Surgical Clinics of North America

Volume 80 Number 3 June 2000

Copyright 2000 W. B. Saunders Company

Unique Challenges
ISSUES IN POTENTIAL ORGAN DONOR MANAGEMENT
Tarek Razek MD
Kim Olthoff MD
Patrick M. Reilly MD
1

1
2

Divisions of Trauma and Surgical Critical Care (TR, PMR)

Transplantation Surgery (KO),

Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Address reprint requests to
Patrick M. Reilly, MD
Division of Trauma and Surgical Critical Care
Hospital of the University of Pennsylvania
3440 Market Street, First Floor
Philadelphia, PA 19104

As of September 1999, 65,793 patients were on the US

transplant waiting list, which continues to grow at an average
rate of 16% per year.
In contrast, the availability of
cadaveric organ donors has remained relatively stagnant. In
1998, the number of cadaveric donors increased for the first
time since 1995, but the modest increase of 5.6% failed to
keep pace with the increase of patients awaiting organs for
transplantation.
An estimated 12,500 to 27,000 potential organ donors die
each year in the United States.
Despite what seems to
be an adequate donor pool, only 15% to 20% of potential
donors become actual donors.
As a result, in 1998, 4855
patients died while on the waiting list for transplantation.
A
review of potential donors in a catchment area serving a
population of 22 million by Gortmaker et al
showed that the
major causes of death among potential donors were head
trauma (49%) and cerebrovascular events (33%).
A more structured approach to and heightened awareness of
potential organ donors may improve the number of donors.
With a significant proportion of potential donors coming from
the trauma setting and treated in ICUs, trauma and critical
care teams must become aware of the importance of organ
procurement and skilled in optimizing donation from potential
donors.
[70] [71]

[70] [71]

[6] [15] [68]

[4] [69]

[70]

[19]

[19]

Several distinct steps exist on the path from a potential donor

to an actual donor. These steps have been defined clearly, and
strategies to maximize the actual donation rates examined in
the literature over the past decade have shown impressive
results. Unfortunately, these steps, and the methods for
implementing them, are not widely practiced. As a result,
cadaveric organ donation remains inadequate despite a large
potential organ donor population. Identifying all potential
donors, determining brain death in a rapid and reliable
method, approaching all potential donor families for consent,
and aggressively managing medical issues of all potential
donors all are important elements necessary to realize
improved actual donation rates.
This article examines the
practical approaches to these steps in an effort to increase
awareness and improve organ procurement rates.
[22] [31]

BRAIN DEATH
History
The introduction of successful kidney transplantation in the 1950s led
to the concept of organ use from "heart-beating cadavers." In 1968,
the Ad Hoc Committee of the Harvard Medical School To Examine the
Definition of Brain Death was created to standardize the definition of
brain death and resolve some of the growing controversies
surrounding organ procurement for transplantation from heart-beating
donors. The resolutions from this committee are known as the
Harvard Criteria of Brain Death (see box below).
[5]

Harvard Criteria for Brain Death

1. No movements or breathing. Observations of at least 1 hour by physicians to

satisfy the criteria of no spontaneous muscular movements or spontaneous
respiration or response to stimuli. Absence of spontaneous breathing may be
established by turning off the respirator for 3 minutes, provided also that the
patient had been breathing room air for at least 10 minutes before the trial.
2. No reflexes. The absence of elicitable reflexes. The pupils are fixed and dilated
and do not respond to light. Ocular movement (to head turning and irrigation of
the ears with ice water) and blinking are absent. No evidence of postural activity
is present. Corneal and pharyngeal reflexes are absent. As a rule, the stretch
tendon reflexes cannot be elicited.

3. Flat electroencephalogram (EEG). Of great confirmatory value is the flat or

isoelectric EEG.

Although this represented a significant step forward at the time, these

Harvard criteria are now considered more stringent than necessary.
Brain-death criteria in the United States are based on the Report of
the Medical Consultants on the Diagnosis of Death to the President's
Commission on the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research of 1981 (see box below).
[60]

