Outline the principles involved in the care of the organ donor.

Study Group Answer

Early identification of potential organ donor
heart beating, whole brain/ brainstem dead donor or non-heart beating donors

Recognition and confirmation of clinical brain death

exclude reversible medical conditions (metabolic, drugs, endocrine, hypothermia ) clinical (coma, absent BS reflex, +apnoea test) other investigations ( Technetium scan, Cerebral angiography, TCD, EEG, SEP )

Obtaining consent from the family involve active participation of intensivist, donor coordinator and donor family
establishing early rapport with family and providing medical information donor family management, emotional management and family support

Maintenance of extra-cerebral physiologic stability

1. aim to maintain organ perfusion and prevention and treatment of physiological derangement caused by brain death. either Supportive and Specific measures SUPPORTIVE measures to maintain normal physiologic parameters Circulatory management -adequate organ perfusion pressure eg. MAP >70, HR<100, CVP 8 Ventilatory management - good oxygenation, normocarbia , minimize circulatory depression, if possible keep good lung function for future lung donation Metabolic management - correct electrolytes, glucose abn , keep core temp >3536.5C 2.SPECIFIC measures to treat the complications of brain death Cardiovascular complications : Autonomic storm -consider BBlocker Hypotension -volume loading, inotropes if unresponsive consider steroids

Arrythmias - correct underlying cause eg. electrolytes abn, hypotension Diabetes Insipidus (high plasma osmol, low urine Na/osmol, high UO) - IV D5W, IV Desmopressin Hypothermia - blankets, warm IV fluids, humidified inspired air Hypothyroidism - either real hypothyroidism or sick euthyroid syndrome Hyperglycemia sec to osmotic diuresis - fluids and electrolytes correction, insulin IV

Donor screening and Organ Retrieval in theatre with proper consent

activation of harvest team and/or transplant team

Aftercare of donor family

follow up, feedback and continued family support

Outline the principles involved in the care of the organ donor. Principles include: Early identification Discuss with transplant coordinator Establish family rapport early Diagnose brain death correctly Establish presence of condition causing brain death. Exclude confounders (sedation, paralysis, endocrine, metabolic, temperature) - use vascular imaging if necessary. Satisfy legal criteria for organ donors relevant to the jurisdiction Non-coercive sensitive family discussion re opportunity for donation High availability. Answer questions Initiate tissue typing, viral screen, further organ function tests Maintain extra-cerebral physiological stability Ventilatory oxygenation, normocapnia, lung protective strategies. Circulatory monitoring, filling, noradrenaline, vasopressin. Normothermia. Diagnose and treat diabetes insipidus (DDAVP/vasopressin, free water). Steroid and T3 replacement Facilitate family time at bedside Ensure aftercare of donor family Transplant co-ordinator. Limited anonymous information available. Further family meeting offered Few candidates considered that the donor could be either living related, or a non-beating heart donor.

MANAGEMENT OF DECEASED ORGAN DONOR

Cardiovascular System
Hypotension and hemodynamic instability Neurogenic shock - Result of defective vasomotor control and subsequent loss progressive loss of SVR Hypovolemic shock - Therapeutic dehydration for cerebral edema - Hemorrhage - Diabetes insipidus with massive diuresis - Osmotic diuresis due to hyperglycemia Cardiogenic shock - Hypothermic depression of myocardial contractility - Left ventricular dysfunction

Brain Death. Irreversible cessation of all functions of the brain. Definition applies in all states and territories except WA and NZ, which have no legal definition of death.

Brain death can be diagnosed by any medical practitioner but for the purposes of organ donation this must be done by 2 medical practitioners each of more than 5 years post graduation, one of whom must be a designated specialist in that hospital. They should not be caring for the potential recipient, be the designated officer who will authorise transplant or be the doctor who will remove tissue to be transplanted. There is no statute about a minimum time period or the time between examinations but it is recommended the patient be observed for 4 hours to have fixed pupils and no respiratory function and the 2 hours elapse between tests. Diagnosis may be done clinically or by diagnostic investigation. Preconditions to clinical testing: Cause of Coma must be known and expected to cause brain death. Cause must not be due to drugs or toxins Metabolic causes have been excluded (electrolyte and endocrine) Normal temperature >32 but preferably >35 Intact neuromuscular conduction No physical reason to preclude eg no facial trauma, Cervical spine injury, occlusion of EAM, glass eye Clinical Testing of Brain Stem function: No pupilary response to light No response to painful stimuli applied in the cranial nerve territory Absent corneal, gag, cough and vestibuloocular reflexes Absent respiratory function. PCO2 must rise above 60mmHg and pH<7.3 All must be satisfied. Brain dead patients may still have: Spontaneous spinal reflexes Sweating, blushing or tachycardia Tendon reflexes and babinskis If clinical testing cannot be done or if confirmatory testing is required 3 or 4 vessel angiography or radionucleotide study may be used to demonstrate there is no intracranial flow. The study should be interpreted by 2 specialists. CTA, MRA, transcranial Doppler or EEG may be done but are not diagnostic. Time of death is the time of the second set of tests or time of conclusion of diagnostic imaging study. General Medical criteria for Organ donation

Irreversible cessation of brain function Absence of Sepsis Absence of malignancy excluding isolated brain primary or isolated malignancy Maintained on a ventilator with intact circulation. Consent: This should be in line with the patients expressed wishes antemortem. NOK consent is not required but should be discussed with them. Medical Management of the potential organ donor: Maintain euvolaemia Maintain MAP 60-70 mmHg, vasopressors if required. Maintain electrolytes Suspect and treat DI Maintain Euglycaemia Maintain temp>35 Maintain respiratory cares, eg suctioning, PEEP, positioning, turning etc HB>80 Hormone replacement remains controversial. Treat according to local protocol. May include T3, methylprednisolone, Vasopressin. Useful links www.legislation.nsw.gov.au www.atca.org.au www.anzics.com.au