Normothermic regional perfusion (NRP) is changing the landscape of organ donation, increasing the potential of viable organs and procuring in such a way that provides viability other than the traditional DCD method provided. SpecialtyCare is one of the largest providers of perfusion in the nation, supporting one in seven cardiac surgeries in the US.
Our teams are involved in NRP for organ procurement, and Greg Diede, the Area Clinical Manager overseeing our teams in Flagstaff, Prescott, and Phoenix, AZ, took some time to explain how NRP is performed with respect to donor care — and the opportunities that it presents to increase successful transplant operations.
NRP and DCD Donation: Opportunities and Parameters
The transplant scene has been altered by the improved utilization of DCD organs. DCD, or donation after circulatory (or cardiac) death, is a status for donors who do not meet the criteria for donation after brain death (DBD), but their condition is devolving to that point through the loss of neurologic function and the need for ventilation support. In the past, DCD organs have frequently been ineligible due to the incidence of ischemic injury, but NRP reduces this risk and preserves function, increasing the viability window for hearts, lungs, livers, pancreases, and kidneys. Cureus reports that DCD donation can increase the number of heart transplants by up to 30%, and the University of Cincinnati revealed in 2024 that the use of perfusion “wiped out” its waiting list for livers.
“NRP… provides warm oxygenated blood to the heart and/or abdominal organs that allows for their reanimation while reducing myocardial injury, preserving energy storage, and maintaining homeostasis,” says Greg. “It also allows the harvesting surgeons to assess each organ under direct visualization.”
Once ventilation support has been withdrawn, DCD donors must expire on their own within a specific timeframe, between 60 minutes and two hours (in the United States), and cannot be touched for up to five minutes after a physician has confirmed their death. “The harvesting team is not allowed to be in the same room as the donor and relies on the staff from the organ procurement organization, or OPO, to give updates on donor vitals and status,” says Greg.
What It Takes to Perform NRP Successfully
The best case scenario is if the withdrawal of ventilatory support occurs in the OR, which creates less friction in terms of timing and transport. It can also occur in a PACU pre-op area or an ICU near the OR. After the donor expires on their own and all necessary regulations have been adhered to, NRP can begin.
“NRP is initiated once sternotomy has been made and the head vessels are completely occluded first and foremost,” says Greg. “An arterial cannula is placed in the aorta and a venous cannula in the right atrium. With an experienced team, we can be on bypass within approximately three minutes after the no‑touch period.
“Anesthesia reintubates the donor, which is critical if heart or lung recovery is planned. … We target flows similar to standard bypass, typically aiming for a cardiac index around 2.4. Blood gases are obtained approximately ten minutes after initiating bypass. If the heart is deemed viable, we wean, transfuse volume back, and expedite teardown so the surgical team can proceed.”
What We Use to Perform NRP
In terms of equipment that SpecialtyCare uses to perform NRP, “We currently use a Medtronic Bio‑Console,” says Greg. “We also have a compact Sprinter cart from a company called CoreSite that fits the Biomedicus perfectly and has a small footprint. To achieve the normothermic component of NRP, we use a MicroTemp LT heater by Cincinnati Sub‑Zero. It’s not the most efficient, but it’s compact and gets the job done. We also bring our own i‑STAT point‑of‑care machines so we can rely on ourselves and not the donor facility. Oxygen is supplied using 100 percent oxygen from the anesthesia machine mask port.
“For disposables, we use Medtronic tubing packs, oxygenators, and reservoirs. We bring two sets of most items except tubing packs and reservoirs due to space constraints, and we rely heavily on checklists to ensure readiness. Our surgical technologists also maintain their own checklists and coordinate with donor facilities for additional supplies.”
Addressing Challenges
NRP involves a highly coordinated effort, and its utilization depends on deceased donors who expressly fit the criteria for donation. There are a number of complications that can occur in the process of preserving and transferring viable organs:
- Donor selection limitations
- Inadequate pre‑deployment diagnostics
- Arterial line malfunction
- Cannula dislodgement
- Inability to reintubate
- Travel constraints
“Arterial line issues are common during rapid transfers, so we often transduce central aortic pressure,” says Greg. “Cannula security is critical, as dislodgement can cascade into additional complications.”
An appropriate staffing model is also critical for successful procurement and transplantation. A surgeon, assistant, perfusionist, scrub tech, and procurement specialists are required, especially since travel is involved, to ensure that every aspect of the procedure is handled properly. Travel may be local or involve air transport, often in multiple vehicles, which includes possibility of logistical and timing issues.
“NRP requires adaptability, preparation, and experience under pressure,” says Greg.
The Future of NRP and Your Opportunity
NRP is increasing the volume of successful organ transplants. Neurologic scoring systems and artificial intelligence tools may be implemented to help improve processes in the future. Hybrid approaches combining NRP with ex vivo perfusion systems, such as the TransMedics Organ Care System, may allow for improved assessment and long‑distance transport.
SpecialtyCare is on the front lines with NRP for DCD donation, and we support 250 hospitals around the country with perfusion services. For both thoracic and abdominal NRP, we offer a response time in as little as 30 minutes and team availability twenty-four hours a day, seven days a week, 365 days a year. In addition to training perfusionists to meet demand, we can place perfusionsists at your hospital and support your organ donation program. Contact us today to learn more!
