**7. Donation after circulatory death**

#### **7.1 DCDD- lung only procurement surgery (heart not placed for transplant)**

Once an offer for a DCDD lung is received the surgeon and the pulmonologist will process the offer just like a standard one. More specifically, the blood gasses, the X-Ray, the CT scan (if not available, request one), the ventilatory timeline, and the bronchoscopy findings (not always done) should all be analyzed. The nature of the donor death should also be scrutinized very closely- such as drowning or hanging [15].

*Thoracic Organ Procurement during Multi-Organ Retrieval DOI: http://dx.doi.org/10.5772/intechopen.95793*

The key in assessing a DCDD lung offer in comparison to a standard DBD offer is that the target PaO2 is 350 mmHg as a rule out. In our clinical practice, we currently do not venture to inspect a DCD lung unless the p/f ratio is adequate [16]. Using 350 mmHg is a good starting point especially in those centers where DCD volume is not very high. There are few centers who place all DCDD lungs on EVLP and have different set of guidelines. For a DBD offer we would venture to inspect the lung even with a PaO2 of 300 mmHg or lower. The reason for this discrepancy is that in a standard DBD we have the ability to recruit the lung, assess it, check the blood gases and decide in the operating room if the lung is suitable for transplantation. In DCD- what we have is what we get- so we must ascertain the lung status before we head over to the center, which explains why we have more stringent cut-off: to make sure that the lung is acceptable radiologically (CT scan preferred) and physiologically. Bronchoscopy is often done after withdrawal of care (most of the time it is for flushing) and it is done in a rush [6].

In conclusion we must be very careful with the pre-operative assessment in a DCD lung. There are certain centers, especially Toronto, where all the DCD lungs are put on EVLP. Hence it does not matter what the PaO2 ratio is [17]. They then evaluate these lungs while on EVLP, but not all centers have that luxury yet. Before a DCD Lung transplant procurement is initiated at the recipient center, the following questions should be asked in a checklist format:


For the actual withdrawal of life support, it is preferable to have 2 surgeons on the lung procurement team. Withdrawal is initiated by removal of the endotracheal tube, however in some cases when there is extensive airway edema due to potential difficulty in securing airway, the ventilator is disconnected instead after discussion with the anesthesiology team.

Of note, it is important to have the nasogastric tube (NG) maintained on continuous suction during the withdrawal of life sustaining therapy. This action prevents aspiration of gastric contents and facilitates dissection near the esophagus [18]. It is also important to communicate the importance of the NG to the anesthesia team before extubating. The surgical team is then scrubbed and ready in the adjacent

**Figure 1.**

*DCD-Donation after circulatory death, ICU-Intensive care unit, OR-Operating Room, NRP-Normothermic Regional Perfusion, OCS-organ Care system, EVLP-Ex-vivo lung perfusion.*

*Thoracic Organ Procurement during Multi-Organ Retrieval DOI: http://dx.doi.org/10.5772/intechopen.95793*

operating room or sterile corridor. The patient is prepped and draped in sterile fashion with a hand being left out for the family if they are coming into the operating room to pay their last respects. A sterile sleeve is made available for the stethoscope usage to auscultate and declare death. The flush solution is prepared by injecting prostaglandin into the first bag of Perfadex [19]. The lines are then passed off the sterile field, hung on the IV pole, and then accessed. Alternatively, the flush bags can be kept in the ice box at the side of the table after being reconstituted and spiked.

Death is declared as per local hospital protocol. The patient is then re-intubated. Median sternotomy is performed, and the pericardium is opened by pick up technique with forceps and scissors. (Please note that there is no bovie used during a DCD procurement!) The IVC is then vented by partial transection in a location previously discussed with the liver procurement team.

At this juncture the Liver team is frantically trying to clamp the descending thoracic aorta in the chest if they do not have access below the diaphragm. The thoracic team can help by quickly opening the left pleura, releasing the inferior pulmonary ligament, mobilizing the lung, then looping the descending thoracic aorta bluntly and helping to place the cross clamp so that they can start perfusing the abdominal organs. We can then focus on perfusing the lungs.