Guidelines for the Determination of Brain Death

1. Cessation is recognized when evaluation discloses:

a. Cerebral functions are absent; "cerebral unresponsivity and unreceptivity"
are present, and
b. Brain stem functions are absent; these include pupillary light, corneal,
oculocephalic, oculovestibular, oropharyngeal, and respiratory reflexes;
apnea is tested with a nasal cannula delivering oxygen and demonstrating
failure of respiratory effort with Pa CO2 of more than 60 mm Hg; spinal
cord reflexes may persist after death; true decerebrate or decorticate
posturing or seizures are inconsistent with the diagnosis of death.
2. Irreversibility is recognized when evaluation discloses:
a. The cause of coma is established and is sufficient to account for the loss
of brain function, and
b. The possibility of recovery of any brain function is ruled out, and
c. The cessation of all brain functions persists for an appropriate period of
observation or trial therapy; confirmation of clinical findings by EEG is
desirable when objective documentation is needed to substantiate the
clinical findings; complete cessation of the circulation to the
normothermic adult brain for more than 10 minutes is incompatible with
survival of brain tissue; absent cerebral blood flow, in conjunction with
the clinical determination of cessation of all brain functions for at least 6
hours, is diagnostic of death
d. Complicating conditions
e. Drug and metabolic intoxication
f. Hypothermia (< 32.2C)
g. Young age (i.e., children)
h. Shock

The President's Commission requires:

1. Loss of brain stem function
2. Loss of cortical function
3. That the condition is irreversible
Using these guidelines, a potential organ donor is identified after
establishing a diagnosis that is likely to produce severe, irreversible
neurologic damage (e.g., severe head trauma or massive
intracerebral hemorrhage). Several confounding factors must be ruled
out, including: hypothermia (< 32C), shock, drug intoxication, severe
metabolic derangement, and the effects of neuromuscular blockade.
The absence of brain stem function is documented by testing for
pupillary response (cranial nerve [CN] I, III), corneal reflex (CN V, VII),
oculocephalic and oculovestibular reflexes (CN VIII). Loss of medullary
function is demonstrated with an apnea test. Although maintaining
adequate oxygenation with endotracheal oxygenation, patients are
removed from the ventilator until the Pa CO2 reaches 60 mm Hg. An
absence of spontaneous respirations with this stimulus is consistent
with loss of brain stem function. Loss of cortical function implies
loss of responsiveness and receptivity. Documentation of a lack of
cortical function with an isoelectric EEG is optional.
A significant change from the Harvard criteria is the recognition that
spinal and tendon reflexes are preserved in brain death, and the
interval between repeat examinations may be as short as 6 hours.
Although the diagnosis is primarily clinical, confirmatory tests are
recommended, especially if the period between examinations is less
than 12 hours and in children less than 5 years of age.
[13] [47]

[62]

Ancillary Studies
The diagnosis of brain death is clinical. No guidelines require any
ancillary tests to confirm the clinical impression; however, the
objective documentation of the clinical findings can be a helpful
adjunct to the diagnosis, especially in difficult cases (e.g., infants or
patients with severe facial trauma). Ideally, a confirmatory study
accurately and rapidly provides objective confirmation of the clinical
examination findings so that a confident declaration of brain death
can be made more quickly.
The EEG was included in the stringent Harvard criteria only for its
"great confirmatory value" but was not viewed as a necessary
criterion for the diagnosis of brain death. Its value in the prognosis
of severe brain injury was recognized as early as 1969 ; however,
good technicians and accurate readings are difficult to access at all
hours in most institutions.
Demonstration of a lack of blood flow to the brain can be an important
adjunct to the diagnosis of brain death. A four-vessel angiogram is
considered the gold standard but is expensive, involves a dye load,
and requires transportation to the angiography suite. An alternative
[65]

[44]

is the nuclear medicine brain flow scan--an accurate, inexpensive test

that may be performed at the bedside.
Transcranial Doppler
blood-flow measurement can also be performed at the bedside, is
inexpensive, and has been reported to be accurate.
[12] [35] [73] [75]

[61]

Rapid Brain Death Determination

Despite the efforts to standardize the definition of brain death,
considerable variation exists among institutions, states or provinces,
and countries in the pattern of brain-death determination.
The policy at the Hospital of the University of Pennsylvania (HUP) for
brain-death determination is summarized in Table 1 and follows
Commonwealth statutes legislated by the Commonwealth of
Pennsylvania.
[24] [30] [68] [72]

[28]

