Organ Retrieval

 

 

Terminology

 

  • DBD: Donation after Brain Death:

    • At least 2 physicians NOT involved in organ procurement must declare brain death in accordance with the American Academy of Neurology guidelines; the anesthesiologist is NOT involved in this process

  • DCD: Donation after Cardiac Death: 

    • A DCD donor does not meet the strict criteria for brain death but has suffered a severe non-recoverable brain insult & the family has decided to withdraw life support 

    • Upon withdrawal of life support, the DCD donor’s death is declared based on cardiopulmonary criteria 

    • After death is declared, 5 minutes must pass before organ procurement begins 

 

 

Considerations for DBD

 

  • Confirm the diagnosis of brain death & confirm wishes of patient & family:

    • Declared by 2 physicians not involved with transplant

    • Minimum clinical criteria for brain death met (see guidelines)

  • Physiologic consequences of brain death:

    • Hemodynamic instability (myocardial dysfunction, vasomotor tone, hypovolemia)

    • Pulmonary dysfunction with ARDS & hypoxemia (neurogenic pulmonary edema, VAP, CHF, etc)

    • Neuroendocrine dysfunction

    • Diabetes insipidus (70%), hypernatremia, hypokalemia

    • Hypothyroid

    • Hypocortisolemia

    • Hyperglycemia

    • Coagulopathy/DIC (brain release of thromboplastin)

    • Poikilothermia secondary to hypothalamic dysfunction

  • Etiology of brain death & secondary injuries

  • Trauma (potential for multi-organ involvement, pulmonary/cardiac contusions)

 

 

Goals for DBD 

 

  • Cardiac:

    • Ensure adequate intravascular volume

    • Use vasopressors to maintain adequate organ perfusion

      • Vasopressin as 1st line agent as it treats BP & diabetes insipidus (dose = 0.01-0.04 IU/min)

      • Norepinehrine & dopamine also reasonable agents

      • Avoid high doses of vasopressors

    • Hemodynamic goals are SBP >100 mmHg, MAP >70 mmHg, HR 60-120 

  • Respiratory:

    • Lung protective ventilatory strategy: TV 6-8cc/kg, PEEP 8-10, avoid fluid overload, FiO2 <40% for lung retrieval 

  • Endocrine:

    • Thyroid replacement: tetraiodothyronine 20 mcg IV bolus, then 10mcg/hr infusion 

    • Vasopressin 1 U IV bolues, then 0.01-0.04 U/hr infusion 

    • Methylprednisolone 15mg/kg IV q24h

    • Keep serum glucose <8 mMol/L 

  • MSK: paralytics should be given during procurement to optimize surgical conditions & stop somatic response to surgical stimulus mediated by spinal cord reflexes 

  • Hematologic:

    • Keep Hgb ~100 

    • Platelets & FFP if clinical bleeding, do NOT simply correct abnormal coagulation tests