Non Heart Beating Multi Organ Donation
1. Organ donation with non-heartbeating donors
1.1. General
Non-heartbeating donors can be divided into the following categories:
Category I:
Category II:
Category III:
Category IV:
deceased at arrival in hospital
acutely deceased in hospital, after an attempt to reanimate or otherwise
death soon to be expected
cardiac arrest in a heart-beating donor
Category I:
Concerns patients that have died outside the hospital and whom reanimation is not
advisable.
Category II:
Concerns patients whom an attempt to reanimate is started which is then terminated in the
hospital because it was not successful. This group of patients qualifies for non-heart beating
kidney donation in hospitals that are equipped for rapid organ procurement.
Category III:
Mostly concerns patients with a critical neurological disease pattern, who, however, do not
meet the criteria for brain death. These patients are actively medically treated for teir
underlying illness. The decision whether or not to stop active treatment has to be
unanimously made by two knowledgeable specialists. The decision to stop active treatment
will most likely result in cardiac arrest and death of the patient. This category is suitable for
non-heartbeating multi-organ donation (lungs, liver, kidneys and pancreas).
Category IV:
Concerns patients who are declared brain dead and in which cardiac arrest occurs during the
preparation for the heart-beating procedure dispite maximum support. These donors are
suitable for multi-organ donations (lungs, liver, kidneys and pancreas)
Non-heartbeating donation category I does not take place in the Netherlands.
Non-heartbeating donation category II at this moment is being applied in the Netherlands on
a limited scale and only for kidneys.
Non-heartbeating donation category III is the most common type of NHB donor.
Non-heartbeating donation category IV is a very rare situation.
1.2. Non-heartbeating multi-organ donation category III
In the following flow chart it is stated which steps are to be taken with ventilated patients with
an infaust prognosis with whom the brain death criteria are not met. In such patients it is
decided by the responsible physician(s) and the family that treatment is stopped and cardiac
death will follow.
NHB Organdonor
Category III
No brain death
Patient on ICU
Age criteria and contra-indications for
NHB organdonation
Potiential NHB donor? Consultation Transplantcoordinator
Registred donor registry?
Consent family?
Switch-off( in ICU or OR)
Cardiac death
5 minutes No Touch (Transport to the OR)
NHB organdonation procedure in OR
Only category III donors qualify for non-heartbeating multi-organ donation.
2. Clarification of non-heart beating multi-organ donation category III
2.1. Criteria for non-heart beating multi-organ donation
Age criteria Non Heart-Beating Organ Donation
Kidney
Pancreas (Whole)
5 - ± 65 year
5 - ± 50 year
Pancreas (islets)
Liver
Lung
- ± 75 year
1 month - ± 55 year
5 - ± 60 year
Contraindications for non-heartbeating multi-organ donation.
These are identical to the contraindications for heartbeating donation. In case of
doubt, consultation of the transplantcoordinator or the Dutch Transplantation
Foundation.
• General contraindications
- unknown cause of death
- unknown identity
- untreated sepsis
- malignancies, with the exception of a few primary, non-metastasized brain tumors
(consultation is necessary if case history states a treated malignancy)
- active viral infections (rabies, herpes zoster, rubella, hiv)
- active tuberculosis
- anencephaly
• Organ-specific contraindications
Kidneys
- primary kidney disease
Liver
- proven liver cirrhosis
Lungs
- chronic obstructive lung disease for which medication is prescribed
- other severe long pathology, such as lung disease with fibroma
- proven aspiration; in case of one-sided aspiration maybe suitable the nonaffected lung
Pancreas
- diabetes mellitus type 1
- chronic or acute pancreatitis
2.2. Actions for non-heartbeating multi-organ donation (category III)
In the hospital protocol functionaries are appointed who are charged with the following tasks:
- consulting the donor register;
- applying donors at the organ centre;
- informing relatives about the further donation procedure if the deceased stated in
the donor registry to leave the decision for donation to the relatives or a
designated,person or if the deceased has not made a decision for donation.
1. Check the criteria for non-heart-beating donation.
2. Check the contraindications for non-heart beating donation. If there is doubt whether
a potential donor is concerned, consultation of the transplant coordinator in charge or
the Dutch Transplantation Foundation via (071) 579 57 95.
