Indkøb af hurtig genopretning af lunger kombineret med abdominal normymisk regional perfusion i kontrolleret donation efter kredsløbsdød
Summary
Protokollen kombinerer en hurtig restitutionsteknik til lungekøling med abdominal normoterm regional perfusion til abdominal transplantatindkøb i kontrollerede asystoldonorer, hvilket er en sikker og nyttig metode til at udvide donorpuljen.
Abstract
Kontrolleret donation efter kredsløbsdød (cDCD) har bidraget til at øge antallet af donorer over hele verden. Erfaringer offentliggjort i de sidste år bekræfter, at resultaterne efter lungetransplantation fra cDCD ligner dem fra hjernedødsdonorer; Imidlertid forbliver udnyttelsen af lunger fra asystoldonorer lav. Flere årsager kan være involveret: forskellige juridiske rammer blandt lande og centre med forskellige præmorteminterventioner, utilstrækkelig lungedonorpleje før indkøb eller endda dårlig erfaring med cDCD-procedurer og protokoller.
Oprindeligt blev den hurtige genopretningsteknik almindeligt anvendt til indkøb af thorax- og abdominale organer i cDCD, men i det sidste årti er abdominal normoterm regional perfusion (ANRP) med ekstrakorporeal membranoxygeneringsanordninger blevet en nyttig metode til at genoprette blodgennemstrømningen til abdominale organer, hvilket muliggør deres kvalitetsforbedring og deres funktionelle vurdering før transplantation. Dette gør donationsproceduren mere kompleks og skaber tvivl om skade på transplantaterne på grund af dobbelt temperatur.
Formålet med denne artikel er at beskrive en protokol baseret på en enkelt centererfaring med Maastricht III-donorer, der kombinerer lungekøling, hurtig genopretning i thorax og abdominal normoterm regional perfusion. Tips og tricks med fokus på premortem interventioner og lunge indkøbsprocedure teknikker forklares. Dette kan bidrage til at minimere modviljen blandt fagfolk til at bruge denne kombinerede teknik og tilskynde andre donorcentre til at bruge den på trods af procedurens øgede kompleksitet.
Introduction
Donation efter kredsløbsdød (DCD) startede i Spanien med ukontrollerede donorer. I 1996 blev det første nationale konsensusdokument om DCD offentliggjort som en vejledning for praksis med ukontrolleret donation efter kredsløbsdød1 (uDCD), der også fastsatte et moratorium for kontrolleret donation efter kredsløbsdød (cDCD). I 2012 opstod der en ny konsensus, der etablerede grundlaget og de lovgivningsmæssige rammer for praksis af både uDCD og cDCD2. I øjeblikket er Spanien et af de mest aktive lande i DCD og når den højeste donorrate efter kredsløbsdød i verden3. Denne type donor repræsenterede næsten 35% af de samlede donorer i 2021 i landet, med et markant fald i uDCD og donorer, der udelukkende var cDCD4.
Organudtagning i cDCD udføres almindeligvis ved hjælp af superhurtig restitutionsteknik5. Efter dødserklæringen, og når ikke-berøringsperioden er gået, udføres en hurtig sternotomi og laparotomi. Den abdominale aorta og lungearterien kanyleres og skylles med kolde perfusionsopløsninger for at bevare abdominale og thoraxorganer, plus topisk afkøling udføres før hentning6. I denne situation er cDCD karakteriseret ved de uforudsigelige konsekvenser af varm iskæmi efter tilbagetrækning af livsopretholdende terapi. Den iskæmiske skade i denne periode med agonisk hypotension og progressiv hypoxi, efterfulgt af ikke-berøringsperioden efter hjertestop, forværres yderligere af den senere periode med kold iskæmi7. Denne kombination af varm og kold iskæmi synes at være skadelig, især for abdominale transplantater 8,9,10, hvilket skaber mere modvilje blandt fagfolk i brugen af disse organer fra cDCD-donorer.
