Summary

肺快速恢复采购联合腹部正常区域灌注在循环死亡后受控捐献中的应用

Published: August 15, 2022
doi:

Summary

该方案将肺冷却快速恢复技术与腹部正常热能区域灌注相结合,用于受控心脏停搏供体的腹部移植物采购,这是扩大供体库的安全且有用的方法。

Abstract

循环死亡后控制捐赠(cDCD)有助于增加世界各地的捐赠者数量。过去几年发表的经验证实,cDCD肺移植后的结果与脑死亡供体的结果相似;然而,心脏停搏供体对肺的利用率仍然很低。可能涉及几个原因:具有不同死前干预措施的国家和中心之间的法律框架不同,采购前肺供体护理不足,甚至对cDCD程序和方案的经验不佳。

最初,快速恢复技术通常用于cDCD中胸部和腹部器官的获取,但是,在过去十年中,带有体外膜肺氧合装置的腹部正常热区域灌注(ANRP)已成为恢复腹部器官血流的有用方法,可以改善其质量并在移植前进行功能评估。这使得捐赠程序更加复杂,并产生对双重温度引起的移植物损伤的怀疑。

本文的目的是描述一种基于马斯特里赫特III供体的单中心经验的方案,将胸部肺冷却快速恢复和腹部正常热区域灌注相结合。解释了侧重于死前干预和肺获取程序技术的提示和技巧。这可能有助于最大限度地减少专业人员不愿使用这种组合技术,并鼓励其他捐赠中心使用它,尽管该程序的复杂性增加。

Introduction

循环死亡后捐赠(DCD)始于西班牙不受控制的捐赠者。1996年,第一份关于DCD的全国共识文件作为循环死亡后无控制捐赠实践指南1(uDCD)发布,也暂停了循环死亡后 控制捐赠(cDCD)。2012年,出现了一种新的共识,为uDCD和cDCD2的实践奠定了基础和立法框架。目前,西班牙是DCD最活跃的国家之一,达到世界上循环死亡后最高的供体比例3。这种类型的供体占该国2021年献血者总数的近35%,uDCD明显减少,供体完全是cDCD4

cDCD中的器官获取通常使用超快速恢复技术进行5。宣布死亡后和非接触期过后,进行快速胸骨切开术和剖腹手术。将腹主动脉和肺动脉插管并用冷灌注溶液冲洗以保留腹部和胸部器官,并在取回前进行局部降温6。在这种情况下,cDCD的特征在于停止维持生命的治疗后,温暖缺血的不可预测的后果。在痛苦性低血压和进行性缺氧期间的缺血性损伤,随后是心脏骤停后的非接触期,在寒冷缺血的后期进一步加剧7。这种冷缺血的组合似乎是有害的,特别是对腹部移植物8910导致专业人员更不愿意使用cDCD供体的这些器官。

为了最大限度地降低这些风险,基于在uCDC11工作的西班牙团队以前的经验,已经开发了一种原位保存模型,并引起了越来越多的兴趣。使用体外膜肺氧合(ECMO)系统在死后和移植物恢复前恢复血流,可以逆转缺血引起的代谢偏差,恢复细胞生理12。腹部正常热能区域灌注(ANRP)可以改善cDCD13缺血损伤器官的质量。可以评估和改善器官功能,从而更好地选择腹部移植物进行移植。

最近的国际多中心经验提供的证据表明,ANRP与快速恢复(RR)技术相比有助于克服cDCD的传统局限性,降低移植后胆道并发症的发生率,促进老年肝脏的成功移植,并提高肝移植存活率1415。在肾脏中,它似乎通过较低的延迟移植功能和较高的1年移植物存活率改善短期结局16。有了这一证据,cDCD中的ANRP比腹部移植物采购的快速恢复技术更具优势,现在已在几个欧洲国家和世界其他地区应用1718

然而,cDCD供体的肺的使用在世界范围内迅速被采用。长达60分钟的肺功能温暖缺血时间似乎不会影响生存19。在过去的十年中,一些中心和多机构的经验报告了cDCD肺移植后的结果与DBD2021相当。RR技术是肺获取的常规方法:局部冷却肺,并在用冷藏溶液冲洗后取出22

两个英国组报告了首次结合ANRP和肺RR治疗cDCD的经验2324。几年后,这种增加死前干预的技术的变体发表25。结果表明,这种双重获取技术对腹部和胸部移植物都是安全有效的26。显然,捐赠程序变得更加复杂。它需要技术和人力资源,足够的组织能力,并且具有较高的经济成本。所有这些都可能会阻止专业人士启动程序。本研究的目的是提出一个特别关注死前干预、插管和主动脉闭塞球囊放置的方案,并提供从经验中学到的提示和技巧,并评论使用 ARNP 时在肺取回过程中要考虑的不同技术细节。目前,在该中心,cDCD供体已成为胸腹移植的主要来源。

Protocol

这些干预措施在重症监护病房(ICU)的床边进行。该协议遵循瓦尔德西利亚侯爵大学医院伦理委员会的指导方针,并符合西班牙有关捐赠程序的法律框架。获得近亲的知情同意,对研究程序进行录像。对于已决定停止维持生命治疗 (WSLT) 的灾难性脑损伤、终末性心脏或神经退行性疾病患者,应考虑使用 cDCD。排除标准和肺部评估与脑死亡供体相同(表 1)。 <strong…

Representative Results

我们对过去 2 年(2020 年和 2021 年)在马奎斯德瓦尔德西拉大学医院进行的 30 例肺移植进行了描述性分析,这些肺移植来自 cDCD 供体的肺。本文将介绍供者和受者的人口统计学特征、技术数据、术后结局和短期结果。这些结果表示为分类变量的绝对数字和百分比,以及连续变量的集中趋势和离散度量。柯尔莫哥罗夫-斯米尔诺夫检验用于检验数据的正态分布。 捐助者特?…

Discussion

尽管在cDCD中使用同时肺冷灌注和ARNP于2014年首次发表,但对此的描述很少252629.此外,无论使用何种技术,cDCD肺的利用率在大多数国家仍然很低。

该协议中的关键步骤是使用死前干预;确保ANRP无法恢复冠状动脉和脑灌注的特定方法;尽量减少由于双重温度对移植物的伤害;以及保持ECMO装置中足够流量以确…

Disclosures

The authors have nothing to disclose.

Acknowledgements

作者感谢参与Marqués de Valdecilla大学医院肺移植计划的所有成员。

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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Cite This Article
Naranjo Gozalo, S., Ballesteros Sanz, M. d. l. A., Alvarez De Arriba, C., Mora Cuesta, V. M., Miñambres García, E., Sánchez Moreno, L. Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death. J. Vis. Exp. (186), e63975, doi:10.3791/63975 (2022).

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