of : resuscitating, meeting relatives, informing other colleagues We know that delays in recognizing futile resuscitative efforts result in lost opportunities of potentially viable organs. Then is early donor identification possible? 8

9 The recent work of Jabre and collegues proposes an interesting way of early and objective udcd donor identification. Confirmed on more that 5000 patients, the association of 3 criteria: - OHCA not witnessed by emergency medical services personnel - Non-shockable initial cardiac rhythm - No return of spontaneous circulation before receipt of a third dose of epinephrine seems to be characterized by a nul survival, with a hundred % of specificity and predictive positive value. These results could make easier end earlier donor identification and could help following time constraints. At nearly 15th 20th mn ressucitative efforts teams could turn to udcd protocol 9

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12 Emergency teams are indeed confronted to a permanent dilemma between: - On the one hand the wish to increase retrieval and graft rates - And on the other hand the risk of increasing graft dysfunction rates The third parameter they have in mind is that the loss of activity also leads to the loss of skills So, we have to keep in mind to select for them the optimal and up to date criteria. It s true that literature is quite poor, with small series, lots of descriptives studies. Waiting for new studies, current recomendations are THE reference on how to select donors Are we able now to determine standard ratio for : Eligible udcd vs Potential udcd? Actual udcd vs Eligible udcd Utilized udcd vs Actual udcd? And so for Acceptable PNF rate? And limit ratio for DGF? I have no answer, but new recommendations seems mandatory 12

13 Anyway, the current updated rules recommend the following criteria: Age should be under 60, absolute contraindications should be: Kidney disease, liver disease, Malignancies, IV Drugs, Sepsis, viral infection And relative contraindications: Arterial hypertension Diabetus Major trauma Homicide or suicide At least, it should be noted that the CA aetiology does not fit the inclusion criteria, except for the traumatic aetiology. But what about myocardial infarction? Ventricular fibrillation? Hypoxic cardiac arrest? Pulmonary embolism ; All causes suggest different underlying diseases, physiological age and could perhaps induce new considerations for age criteria or relative contraindications. I m already a «to bad donor» in France! 13

14 This table from the latest recommendations shows how various are the exclusion criteria even in the 3 Europeans countries. If we compare exclusion criteria, we see that in France it is not easy for us! Exclusion criteria are too restrictive. For example, the age-criteria could to be discussed. The technical evolutions (normothermic reperfusion, preservation machines ) should lead to an adaptation of the exclusion criteria. A contraindication 15 years ago can lack sense after improvment of preservation techniques. On this topic, Hoogland s work, from Maastricht, is interesting. They setting an upper limit PNF rate; then, they worked on improving organisation and preservation techniques and could finally stay under this PNF rate (and even improve it) as well as extend the inclusion criteria. 14

15 The primary objective must be to shorten warm ischemic time, and the way to reach it is to go faster on each stage of the process to increase the number of viable organs. These times are quite comparable in the contributing countries. Then the Key messages are : - Go fast and safely - Start transport at mn after CA onset - Use volemic expansion and stop epinephrine infusion 15

16 As it s specified in most of the protocoles, there s no need of any specific material. The use of a mechanical cardiac compressor is not essential, though it can improve cardiac compression regularity and efficiency (especially for long distances transport). It has been proven that it s not not harmful for lungs. These devices can above all facilitate team organization and efficiency, which is often a real problem in such procedures. 16

17 For a basic implementation of the programme, additional means to those already available in any EMS are not necessary, as all are equipped with material for advanced life support. This means that these udcd protocols can be developed either in medicalized or in non medicalized prehospital systems. In those situations, written protocols compatibles with local constraints are fundamental Nevertheless, the presence of physicians at the scene of the CA does not only improve the quality of assistance, but also facilitates this particular donation process. The physician-based EMS model in Spain or France may be one of the underlying reasons for the important expansion of udcd in these countries 17

18 The ethical, cultural or legal constraints, even if not in the foreground in the process, are in fact essential to consider. What if the perfect donor but a incompatible legal system? Or a definitely opposed population? The legal constraint must be taken into account; for example, the protocol will be feasible, but different, wether the preservation techniques can be positioned prior to relatives interview, or wether it s an «opt-in» or an «opt-out» statement system. A debate between professionnals prior to implement such a protocol seems inevitable, as well as with the general public or its representative organizations. And despite all this, you ll need sometimes strenuous efforts to overcome barriers. We can take the example from the NY city udcd program, which is technically functional but for which consumer associations have erected such barriers that it can t effectively start. 18

19 Relatives are rarely ready to hear from udcd, even when messages are provided progressively and adapted to their emotional situation and their understanding of the situation. The need of learning how to approach relatives must be emphasized: how to face violence of emotions and time perception, how to preserve relatives from post traumatic stress disorder. There is evidence that the way in which the possibility of donation is presented to a grieving family can have a critical impact both positive and negative upon the decision that they make. It is particularly important that families are approached at the appropriate time, in the appropriate fashion and by someone with the appropriate skills The challenge in approaching relatives in this situation is in successfully creating a dialogue. Through their professional attitude, the timing of their meetings, their ability to listen, they must try to attune themselves to the grieving families. 19

20 As a first conclusion, I would say that beyond all this practical elements, udcd can only work if out-of-hospital teams and in-hospital services work hand in hand, with a smooth and appropriate communication, a close cooperation and collaboration, and manage to establish protocols defining roles and responsibilities of each actor The informations from the transplanting teams upon amount of activity, results of retrievals and grafts, and graft survival, are a permanent motivating factor for prehospital teams. 20

21 Then, before implementing a new udcd programme, don t forget to: - Consider your local experience, evaluate the number of actual cardiac arrests and potential donors, analyse existing registries, construe statistics and follow up analysis - don t neglect drafting training of all contributors and promote simulation - Consider economic issues: Evaluate existing resources and needed investment, and above all be sure of an institutional support 21

22 Finally, when the programme seems effective, it s a priority to: - Follow up activity, with a completeness preoccupation as good as possible - Learn from technical improvements and optimize protocols - Promote research, by using each center s volume of activity and specificities, with the aim to find out how to increase graft and functional rates. It is, in my opinion, the only way to consolidate these programmes, in the era of controled DCD programmes developpement throughout Europe. 22

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