Critical Care of the Deceased Organ Donor



Critical Care of the Deceased Organ Donor


Christoph Troppmann



I. GENERAL PRINCIPLES

A. The gap between available donor organs and those waiting for transplants is widening, and the wait list mortality has been increasing.

B. Critical care physicians and other health care personnel play a key role in (1) early identification of potential organ donors; (2) early referral to organ procurement organizations (OPOs); (3) a coordinated approach to the potential donors’ families for obtaining consent; and (4) maintaining and optimizing organ function and viability for transplantation. Physicians providing end-of-life care should routinely consider the option of organ donation (see also Chapter 23).

C. Predicted annual number of brain-dead potential organ donors in the United States ranges between 10,500 and 13,800, but in 2012, organs were recovered from only 8,143 deceased donors.

II. DONOR CLASSIFICATION

A. Brain-dead deceased donors.

1. The most common deceased donor type (88.3% of all deceased donors in the United States in 2011).

2. Unequivocal diagnosis of brain death is required before proceeding with organ recovery.

B. Donation after cardiac death (DCD) donors.

1. DCD donors have been increasing substantially in the United States over the past decade and currently represent 11.7% of all deceased organ donors.

2. Usually, time and place of death are controlled (e.g., families of patients with severe irreversible terminal brain injuries, refractory medical diseases, or advanced neurologic disorders, who do not fulfill the formal criteria of brain death, decide to withdraw all life-sustaining technology and then decide to donate the organs).

3. Supportive treatment is withdrawn in the ICU or the operating room, and organ recovery is initiated once death has been pronounced by a physician not belonging to the organ recovery and transplant team.


III. PATIENT SCREENING (FOR POTENTIAL BRAIN-DEAD DECEASED DONORS AND DONATION AFTER CARDIAC DEATH DONORS)

A. Age 0 to 90 years.

B. Severe neurologic injury (trauma, cerebrovascular accident [CVA], hypoxia, brain tumor), or near brain death, or brain-dead (with or without impending withdrawal of support), or intent to withdraw support in non-brain-dead patients with other terminal nontraumatic conditions (e.g., advanced neurological disease).

C. Patients with systemic bacterial or fungal infections, and those with localized viral infections, may in some cases still be considered as organ donors. Intensive care physicians caring for potential donors with these criteria should consult with the local OPO, where the ultimate decision regarding organ donor candidacy is made, together with the Transplant Center.

D. Absolute contraindications.

1. Viral encephalitis with systemic viral infection.

2. Human immunodeficiency virus (HIV) positive.

3. Malignancy (except nonmelanoma skin cancers and primary brain tumors with little propensity to disseminate).

E. After identification of any potential donor, federal required request legislation mandates that hospitals notify their local OPO in a timely manner.

F. If the local OPO address is unknown, a 24-hour access number to the United Network for Organ Sharing (UNOS) is available for further referral information: 1-800-292-9537.

G. The OPO will assist with completing preliminary screening of the potential donor and coordinating the approach to the potential donor’s family and will consult with the transplant team(s) regarding use of donor organs that do not meet standard criteria.

IV. BRAIN DEATH DIAGNOSIS

A. “An individual who has sustained either irreversible cessation of circulatory and respiratory function or irreversible cessation of all functions of the entire brain, including the brainstem, is dead. A determination of death must be made in accordance with accepted standards” (President’s Commission for the Study of Ethical Problems in Medicine Uniform Determination of Death Act, 1981).

B. The clinical diagnosis of brain death rests on three criteria:

1. Irreversibility of the neurologic insult.

2. Absence of clinical evidence of cerebral function.

3. Most important, absence of clinical evidence of brainstem function.

C. Clinical brain death examination and apnea test are outlined in Table 132-1.

D. Spinal reflexes can be preserved and do not exclude the diagnosis of brain death.

V. OBTAINING CONSENT FOR ORGAN DONATION

A. Early involvement of the OPO in the potential organ donor screening and organ donation and consent process is crucial.










TABLE 132-1 Brain Death Criteria and Clinical Diagnosis of Brain Death







  1. Irreversible, well-defined etiology of unconsciousness:




    1. Structural disease or metabolic cause (hypoxia).



    2. Exclusion of hypothermia; hypotension; severe electrolyte, glycemic, uremic, endocrine, or acid-base disturbance; hepatic encephalopathy; drug or substance intoxication.



    3. Sufficient observation period (at least 6 h) between two brain death examinations.



  2. No clinical evidence of cerebral function:




    1. No spontaneous movement, eye opening, or movement or response after auditory, verbal, or visual commands.



    2. No movement elicited by painful stimuli to the face and trunk (e.g., sternal rub, pinching of a nipple or fingernail bed) other than spinal cord reflex movements.



  3. No clinical evidence of brainstem function:




    1. No pupillary reflex: pupils are fixed and midposition; no change of pupil size in either eye after shining a strong light source in each eye sequentially in a dark room.



    2. No corneal reflex: no eyelid movements after touching the cornea (not the conjunctiva) with a sterile cotton swab or tissue.



    3. No gag reflex: no retching or movement of the uvula after touching the back of the pharynx with a tongue depressor or after moving the endotracheal tube.



    4. No cough reflex: no coughing with deep tracheal irrigation and suctioning.



    5. No oculocephalic reflex (doll’s eyes reflex): no eye movement in response to brisk turning of the head from side to side with the head of the supine patient elevated 30°.



    6. No oculovestibular reflex (caloric reflex): no eye movements within 3 min after removing earwax and irrigating each tympanic membrane (if intact) sequentially with 50 mL ice water for 30-45 s while the head of the supine patient is elevated 30°.



    7. No integrated motor response to pain: no localizing or withdrawal response, no extensor or flexor posturing.



  4. Apnea testing:




    1. Patient must be normothermic (>36.5°C) and normotensive (systolic blood pressure >90 mm Hg).



    2. Patient is preoxygenated with FiO2 of 1.0 for 10-15 min while adjusting ventilatory rate and volume so that paCO2 reaches 40-45 mm Hg.



    3. Obtain arterial baseline blood gas, disconnect the patient from the ventilator, deliver O2 at 6-8 L/min through a cannula advanced 20-30 cm into the endotracheal tube (cannula tip at the carina).



    4. Use continuous pulse oximetry for early detection of desaturation.



    5. If brain-dead, a paCO2 >60 mm Hg is achieved within 3-5 min after withdrawal of ventilatory support; at this point the patient should be reconnected to the ventilator (or earlier, should hemodynamic instability, desaturation, or spontaneous breathing movements occur).



    6. Arterial blood gas sampling immediately before reinstitution of mechanical ventilation to confirm the paCO2 rise to >60 mm Hg.



    7. Criteria for positive apnea test: No evidence of spontaneous respirations before reinstitution of mechanical ventilation in the presence of paCO2 >60 mm Hg or paCO2 increase of >20 mm Hg from the normal baseline value.

    Only gold members can continue reading. Log In or Register to continue

    Related posts:

    Pulmonary Artery Catheters Gastroesophageal Balloon Tamponade for Acute Variceal Hemorrhage Default ThumbnailEchocardiography in the Intensive Care Unit Critical Care of Pericardial Disease Supraventricular Tachycardia Default ThumbnailExtrapulmonary Causes of Respiratory Failure

    Stay updated, free articles. Join our Telegram channel
    Tags:
    Jun 11, 2016 | Posted by in CRITICAL CARE | Comments Off on Critical Care of the Deceased Organ Donor

    Full access? Get Clinical Tree

     Get Clinical Tree app for offline access