For at minimere disse risici er der udviklet en de situ-bevaringsmodel, baseret på tidligere erfaringer fra spanske teams, der arbejder i uCDC11, med stigende interesse. Anvendelse af ECMO-systemer (extracorporeal membrane oxygenation) til at genoprette blodgennemstrømningen efter døden og før transplantatgendannelse kan vende de metaboliske afvigelser som følge af iskæmi og genoprette cellulær fysiologi12. Abdominal normoterm regional perfusion (ANRP) kan forbedre kvaliteten af iskæmisk beskadigede organer i cDCD13. Organfunktionen kan vurderes og forbedres, hvilket muliggør et bedre udvalg af abdominale transplantater til transplantation.
Nylige internationale multicentererfaringer giver bevis for, at ANRP versus RR-teknikken (hurtig genopretning) hjælper med at overvinde traditionelle begrænsninger i cDCD, reducere antallet af galdekomplikationer efter transplantation, lette vellykket transplantation af ældre lever og forbedre levertransplantatoverlevelse14,15. I nyrerne ser det ud til at forbedre kortsigtede resultater med en lavere forsinket transplantatfunktion og højere 1-årig transplantatoverlevelsesrate16. Med dette bevis har ANRP i cDCD opnået fordele i forhold til den hurtige genopretningsteknik til indkøb af abdominal transplantat og anvendes nu i flere europæiske lande og andre dele af verden17,18.
Brugen af lunger fra cDCD-donorer blev imidlertid straks vedtaget over hele verden. En lungefunktionel varm iskæmisk tid på op til 60 min synes ikke at påvirke overlevelsen19. I det sidste årti har flere centre og multiinstitutionelle erfaringer rapporteret resultater efter lungetransplantation fra cDCD, der kan sammenlignes med dem fra DBD20,21. RR-teknikken er den rutinemæssige metode til lungeindkøb: lungerne afkøles topisk og fjernes efter skylning med kold konserveringsopløsning22.
De første erfaringer, der kombinerede ANRP og RR af lunger i cDCD, blev rapporteret af to britiske grupper23,24. År senere blev en variation af denne teknik, der tilføjede præmorteminterventioner, offentliggjort25. Resultaterne præsenterer denne dobbelte indkøbsteknik som sikker og effektiv til både abdominale og thoraxtransplantater26. Det er klart, at donationsproceduren bliver mere kompleks. Det kræver teknologiske og menneskelige ressourcer, tilstrækkelige organisatoriske evner og har højere økonomiske omkostninger. Alt dette kan afskrække fagfolk fra at starte et program. Formålet med denne undersøgelse er at præsentere en protokol, der især fokuserer på præmorteminterventioner, kanylering og placering af aortaokklusionsballon med tips og tricks lært af erfaring og kommentere de forskellige tekniske detaljer, der skal overvejes under lungehentning, når ARNP anvendes. På nuværende tidspunkt er cDCD-donorer i centret blevet den vigtigste kilde til transplantater til thorax- og abdominaltransplantation.
Protocol
Representative Results
Discussion
Selvom brugen af samtidig lungekold perfusion med ARNP i cDCD først blev offentliggjort i 2014, er der beskrevet meget få oplevelser for disse25,26,29. Desuden forbliver udnyttelsen af cDCD-lunger, uanset hvilken teknik der anvendes, lav i de fleste lande.
De kritiske trin i denne protokol er brugen af præmorteminterventioner; en specifik metode til at sikre, at koronar og cerebral perfusion ikke g…
Declarações
The authors have nothing to disclose.
Acknowledgements
Forfatterne anerkender alle de medlemmer, der er involveret i lungetransplantationsprogrammet på universitetshospitalet Marqués de Valdecilla.
