Donor Management Somchai Limsrichamrern M D Department of

Donor Management Somchai Limsrichamrern, M. D. Department of Surgery Faculty of Medicine, Siriraj Hospital

Pathophysiology of brain death X Cushing’s response X Autonomic storm X Decreased hepatic perfusion due to intrahepatic shunt X Neurogenic pulmonary edema X Catecholamine decreased to below baseline in 15 minute

Pathophysiology of brain death X Abolished vagal tone X Decreased carbon dioxide production X Arterial and venous vasomotor collapse X Activation of proinflammaory and immunoregulatory pathway

Routine care and monitoring X Arterial line X CVP X Temperature X Hourly urine output X Frequent laboratory tests X Swan-Ganz catheter

Goal of management X Organ viability and function after transplantation correlates with donor care X To increase usability of organs X To optimize organ perfusion and tissue oxygen delivery

Goal of management X Systolic blood pressure: 100 -120 mm. Hg X Central venous pressure: 8 -10 mm. Hg X Urine output: 100 -300 ml/hr X Core temperature: > 35º c X Arterial oxygen pressure: 80 -100 mm. Hg X Oxygen saturation: > 95% X p. H: 7. 35 -7. 45 X Hematocrit: 30 -35%

Cardiovascular support X Hypertension X Hypovolemia X Decreased vascular resistance

Cause of hypotension X Hypovolemia X Hypothermia X Cardiac dysfunction X Arrhythmia X Acidosis X Hypoxemia X Excessive PEEP X Congestive heart failure X Myocardial sequelae of autonomic storm

Cause of hypotension X Cardiac dysfunction X Cardiac injury X Preexisting cardiac disease X Hypophosphatemia X Hypocalcemia X Drug side effect or overdose (beta blocker, calcium channel blocker)

Hypovolemia X Arterial and venous vasomotor collapse X Dehydration (fluid restriction) X Insufficient resuscitation X Polyuria (Osmotic diuresis, diabetes insipidus, hypothermia) X Third space loss X Decreased intravascular oncotic pressure

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

Respiratory support X Frequent endotrachial suctioning X Use low level of PEEP X Tidal volume 10 -15 ml/kg X Maintain Pa. O 2 greater than 100 mm. Hg X Avoid using high PEEP X Increase Fi. O 2 non-lung donor

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

Central diabetes insipidus X Urine output > 500 ml/hr X Serum sodium > 155 m. Eq/L X Urine specific gravity < 1. 005 X Serum osmolarity > 305 m. Osm/L

Effect of hypernatremia X Hypernatremia was associated postoperative graft dysfunction X Graft loss in up to 33% X Correction of hypernatremia X Keep final serum sodium level < 155 m. Eq/L Liver Transpl Surg - 1999 Sep; 5(5): 421 -8

Treatment of DI X Hypotonic solution (D 5 W, . 45 Na. Cl) X Desmopressin 1 -2 µg IV every 8 -12 hr X Vasopressin infusion 1. 2 unit/hr

Endocrine therapy X Low T 3 level: routine use not recommended X Steroid: may decrease proinflammatory reaction, routine use not recommended X Insulin: use to treat hyperglycemia, increase hepatic glycogen storage

Prevention of hypothermia X Brain dead donors are poikilothermic X Maintain temperature > 35ºc X Prevent heat loss X Rewarm

Organ preservation X To preserve the viability of organ for as long as possible X Hypothermia slows metabolism X Cooling organs from 37 to 0 degree Celsius slows metabolism by a factor of 12 -13 X Ischemia causes cell swelling

Organ preservation X Collin’s solution X University of Wisconsin solution X Both are high in potassium X UW solution contain impermeants which help reduce cell swelling

Ideal cadaver donor X Young adult with no significant medical problem X Brain death due to closed head injury X No extracerebral trauma X Brief hospitalization X Normal blood pressure and heart rate without vasopressor X Excellent organ function

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

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

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

Diagnosis of brain dead X Drug X Hypothermia X Decorticate X Decerebrate X Spinal cord injury

Documentation of brain death

Thank you.