The World Health Organization has defined the two clinical paths that can lead to the donation of organs after confirmed death, respectively, with neurological or cardiovascular criteria. The Italian legislation is simple and clear, identifying death and the necessary criteria for the assessment. completely independent of the possibility of donation (law n.578, 1993; Decree of the Ministry of Health n.582, 2008). There is no legislative difference between the donation in brain death and that a steady heart.
The removal of organs can only take place after the ascertainment of death and in the absence of opposition; this means, with regard to cardiac criteria, the recording continues for no less than 20 minutes of an electrocardiogram that demonstrates the complete absence of electrical activity of the heart. This period is far longer than that required by law, or by the guidelines of most other countries (5 -10 minutes), and makes it completely clear, on the one hand, the absolute respect for the fundamental principles of organ donation (ie the so-called "Dead Donor Rule", which provides for the procedure to be started after the person's death) on the other hand, respect for the uniqueness of the concept of death, ie the irreversible cessation of the functions of the brain (brain death), which is absolutely certain after a prolonged absence of blood flow to the brain (read the Hoax).
The donation can take place in people with sudden and unexpected cardiac arrest, inside or outside the hospital, who do not respond to resuscitation treatment (a procedure that today can also reach extracorporeal circulation in emergency rooms).
Donation after extra or in-hospital intractable cardiac arrest, however, requires organization, technology and human resources that are hard to find outside a few large hospitals.
Much more frequently, the donation occurs following terminal cardiac arrests that occur, in the ICU, in people with devastating brain injuries who do not respond to any treatment. This situation corresponds to a very substantial part of the deaths that occur, in Italy and in the world, in the intensive care and resuscitation wards.
In many countries, donation after cardiac death (DCD) is a reality that has allowed a significant increase in the number of transplants. It is a numerically consistent procedure (a quarter of all donations) in Spain, a country that has particular cultural, ethical and organizational affinities with Italy.
It is important that the DCD donation takes place without decreasing the number of donors in "brain death"And without changing the" approach and quality of care of people in resuscitation, giving more value to the ethical and clinical choices that the doctor, in agreement with the family, can undertake to alleviate the suffering of the dying person: suspension of ineffective therapies and futile, including artificial ventilation or extra-body support; execution of palliative therapies to abolish pain and suffering in the final path of life. This is expressed in the essential values of good medicine and good relationship with family members.The DCD donation is, therefore, an "opportunity that the doctors of the Intensive Care Units, the Emergency Department and the whole Emergency-Urgency area of the hospitals can consider and offer whenever an irreversible cardiac arrest occurs.
A fair percentage of kidneys used successfully for transplantation, but also of lungs and livers (and in particular cases of heart), today derive from DCD donation in the United States, Australia and some European countries. In Europe alone, thousands of DCD transplants are performed with very good long-term results and, on the whole, comparable to those observed after the removal of beating heart organs in donors in brain death.
The regulatory constraint of "20 minutes" places Italy in a very particular condition compared to the rest of the world: certainly the most guaranteed with respect to the certainty of death (which is in any case the death of the brain), but the most problematic with respect to the quality of the organs to be transplanted. , together with cultural factors linked to the lack of regulations regarding the limitation or suspension of ineffective resuscitation treatments, capable only of artificially prolonging the end of life, has determined a delay in "Italy" in undertaking programs of donation a steady heart. However, after the pilot experience, undertaken in Pavia in 2007, of organ donation from people who died following a cardiac arrest which became irreversible despite the maximum therapeutic attempt carried out by the 118 staff and the emergency room, programs have been developed since 2015. from donation with a firm heart in numerous hospitals and in different Italian regions. This new donation activity, conducted with innovative organ preservation techniques, has led not only to kidney transplants but also to liver and lung transplants with good results.
In Italy the feasibility of DCD donation was demonstrated, despite the 20 minutes of complete absence of blood circulation in the organs during the ascertainment of death, with more than 100 donors and more than 150 transplants obtained thanks to the quality of the donor's medical treatment , before organ harvesting, and the use of innovative perfusion and organ reconditioning techniques, after harvesting and before transplantation. The potential of these new techniques is still to be evaluated but is probably considerable if they are integrated into a path multidisciplinary that begins in resuscitation and continues until the moment of transplantation.
The possibility of ensuring blood circulation (perfusion) and oxygenation before and after collection, during transport and for a few hours before carrying out the transplant can limit the damage caused by ischemia; a physiological perfusion, at normal temperature, can also facilitate the recovery of metabolic functions and allow the evaluation of organ functionality before transplantation. Although resistance to ischemia differs according to the organs, the maintenance and recovery of the best functionality is an essential condition for being able to effectively use an organ for transplanting it. The results obtained today by the Italian centers are very encouraging and lead to a rapid increase in the number of heart-stopping donations and a further improvement in the quality of transplants.
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