Outline the principles involved in the care of the organ donor.
Discuss with transplant coordinator
Establish family rapport early
Diagnose brain death correctly
Establish presence of condition causing brain death. Exclude confounders (sedation, paralysis, endocrine, metabolic, temperature) - use vascular imaging if necessary. Satisfy legal criteria for organ donors relevant to the jurisdiction
Non-coercive sensitive family discussion re opportunity for donation
High availability. Answer questions
Initiate tissue typing, viral screen, further organ function tests
Maintain extra-cerebral physiological stability
Ventilatory - oxygenation, normocapnia, lung protective strategies. Circulatory - monitoring, filling,
noradrenaline, vasopressin. Normothermia. Diagnose and treat diabetes insipidus
(DDAVP/vasopressin, free water). Steroid and T3 replacement
Facilitate family time at bedside
Ensure aftercare of donor family
Transplant co-ordinator. Limited anonymous information available. Further family meeting offered
Few candidates considered that the donor could be either living related, or a non-beating heart donor.
This question closely resembles Question 1 from the second paper of 2012.
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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