Question 18

College answer

Not available.

Discussion

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 FiO₂  must 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.