Materials
| Vial 5 mL Heparin 1000 UI/mL | ROVI | For donor heparinization | |
| ECMO KIT (MATERIALS FOR CANNULATION) | |||
| Artery pressure lines | BEXEN MEDICAL | 137.15 | Artery pressure line por radial artery and femoral cannula |
| Bandage scissors | SURGIMEDIC | BC-881R | Shear to cut ECMO lines |
| Bio-medicus Venous cannula 21 Fr (7.0 mm) x 27.5 in (69.9 cm) | MEDTRONIC | 96670-121 | Venous cannula |
| Clhorhexidine solution 2% | Disinfectant solution | ||
| ECMO device Maquet Rotaflow | Maquet, Rasttat, Germany | ECMO system | |
| Electrocautery handle | DEXTRO | SW12200 | |
| EndoReturn Arterial Cannula Kit 21-23F | Edwards Lifesciences | ER21B, ER23B | Arterial cannula with a doble lumen to ECMO connection and to introduce aortic oclussion balloon |
| Ethicon LigaClip med/short 20 titanium medium | ETHICON | MCS30 | Ligaclips for control bleeding during groin dissection |
| Ethicon LigaClip med/short 20 titanium small | ETHICON | MCS20 | Ligaclips for control bleeding during groin dissection |
| Insertion Kit Bio-medicus 180cm | MEDTRONIC | 96551 | Insertion Kit for ECMO cannulas, with catheter, metal wire guide and dilators |
| Irrigation pear | MEDLINE | DYNDE 20125 | Pear to be filled with saline and purge ECMO lines at the site of connection with cannulas |
| Luer cone syringe 50cc | CARDIONATUR | 60ML | Syringe filled with saline to fill occlusion balloon |
| Mersilk no 1, LR-60 CONV , 75 cm | ETHICON | W562H | Silk curved suture for ECMO cannulas fixation |
| Prolene 4/0 | ETHICON | W8355 | polypropylene suture for purse string in femoral vessels or vascular suture |
| Prolene 5/0 , 60 cm | ETHICON | 8325 | polypropylene suture for vascular suture |
| Prolene 5/0, 90 cm | ETHICON | 8720 | polypropylene suture for vascular suture |
| Reliant Stent Graft Balloon Catheter 12F | Medtronic, Ireland | AB46 | Aortic occlusion balloon introduced through femoral artery. It is used as an endoclamp |
| Scalpel blade no 11 | INTRAVEN | 150011 | |
| Scapel blade no 23 | INTRAVEN | 150023 | |
| Silicone tube | IBERHOSPITEX | 0027224-P | Silicone tube to connect suction system |
| Sofsilk braided silk no 1 strands | COVIDIEN | L-12 | Silk strand for ligation or bleeding control |
| Sofsilk braided silk no 3 strands | COVIDIEN | L-115 | Silk strand for ligation or bleeding control |
| straight connector 3/8"x3/8" with Luer lock | ANDOCOR | 04CS0022 | Piece to connect arterial cannula with ECMO line and the three way stop-cock for pressure line and blood sampling |
| Surgical pads pack | TEXPOL | 146500 | |
| Surgical stapler | COVIDIEN | 8886803712 | Stapler to close surgical wound |
| Three-way stopcock | BD CONNECTA | 394501 | Three way stop-cock to connect farterial cannula with pressure line |
| Vessel loop large | MEDLINE | VLMAXR | Vascular loop to embrace femoral artery and vein for bleeding control. |
| Vessel loop small | MEDLINE | VLMINR | Vascular loop to embrace femoral artery and vein for bleeding control. |
| Yankauer suction terminal 50 V | DEXTROMEDICA | 349701 | Suction terminal for suction while surgical dissection |
| SURGICAL TOOLS FOR CANNULATION | |||
| Adson retractor 20 cm adn 33 cm | |||
| Aortic clamp | |||
| Boyd Scissors 18 cm | |||
| Dissection forceps without jaws 21 cm | |||
| Farabeuf retractor small | |||
| Mayo scissors straight 14 cm and 16 cm | |||
| Metzembaum scissors 18 cm, 20 cm and 23 cm | |||