TABLE 1 -- METHODS OF BRAIN DEATH DETERMINATION AT THE

HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA
Method
ClinicalExamination ApneaTest
Interval
Confirmatory Test
A
Yes
Yes
12 h
Second clinical
examination
B
Yes
Yes
6h
Second clinical
examinationand
electroencephalogram
C
Yes
Yes
Minimal
Cerebral blood flow
study
Modified from Jenkins DH, Reilly PM, Schwab CW: Improving the approach to organ
donation: A review. World J Surg 23:644, 1999; with permission.
Complications related to prolonged supportive care, often as a
consequence of delays in the diagnosis of brain death, reduce the
availability and suitability of potentially transplantable organs. An
estimated 17% to 25% of potential donors are lost because of medical
failure while awaiting the formal declaration of brain death. In an
effort to improve organ procurement rates at the authors' institution,
the Division of Trauma and Surgical Critical Care at HUP evaluated a
Rapid Brain Death Determination (RBD) Protocol. Following one
clinical examination consistent with brain death (i.e., no cortical or
brain stem function, irreversibility, and no complicating conditions) a
nuclear medicine brain flow scan is obtained to confirm brain death.
The use of brain scanning as a confirmatory test for brain death has
been well described.
The RBD protocol significantly reduced
time to declaration of brain death (from 12.4 to 3.4 hours) and
associated charges ($16,645-$6125) for potential donors at HUP.
Given the ubiquitous physiologic deterioration of brain-dead donors, a
more rapid, accurate determination of brain death could have a
significant impact on the number of actual donors and the number of
organs per donor through a decrease in the incidence of medical
[36]

[30]

[12] [35] [73] [75]

[30]

failure. The authors have realized such increases at HUP and now
average more than 4.5 solid organs per donor.
[30] [31]

IDENTIFICATION AND CONSENT

The inequality between potential organ donors and actual organ
donors has not escaped the eye of government policy makers. The
1986 Omnibus Reconciliation Act, section 1138, requires that all
hospitals participating in Medicare and Medicaid programs refer all
potential organ donors to their local organ-procurement organization
(OPO) and that families of all potential organ donors become aware of
their option to donate. The act is supplemented by required request
legislation, which mandates that hospitals ask all families of deceased
patients to consider organ donation. More than 40 states have
enacted similar legislation.
Despite these public-policy efforts, the
effect on organ availability has been limited.
Even if all potential donors are identified and approached about
donation, the shortage of organs will be difficult to address as long as
consent rates remain in the 40% range.
Investigations have
shown that, by organizing the consent process such that death
notification and consent request are decoupled, hospital staff and the
OPO coordinator participate in the consent process, and the request
takes place in a private setting, the consent rate can be as high as
74%.
Applying this simple, organized approach to all potential
donor situations may significantly improve donor rates.
In Spain, a highly structured approach to organ donation has been
established with the designation and formal training of donation
coordinators in every hospital with potential donors.
Spain has
one of the highest donation rates (20.2 per million) in the world. A
potential confounder is that Spain has presumed consent laws, which
provide for routine donation of organs at the time of death unless the
individual registers a premortem opposition to organ donation.
Although some of the 13 European countries using presumed consent
have higher donation rates than do countries without presumed
consent, others do not, and no country has sufficient organs to meet
the demands of those waiting for transplantation.
At HUP, aggressive care using the team approach and the
determination of brain death using a single clinical examination
performed by consultant neurosurgeons and nuclear medicine flow
studies have significantly increased the consent rate to organ
donation and the number of organs procured from eligible donors
(Table 2) .
Although the reasons for these increases are likely
multifactorial, the protocol described seems to provide appropriate
[22] [63]

[19] [66]

[19] [66]

[39] [40]

[34] [43]

[31] [32]

resuscitation and maintain potential organ donors until a decision on

consent can be reached. The objectivity of nuclear medicine scans
linked to the "decoupled" procurement team seems to positively
influence families' decision to donate. The increase in organs donated
per eligible donor not only is caused by the increased consent rate
but also is reflective of the aggressive care of potential donors
undertaken to minimize medical failures. Having a definitive study,
such as a nuclear flow scan, to confirm the diagnosis of brain death
may help families with the understanding and acceptance of brain
death.
[31]

TABLE 2 -- EFFECT OF RAPID BRAIN DEATH DETERMINATION PROTOCOL

Potential donors
Medical failure rate
Other unsuitability
Organ/potential donor
Eligible donors
Family refusal
Consent

Post-RBD Protocol
141
13%
7%
1.5 0.2
113
63 (56%)
50 (44%)

Pre-RBD Protocol
16
0%
0%
3.3 0.6
14
4 (29%)
*

10 (71%)
3.4 0.6

Organ/eligible donor
1.8 0.2
RBD = rapid brain death
Modified from Jenkins DH, Reilly PM, Schwab CW: Improving the approach to organ
donation: A review. World J Surg 23:647, 1999; with permission.
*

* P < 0.05 versus pre-RBD protocol.