3. Consult the transplant coordinator before treatment is interrupted via (071) 579 57 95.
4. Consult the donor register for the patient’s will.
5. Inform relatives if the deceased in registered as a potential donor in the donor
registry.
6. Ask relatives for permission for donation when a will is not found in the registry nor
any other declaration of the deceased is present. Moreover, when the registry or a
personal declaration shows that the deceased explicitly leaves the decision to
relatives or a designated person, the relatives or the designated person need to be
asked for permission.
7. If there is permission for donation, contact the transplant coordinator in charge or the
Dutch Transplantation Foundation via (071) 579 57 95. The transplant coordinator
makes sure the donor is applied at the organ centre (Dutch Transplantation
Foundation) and starts the procedure.
8. In case of doubt whether a death has natural cause and in case of a death from nonnatural cause the responsible physician has to report to the coroner. Organ removal
is only possible with permission of the district attorney. The transplant coordinator can
assist with the obtaining of permission if desired.
9. Fill out the donation form and put these data down in accordance with the donation
form in the medical file. A report should always be made, even in case the patient
does not qualify for (organ) donation.
Organization around non-heart beating multi-organ donor procedure of category III
donor
If the patient is a potential donor, the transplant coordinator is to be informed as soon as
possible. The physician in charge communicates with the family and the decision,
whether tp active medical treatment is made. When the family agrees they are informed
about the non-heart beating donation procedure. The transplantation coordinator
counsels the family, together with an ICU-nurse. He or she also handles every necessary
organ-specific diagnostic test.
It is important that there is some time between the circulatiory arrest and the start
of the perfusion, which is conducted by means of thoraco-laparotomy with open
inserting of the canules. (no touch period)
For the non-heartbeating donation procedure, the aim will be to keep the period between
circulatory arrest and the starting of the perfusion as short as possible. As soon as the
circulation has stopped, there is a standard five minute No Touch period which no
invasive actions are conducted. This so-called no-touch-period guarantees brain death.
Within 30 minutes after circulatory arrest, preservation of the abdominal organs must be
started, and within 1 hour, preservation of the lungs.
During this procedure the surgical retrieval team is ready to start operating. This team is
not involved in switch-off procedure itself whatsoever, even if this takes place in the
operation room.
The time period allowed between ventilator switch-off and circulatory arrest has to be
limited.
Allowed period of time from ventilator switch-off and circulatory arrest for non-heart
beating multi-organ donation (category III)
Kidneys < 2 hrs
Liver < 1 hr
Lungs < 1 hr
Pancreas < 1 hr
During this period of time there may be a period with insufficient perfusion and
oxygenation of the organs. A period with a MAP < 50 mm Hg and a peripheral
oxygenation < 80 % is not allowed to take longer than 15 minutes, because of an
unacceptable chance of ischemic damage of the organs.
Performing the switch-off procedure in the operation room has a major advantage: there
is less time between circulation arrest and the preservation of the organs. One of the
requirements for non-heart beating multi-organ donation is that the time between
ventilator switch of and start of the perusion is no longer than thirty minutes , including
the no-touch-period of five minutes. However, for the non-heartbeating multi-organ
donation procedure, it is of great importance to take the wishes of the family into account.
If it is the family’s wish that the patient dies at the intensive-care-unit, this needs to be
complied with.
Switch-off
Cardiac arrest
Circulation arrest
Kidneys max 2 hr
Liver, Lung, Pancreas max 1 hr
5 min
No Touch
Preservation
Within 30 minutes
Non Heart Beating Form
Donornumber
Bloodgroup
NHB III
Date of
birth
Reason for NHB:
NHB type III
Switch off
Date:
Switch off
Time:
Circulatory arrest
No touch period:
Date:
Circulatory arrest
Time:
min
Switch off untill Circulation arrest/Cardiac arrest
Date
Time
Heart rate
Saturation Blood pressure
Data explantation
Warm ischaemia period:
Time start incision:
min
Time intubation OR:
Time start abdominal perfusion:
Time start thoracic perfusion:
Time Pneumectomy:
Time Hepatectomy:
Time Nephrectomy left:
Time Nephrectomy right:
Type perfusion
abdominal organs:
Type perfusion
thoracal organs:
Perfusion volume
abdominal organs:
Perfusion volume
thoracal organs:
Inspection organs:
ml
ml