Management of the heartbeating brain-dead organ donor

Abstract

The main factor limiting organ donation is the availability of suitable donors and organs. Currently, most transplants follow multiple organ retrieval from heartbeating brain-dead organ donors. However, brain death is often associated with marked physiological instability, which, if not managed, can lead to deterioration in organ function before retrieval. In some cases, this prevents successful donation. There is increasing evidence that moderation of these pathophysiological changes by active management in Intensive Care maintains organ function, thereby increasing the number and functional quality of organs available for transplantation. This strategy of active donor management requires an alteration of philosophy and therapy on the part of the intensive care unit clinicians and has significant resource implications if it is to be delivered reliably and safely. Despite increasing consensus over donor management protocols, many of their components have not yet been subjected to controlled evaluation. Hence the optimal combinations of treatment goals, monitoring, and specific therapies have not yet been fully defined. More research into the component techniques is needed.

Anesthetic considerations in organ procurement surgery: a narrative review

“…In the presence of brain death, spinal cord function is still intact and both somatic and visceral reflexes remain. 19,20 Effective anesthetic management of donation requires an understanding of the effects of brain death on each organ system.…”

“…Resultant respiratory distress can progress to apnea and cardiac arrest. 19 A lung-protective ventilatory strategy should be employed, with tidal volumes of 6-8 mLÁkg -1 and a positive end-expiratory pressure (PEEP) of 8-10 cm H 2 O, 6 especially if lung procurement is planned. Evidence is lacking to support the maintenance of respiratory alkalosis during organ procurement.…”

“…19 Animal studies show that these are mediated by spinal cord reflexes below the level of the brain stem. An animal study showed the minimal alveolar concentration was unaltered by high cervical cord section and suggested that anesthetics inhibit the motor response via sites in the spinal cord.…”

Manejo del potencial donante cadáver

“…l trasplante de órganos sólidos (riñón, híga-do, páncreas, corazón y pulmón) está muy limitado por la disponibilidad de donantes 1,2 . La muerte encefálica es una condición catastrófica con marcada inestabilidad circulatoria, que si no es manejada en forma oportuna y adecuada puede llevar al deterioro de los órganos antes de su procuramiento 3,4 .…”

“…Los injertos "marginales" tienen mayor tasa de disfunción primaria del injerto y muerte, pero su definición y manejo apropiado es importante pues hay receptores que se beneficiarán aun de órganos procurados en un paciente con estas características. Como siempre, la evaluación de cada caso en particular, considerando la mortalidad del paciente en espera, es fundamental para una correcta toma de decisiones 1,6,8 . En otros centros, ya existe amplia experiencia en la donación de órganos después de la muerte o paro cardiaco, pero este tema excede los objetivos de la presente revisión 9,10 .…”