| Mosquito forceps straigth and curved | |||
| Needle holder 18 cm and 23 cm | |||
| Russ dissection forceps 15 cm | |||
| Scalpel handle no 23 and no 21, 21 cm | |||
| Surgical Dissector 23 cm | |||
| MATERIALS FOR LUNG PROCUREMENT | |||
| 10 cc syringe | BD DISCARDIT | 309110 | |
| Alprostadil 500 mcgs injectable solution | PFIZER | Prostaglandin injected with lung preservation solution | |
| Disposable GIA cartridge Steril 6/Ca | MEDTRONIC | 1141634 | |
| Disposable GIA stapler 60/3.8 3/Ca | MEDTRONIC | 2802122 | Stapler for trachea and bronquial division |
| Foley catheter 18 Ch Folysil | Folysil, Coloplast | AA6118 | urinary catheter employed to canulated pulmonary veins for retrograde perfusion |
| Lung preservation solution Perfadex 1000 mL | Medisan, Uppsala, Sweeden | 19811 ( box of 10 units) | Lung preservation solution |
| Mersilk no 1, LR-60 CONV , 75 cm | ETHICON | W562H | Silk curved suture for pericardium sutures |
| Paediatric Venous cannula | SORIN GROUP | V132-12 | Cannula used for pulmonary artery cannulation |
| Prolene 4/0 | ETHICON | W8355 | polypropylene suture for purse string in pulmonary artery |
| Scalpel blade no 11 | INTRAVEN | 150011 | |
| Sofsilk braided silk no 1 strands | COVIDIEN | L-12 | Silk strand to fix arterial cannula with the tourniquet |
| Sofsilk braided silk no 3 strands | COVIDIEN | L-115 | Silk strand for vessel ligation |
| Sterile bags | To keep and store lungs. | ||
| Straigth connector 1,4"/1,4" with luer lock | ANDOCOR | 04CS0032 | Piece to connect pulmonary artery arterial cannula with preservation line and the three way stop-cock for prostaglandin |
| Three-way stopcock | BD CONNECTA | 394501 | Three way stop-cock to connect farterial cannula with pressure line |
| Uromatic set for irrigation double lead | MEDISAVE | TRC4007N | Irrigation system for lung preservation solution |
| Uromatic set for irrigation single lead | MEDISAVE | TRC4002 | Irrigation system for lung preservation solution |
| SURGICAL TOOLS FOR LUNG PROCUREMENT | |||
| Aortic cross- clamp | |||
| Battery-powered surgical saw | |||
| Cooley vascular clamp | |||
| Dissecting forceps 18 cm and 27,9 cm | |||
| Finochietto sternal retractor | |||
| Metzembaum scissors 20 cm and 23 cm | |||
| Mosquito forceps curved 12,5 cm | |||
| Vascular clamps | |||
| SURGICAL TOOLS FOR ABDOMINAL ORGAN PROCUREMENT | |||
| Adson articulated retractors | |||
| Allis forceps 16 cm | |||
| Aortic cross-clamps | |||
| Boyd scissors 17 cm | |||
| Castroviejo needle holder | |||
| Cooley Vascular clamps | |||
| Crile forceps curved 18 cm | |||
| Davis retractor 24.5 cm | |||
| DeBakey dissecting forceps 19.7 cm adn 24.1 cm | |||
| DeBakey vascular clamps | |||
| Dissecting forceps 18 cm and 27.9 cm | |||
| Duval forceps 23 cm | |||
| Farabeuf retractors | |||
| Kidney Trays 300 cc and 500 cc | |||
| Kocher forceps straigth 18 cm | |||
| Langenbeck retractors 21 cm and 23 cm | |||
| Mayo scissors straigth and curved , 17 cm | |||
| Mosquito forceps straigth and curved, 12.5 cm | |||
| Needle holders 15 cm, 18 cm, 23 cm and 23 cm. | |||
| Pean forceps 16 cm | |||
| Potts scissors 19cm | |||
| Rochester forceps curved 24 cm | |||
| Rochester forceps straigth 24 cm | |||
| Russ dissection forceps 15 cm and 20 cm | |||
| Scalpel handles | |||
| Senn-mueller retractor 16 cm |
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