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Donation after circulatory death (DCD) programs are expanding in Europe, in the attempt to expand donors pool. Even in controlled DCD donors, however, a protracted warm ischemia time occurring in the perimortem period might damage organs, making these unsuitable for transplantation. Implementing a strategy of extracorporeal interval support for organ retrieval (EISOR), a regional reperfusion with normothermic, oxygenated blood provides a physiologic environment allowing extensive assessment of potential grafts, and potentially promotes recovery of native function. Here we report the results of a multi-center retrospective cohort study including 29 Maastricht Category III controlled DCD donors undergoing extracorporeal support in a regional DCD/EISOR Training Center, and in the network of referring In-Training Centers, under the liaison of the regional Transplant Coordination Center during COVID-19 pandemic, between March 2020 and November 2021. The study aims to understand whether a mobile, experienced EISOR team implementing a consistent technique and sharing its equipe, expertise and equipment in a regional network of hospitals, might be effective and efficient in implementing the regional DCD program activity even in a highly stressed healthcare system., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is usually performed in cases of severe respiratory failure in which conventional and advanced mechanical ventilation strategies are ineffective in achieving true lung-protective ventilation, thus triggering ventilatory-induced lung injury. If circulatory failure coexists, veno-arterial ECMO (VA-ECMO) may be preferred over VV-ECMO because of its potential for circulatory support. In VA-ECMO, the respiratory contribution is less effective and the complication rate is higher than in the VV configuration., Case Presentation: The authors present a case in which VV-ECMO was performed in an emergency setting to treat a 68-year-old White male patient who experienced acute respiratory failure after massive aspiration. Despite intubation and intensive care unit admission, multiple organ failure occurred suddenly, thus prompting referral to a level-1 trauma center with an ECMO facility. The patient's condition slowly improved with VV-ECMO support along with standard treatment for hemodynamic impairment. VV-ECMO was discontinued on day 8. The patient was extubated on day 14 and discharged home fully recovered 34 days after the event., Conclusions: Attention was focused on the decision to initiate VV-ECMO support even in the presence of severe hemodynamic derangement, although VA-ECMO could have provided better hemodynamic support but less effective respiratory support., (© 2021. The Author(s).)

Even with encouraging recipient outcomes, transplantation using donation after circulatory death (DCD) is still limited. A major barrier to this type of transplantation is the consequences of warm ischemia on graft survival; however, preservation techniques may reduce the consequences of cardiac arrest and provide better organ conservation. Furthermore, DCD in trauma patients could further expand organ donation. We present five cases in which organs were retrieved and transplanted successfully using normothermic regional perfusion (NRP) in trauma patients. Prompt critical care support and surgical treatment allowed us to overcome the acute phase. Unfortunately, owing to the severity of their injuries, all of the donors died. However, the advanced and continuous organ-specific supportive treatment allowed the maintenance of general clinical stability and organ preservation. Consequently, it was possible to retrieve and transplant the donors' organs. Death was ascertained in accordance with cardio-circulatory criteria, which was followed by NRP. We consider that DCD in trauma patients may represent an important source of organs.

