donor management

Donor Donor Management Management

Somchai Limsrichamrern, M.D.Department of Surgery

Faculty of Medicine, Siriraj Hospital

Pathophysiology of brain death

Cushing’s response Autonomic storm Decreased hepatic perfusion due to

intrahepatic shunt Neurogenic pulmonary edema Catecholamine decreased to below

baseline in 15 minute

Pathophysiology of brain death

Abolished vagal tone Decreased carbon dioxide production Arterial and venous vasomotor collapse Activation of proinflammaory and

immunoregulatory pathway

Routine care and monitoring

Arterial line CVP Temperature Hourly urine output Frequent laboratory tests Swan-Ganz catheter

Goal of management

Organ viability and function after transplantation correlates with donor care

To increase usability of organs To optimize organ perfusion and tissue

oxygen delivery

Goal of management Systolic blood pressure: 100-120 mmHg Central venous pressure: 8-10 mmHg Urine output: 100-300 ml/hr Core temperature: > 35º c Arterial oxygen pressure: 80-100 mmHg Oxygen saturation: > 95% pH: 7.35-7.45 Hematocrit: 30-35%

Cardiovascular support

Hypertension Hypotension Hypovolemia Decreased vascular resistance

Cause of hypotension Hypovolemia Hypothermia Cardiac dysfunction

Arrhythmia Acidosis Hypoxemia Excessive PEEP Congestive heart failure Myocardial sequelae of autonomic storm

Cause of hypotension

Cardiac dysfunction Cardiac injury Preexisting cardiac disease Hypophosphatemia Hypocalcemia

Drug side effect or overdose (beta blocker, calcium channel blocker)

Hypovolemia

Arterial and venous vasomotor collapse Dehydration (fluid restriction) Insufficient resuscitation Polyuria (Osmotic diuresis, diabetes

insipidus, hypothermia) Third space loss Decreased intravascular oncotic pressure

Cardiovascular support

Optimize volume status Dopamine is the drug of choice Try to avoid α-adrenergic agonist Urine output not reliable

Respiratory support

Frequent endotrachial suctioning Use low level of PEEP Tidal volume 10-15 ml/kg Maintain PaO2 greater than 100 mmHg

Avoid using high PEEP Increase FiO2 non-lung donor

Renal function

Maintain adequate perfusion Maintain adequate urine output Minimize use of vasopressor Polyuria (DI, osmotic diuresis) Diabetes insipidus found in 80%

Central diabetes insipidus

Urine output > 500 ml/hr Serum sodium > 155 mEq/L Urine specific gravity < 1.005 Serum osmolarity > 305 mOsm/L

Effect of hypernatremia

Hypernatremia was associated postoperative graft dysfunction

Graft loss in up to 33% Correction of hypernatremia Keep final serum sodium level < 155

mEq/L

Liver Transpl Surg - 1999 Sep; 5(5): 421-8

Treatment of DI

Hypotonic solution (D5W, .45NaCl) Desmopressin 1-2 µg IV every 8-12 hr Vasopressin infusion 1.2 unit/hr

Endocrine therapy

Low T3 level: routine use not recommended

Steroid: may decrease proinflammatory reaction, routine use not recommended

Insulin: use to treat hyperglycemia, increase hepatic glycogen storage

Prevention of hypothermia

Brain dead donors are poikilothermic Maintain temperature > 35ºc Prevent heat loss Rewarm

Organ preservation

To preserve the viability of organ for as long as possible

Hypothermia slows metabolism Cooling organs from 37 to 0 degree

Celsius slows metabolism by a factor of 12-13

Ischemia causes cell swelling

Organ preservation

Collin’s solution University of Wisconsin solution Both are high in potassium UW solution contain impermeants which

help reduce cell swelling

Ideal cadaver donor

Young adult with no significant medical problem

Brain death due to closed head injury No extracerebral trauma Brief hospitalization Normal blood pressure and heart rate without

vasopressor Excellent organ function

Contraindication

Unknown cause of death Extracranial malignancy HIV + Uncontrolled sepsis especially fungal

Relative contraindication

Extreme age Intracranial malignancy HCV + or HB core antibody + Bacteremia Procurement injury Preexisting medical problem

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Pitfall

Care of potential donor Diagnosis of brain death Documentation of brain death Consent form Preparation for organ retrieval Operative injury Packaging

Diagnosis of brain dead

Drug Hypothermia Decorticate Decerebrate Spinal cord injury

Documentation of brain death

Thank you.