Facilitating donation after circulatory death subsequent to withdrawal of extracorporeal membrane oxygenation support.

Alice Coulson¹, Carrie Alvaro¹, Robert Herkes^1,2, Hazel Christine¹

¹NSW Organ and Tissue Donation Service, Sydney, Australia, ²Intensive Care Services, Royal Prince Alfred Hospital, Sydney, Australia

Patients dependent on extracorporeal membrane oxygenation (ECMO) for cardio-respiratory support are rarely considered for donation after circulatory death following agreement to withdraw treatment. In NSW, management of these potential organ donors typically involves complex medical suitability assessment and logistical planning for withdrawal of treatment.

The referral database at the NSW Organ and Tissue Donation Service was reviewed from 2007 to 2013. Five ECMO-dependent patients were identified. Four patients were supported with veno-venous ECMO for respiratory failure and the other with veno-arterial ECMO for cardiac failure from idiopathic cardiomyopathy. 

Consent for organ donation was obtained in four cases. The family declined donation in the remaining case.  Of those consented hospital length of stay ranged from 8 to 60 days, and ECMO duration ranged from 12 to 43 days.  Unexpectedly, the patient supported with veno-arterial ECMO did not die within the required sixty minutes.  The remaining three cases successfully donated kidneys, resulting in six kidneys being available for transplantation.  Liver donation was considered in two of the donors but was ultimately not possible due to timeframes within which the patients died.  Medical suitability determination in all cases required thorough evaluation of admission history and multiprofessional consultation, including transplant professionals.

The logistics of ceasing ECMO as part of withdrawing treatment are complex.  While the process of withdrawing treatment remains the responsibility of the treating Intensive Care team, collaboration and guidance from donation and retrieval staff was required to ensure that management of the cannulae and circuit did not inhibit organ retrieval.

Patients dependent on ECMO for cardiorespiratory support can be successful kidney donors with thorough assessment of suitability and collaborative planning of withdrawal and retrieval.  Liver donation may be feasible, but cessation of ECMO was not consistent with a rapid progression to death making retrieval of the liver possible.