Quality Problem or Issue: The on-going COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalization rates., Initial Assessment: A total of 8.2 individuals per 1000 inhabitants have been diagnosed with COVID-19 in our province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse., Choice of Solution: Instead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload., Implementation: A nine-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second six-bed SDU was also created., Evaluation: Patients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, and there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety and economic points of view., Lessons Learned: COVID-19 is like an enduring mass casualty incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve the efficiency and adaptability of our institutions and provide the adequate sanitary response., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Background: This study was conceived to provide systematic data about lung mechanics during early phases of CoVID-19 pneumonia, as long as to explore its variations during prone positioning., Methods: We enrolled four patients hospitalized in the Intensive Care Unit of "M. Bufalini" hospital, Cesena (Italy); after the positioning of an esophageal balloon, we measured mechanical power, respiratory system and transpulmonary parameters and arterial blood gases every 6 hours, just before decubitus change and 1 hour after prono-supination., Results: Both respiratory system and transpulmonary compliance and driving pressure confirmed the pseudo-normal respiratory mechanics of early CoVID-19 pneumonia (respectively, C RS 40.8 ml/cmH 2 O and DP RS 9.7 cmH 2 O; C L 53.1 ml/cmH 2 O and DP L 7.9 cmH 2 O). Interestingly, prone positioning involved a worsening in respiratory mechanical properties throughout time (C RS,SUP 56.3 ml/cmH 2 O and C RS,PR 41.5 ml/cmH 2 O - P 0.37; C L,SUP 80.8 ml/cmH 2 O and C L,PR 53.2 ml/cmH 2 O - P 0.23)., Conclusions: Despite the severe ARDS pattern, respiratory system and lung mechanical properties during CoVID-19 pneumonia are pseudo-normal and tend to worsen during pronation., Trial Registration: Restrospectively registered., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Organ retrieved from donors after circulatory deaths (DCD) is vulnerable of the effects of warm ischemia with important consequence on graft survival and posttransplant outcome. Preservation techniques, such as normothermic regional perfusion (NRP), can be used to reduce the effects of the cardiac arrest and to generate a continuous flow to the organs, resulting in a better preservation of the organs for transplantation. However, technical complications may occur during NRP which can compromise the retrieve of donors' organs. We present a case report of a technical complication arisen during an NRP for DCD. During the extracorporeal circuit, we observed a dramatical decrease in the blood flow with excessive negative inlet pressure. It was because of a later recognized venous cannula malposition. In fact, we did not perform the radiological control for wire position. As a consequence, our clinical practice was modified. Currently, a radiological control of the wire is performed before the insertion of the catheter. Even if the donation was accomplished successfully, we reckon that it is fundamental to describe the technical issue that may occur during perfusion technique in order to improve the safety and the effectiveness of these procedures.

Background: Trauma victims could be an important source of organs. This article presents two cases of successful organ donation and transplant, after Maastricht category III cardiac death in patients with successfully repaired AAST grade V traumatic cardiac injuries., Case Presentation: The first donor was an adult patient with self-inflicted heart stab wound and non-survivable burn injury. The second one was an adult patient with blunt cardiac and abdominal trauma and an anoxic brain injury due to a car accident. The cardiac injury was promptly repaired in both patients. In the first case, adequate organ perfusion ante-mortem was achieved thanks to venoarterial extracorporeal membrane oxygenation and intensive care unit support. The above procedure allowed successful organ donation and transplantation even after Maastricht category III cardiac death. This is the first case reported where, for organ donation purposes, it was made necessary first thing to avoid the immediate death of the patient, due to a rare and frequently not survivable cardiac injury. The challenge of preserving organ perfusion, due to major burn injury effects, was faced afterwards., Conclusions: The outcomes of these two cases suggest that a repaired heart injury should not be considered as an absolute contraindication to organ donation, even if it is associated with non-survivable major burns. Therefore, cardiac death could provide an opportunity for these kinds of patients to contribute to the pool of potential organ donors., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s). 2019.)

Aims: Resuscitative endovascular balloon occlusion of the aorta has been a hot topic in trauma resuscitation during these last years. The aims of this systematic review are to analyze when, how, and where this technique is performed and to evaluate preliminary results., Methods: The literature search was performed on online databases in December 2016, without time limits. Studies citing endovascular balloon occlusion of the aorta in trauma were retrieved for evaluation., Results: Sixty-one articles met the inclusion criteria and were selected for the systematic review. Overall, they included 1355 treated with aortic endovascular balloon occlusion, and 883 (65%) patients died after the procedure. In most of the included cases, a shock state seemed to be present before the procedure. Time of death and inflation site was not described in the majority of included studies. Procedure-related and shock-related complications are described. Introducer sheath size and comorbidity seems to play the role of risk factors., Conclusions: Resuscitative endovascular balloon occlusion of the aorta is increasingly used in trauma victim resuscitation all over the world, to elevate blood pressure and limit fluid infusion, while other procedures aimed to stop the bleeding are performed. High mortality rate is probably due to the severity of the injuries. Time and place of balloon insertion, zone of balloon inflation, and inflation cutoff time are very heterogeneous.