Outline the Intensive Care management of a 25-year-old male who has fulfilled brain death criteria and is awaiting surgery for organ donation.

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College Answer

Temperature Maintenance:

  • Hypothermia is common due to: cold fluids, heat loss through exposure, inability to vasoconstrict or shiver, reduced metabolic rate.
  • Maintain normal core temperature
    • Cover patient
    • Warm room
    • Warming blanket
    • Warm fluids especially high volume
    • Humidification

Respiratory support:

  • Aim to avoid fluid overload
  • Aim for adequate Sp02 and normocarbia with lowest Fi02 and limit tidal volumes
  • Bronchoscopy for persisting collapse
  • Chest physiotherapy may be helpful

Circulatory Support:

Immediately prior to brain death there is often a period of sympathetic hyperactivity with associated tachycardia and hypertension. This is lost following brain death commonly resulting in vasodilation and hypotension

  • Maintain adequate mean arterial pressure. Use judicious volume expansion and low dose inotropes (usually noradrenaline)
  • Monitor peripheral perfusion and urine output regularly
  • Continue maintenance fluids

Metabolic haematology and biochemistry:

Diabetes insipidus is common and if not recognized and treated can quickly lead to hypernatraemia and hyperosmolality

  • Measure electrolytes and creatinine regularly and treat as appropriate to maintain normal ranges
  • Treat Diabetes insipidus with desmopressin (DDAVP) 4-8µgrams intravenously and repeat if necessary, or low dose vasopressin
  • Start low dose insulin infusion if blood glucose persistently above 12mmol/L
  • Stop bleeding, correct coaguloapthy, thrombocytopaenia and anaemia
  • Avoid hypernatraemia
  • Other electrolyte abnormalities – K, PO4, Ca, Mg
  • Consider thyroxine replacement

Communication:

  • Family - counsel, explain, keep updated
  • Liaison with donor coordinator and surgical retrieval teams
 

Discussion

This is a straightforward question about the care of the brain-dead organ donor. A summary exists on this site, which was derived directly from the recent ANZICS guidelines. If one were to rearrange the answer to fit some sort of primitive alphabetical template, it could resemble this:

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
  1. The circuit should be humidified.
  2. Normoxia and normocapnea must be maintained.
    There will be periodic requests for ABGs on 100% FiO2 from the donor coordinator, but afterwards the FiOmust be minimised to prevent oxidative stress damage to the lungs.
  3. 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".
  4. Normoglycaemia must be maintained.
  5. 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
  6. 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.
  7. Nutrition must continue.
    Good nutrition (or rather, the absence of malnutrition) has been associated with improved raft function (Singer et al, 2005)
  8. Coagulopathy must be observed and corrected; if worsening coagulopathy or DIC develop, organ retrieval should be expedited.

References

References

Summarized from the ANZIC statement on Brain Death and Organ Donation, Version 3.2

Dujardin, Karl S., et al. "Myocardial dysfunction associated with brain death: clinical, echocardiographic, and pathologic features." The Journal of heart and lung transplantation 20.3 (2001): 350-357.

Totsuka, Eishi, et al. "Influence of high donor serum sodium levels on early postoperative graft function in human liver transplantation: effect of correction of donor hypernatremia." Liver Transplantation and Surgery 5.5 (1999): 421-428.

Novitzky, D., D. K. C. Cooper, and B. Reichart. "Hemodynamic and metabolic responses to hormonal therapy in brain-dead potential organ donors." Transplantation 43.6 (1987): 852-854.

Phongsamran, Paula. "Critical care pharmacy in donor management." Progress in Transplantation 14.2 (2004): 105-113.

RANDELL, TARJA T., and KRISTER AV HöCKERSTEDT. "TRIIODOTHYRONINE TREATMENT IN BRAIN-DEAD MULTIORGAN DONORS-A CONTROLLED STUDY." Transplantation 54.4 (1992): 736-737.

Goarin, Jean-Pierre, et al. "The effects of triiodothyronine on hemodynamic status and cardiac function in potential heart donors." Anesthesia & Analgesia 83.1 (1996): 41-47.

Follette, David M., Steven M. Rudich, and Wayne D. Babcock. "Improved oxygenation and increased lung donor recovery with high-dose steroid administration after brain death." The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 17.4 (1998): 423-429.

Lisman, T., et al. "Activation of hemostasis in brain dead organ donors: an observational study." Journal of Thrombosis and Haemostasis 9.10 (2011): 1959-1965.

Lim, H. B., and M. Smith. "Systemic complications after head injury: a clinical review." Anaesthesia 62.5 (2007): 474-482.

Dalle Ave, Anne L., Dale Gardiner, and David M. Shaw. "Cardio‐pulmonary resuscitation of brain‐dead organ donors: a literature review and suggestions for practice." Transplant International (2015).

Singer, Pierre, Haim Shapiro, and Jonathan Cohen. "Brain death and organ damage: the modulating effects of nutrition." Transplantation 80.10 (2005): 1363-1368.