A 30 year old woman has been certifted "brain dead". While awaiting organ donation she ishypotensive, polyuric and hypothermic. Outline your management.
Efficient support of the potential organ donor is an integral part of IC practice. Since we know nothing of this patient's story a back to basics detailed approach to the patient should have included:
(a) Check airway patency, tube position.
(b) Ensure adequate ventilation:
• Examination, ABG, CXR (to exclude pneumothorax/lung injury, hypoxialhypercarbia) (c) Restore circulation with fluid challenge. Assess filling pressures and response to challenge.
• If diabetes insipidus is apparent (eg. urine output >300mlslhr, serum osmolality >300, urine osmolality <300 in the absence of diuretics) give lug ofDDAVP lV or SC
• If restoration of fluid status does not restore BP and organ perfusion, commence vasoconstrictor infusion (aramine or noradrenaline)
• Moderate hypothermia (35°C} may be well tolerated and require no specific therapy
• Persistent hypotension in the presence of impaired pituitary functiODt as evidenced by DI. It may be an indication for intravenous corticosteroids and T3. There usually is no time for a random cortisol level
• Maintain fluid and electrolyte homeostasis eg. replacing urine output ml for ml
This question discussess the generic principles of care for the brain-dead organ donor. This issue is explored in great depth in the answer to Question 1 from the first paper of 2012:
"Outline the Intensive Care management of a 25-year-old male who has fulfilled brain death criteria and is awaiting surgery for organ donation."
Non-clinical issues: (presumably, these have been dealt with now that the patient is "awaiting surgery for organ donation"
- Early involvement of the transplant coordinator
- Non-coercive sensitive family discussion re opportunity for donation
- Tissue typing, viral screen, further organ function tests
- Facilitate family time at bedside
- Ensure aftercare of donor family
- The circuit should be humidified.
- Normoxia and normocapnea must be maintained.
There will be periodic requests for ABGs on 100% FiO2 from the donor coordinator, but afterwards the FiO2 must be minimised to prevent oxidative stress damage to the lungs.
- Haemodynamic instability is to be expected:
- The initial autonomic storm should be managed with nitroprusside and esmolol
- The subsequent collapse should be treated with noradrenaline and/or vasopressin
- Bradycardia will be resistant to atropine (no vagus to block); catecholamines or pacing will be required
-Though they do not make a direct statement to this effect, ANZICS tacitly support CPR in the brain-dead organ donor; "cardiopulmonary resuscitation may result in recovery of cardiac function and successful transplantation".
- Normoglycaemia must be maintained.
- Normothermia must be maintained by warming externally, and by using warmed fluids.
Electrolytes need to be maintained within normal laboratory ranges;
particular attention needs to be paid to the sodium.
DDAVP may be required as a hormone replacement.
Other "endocrine support" (T3, hydrocortisone) should be considered in the following circumstances:
- haemodynamic instability
- an ejection fraction of less than 45%
- heart donation is being considered
- Fluid resuscitation should be conservative if you plant to donate lungs, aggressive if you plan to donate kidneys, and an intelligent compromise if both organs are being considered.
- Nutrition must continue.
Good nutrition (or rather, the absence of malnutrition) has been associated with improved raft function (Singer et al, 2005)
- Coagulopathy must be observed and corrected; if worsening coagulopathy or DIC develop, organ retrieval should be expedited.
Summarized from the ANZIC statement on Brain Death and Organ Donation, Version 3.2
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