Organ donation after cardiocirculatory death

The Canadian recommendations for organ donation after cardiocirculatory death advocate confirming the irreversibility of cardiocirculatory arrest by the absence of palpable pulses, blood pressure and respiration during a 5-minute period of continuous observation by at least 1 physician.1 This criterion does not fulfill the prerequisite requirement of irreversibility for the determination of death.

First, autoresuscitation (the spontaneous return of circulatory and neurological function), also known as the Lazarus phenomenon, has been reported after more than 10 minutes of cardiac electric asystole in humans.2 Second, the presence of electrocardiographic activity without blood pressure (i.e., pulseless electric activity or ventricular fibrillation) does not indicate irreversible cessation of mechanical cardiac activity.3 Third, the applicability of criteria for organ donation after cardiocirculatory death becomes questionable when artificial circulatory and ventilatory support is resumed after death in order to maintain the viability of abdominal and thoracic organs in potential donors.4^,5 Extracorporeal circulatory support can lead to the return of neurological function in people who are neurologically intact before cardiac death.6 Mechanical occlusion of coronary and cerebral circulation has been used to try to prevent reanimation during the organ procurement process, without substantial evidence for its effectiveness.5

The timing involved in cardiocirculatory criteria is arbitrary, and the use of such criteria alone to determine death without simultaneous total cessation of all activity in the donor's brain (including the brain stem) during procurement circulatory support will not fulfill the “dead donor rule.”7^,8 It may be necessary to abandon the dead donor rule to permit the recovery of transplantable organs after cardiocirculatory death.