P < 0.01 versus pre-RBD protocol.

CARE OF THE POTENTIAL ORGAN DONOR

Major Medical Complications
Severe physiologic derangements are common in brain-dead potential
donors and can present significant medical challenges in their
management. Potential donors manifest profound hemodynamic and
metabolic abnormalities, which can result in a loss of valuable organs.
[14] [23] [25] [55]

Autonomic instability and hypotension occur in 80% to 85% of donors.

Hypovolemia from osmotic agents given to treat high intracranial
pressure (ICP), poorly treated diabetes insipidus, and traumatic blood
[25] [55]

loss all may contribute to hypotension. A sudden increase in ICP may

cause hypotension and severe bradyarrhythmia because of
parasympathetic stimulation from dural stretch, which commonly is
followed by Cushing's reflex. In an attempt to compensate for
intracranial hypertension, severe systemic hypertension occurs. This
marked increase in vascular resistance may be associated with signs
of myocardial ischemia.
Animal models have demonstrated profound systemic and pulmonary
vasoconstriction with a massive systemic increase in catecholamine
levels, termed autonomic storm. Experimentally, the extent of release
of catecholamines and their effects depend on the rate of increase
ICP, the technique of production of brain death, and the animal
species examined.
This "autonomic storm" is followed by a
transient shift of systemic intravascular volume to the lungs. Cardiac
output (CO) decreases and left atrial pressure may exceed pulmonary
artery pressure. This may result in capillary-wall disruption and the
leakage of protein-rich fluid into the pulmonary interstitium, resulting
in pulmonary edema.
[9] [26] [54] [57] [58]

[53]

A profound reduction in sympathetic outflow follows,

occurring during a variable time when cerebral cortical
and brain stem function is lost.
Inotropic and
chronotropic control of the heart is impaired and CO
decreases further. The loss of hypothalamic influence
and sympathetic tone is characterized by a progressive
decrease in serum norepinephrine and a decrease in
systemic vascular resistance. This is analogous to a
high cervical spinal cord transection.
[1] [21] [52]

Ali MJ, Gelb AW: Catecholamine levels in a brain death model. Chest
98(suppl):63, 1990 abstract
1.

Ali MJ, Wood G, Gelb AW: Organ donor problems and their management: A four
year review of a Canadian transplant center [abstract]. Can J Anaesth 39:125, 1992
2.

Ali MJ: Essentials of organ donor problems and their management. Anesth Clin
North Am 12:655, 1994 [67] As a result, most potential organ donors
3.

require vasoactive agents to maintain blood pressure.

Neuroendocrine failure as a cause of hypotension in donors has
received much attention. Most investigators accept a link between
brain death and hypothalamic-pituitary axis dysfunction.
This dysfunction leads to neurogenic diabetes insipidus and a marked
decrease in levels of thyroid hormone and cortisol in animal models.
In the absence of normal thyroid levels, the mitochondria are
inhibited, resulting in high-energy phosphate depletion, anaerobic
metabolism, hemodynamic instability, and deterioration of organ
function.
Wide variations in body temperature may also result
from the central dysregulation. This depletion of high-energy stores
and the subsequent physiologic derangements have been reversed
[16] [37] [38] [42]

[48] [49] [50] [51]

[18]

successfully with a combination of thyroxine (T3), cortisol, and insulin

administration, suggesting that the hormonal changes cause these
effects.
Some investigators have, however, demonstrated only minimal
neuroendocrine changes in humans.
Brain death does not
necessarily lead to endocrine failure; sufficient functional hormone
levels can be preserved in many donors for extended periods.
These findings suggest some residual function and perfusion of the
hypothalamic-pituitary axis. This is, however, not unexpected because
the anterior pituitary receives a dual blood supply. The inferior
hypophysial artery arises extradurally from the internal carotid artery
and is therefore relatively protected from the effects of high ICP.
These differences between experimental and clinical findings are not
surprising given the controlled environment of the former and the
variety of mechanisms of brain death encountered in a clinical
setting. The role that endocrine abnormalities play in the status of
donors may vary among donors dependent on the clinical scenario.
Consequently, the efficacy of hormone replacement also is expected
to vary. A rigorous prospective, controlled trial is required to better
understand the role of hormonal replacement in the management of
organ donors.
Aspiration pneumonitis, pulmonary contusions, neurogenic pulmonary
edema, and pneumonia are common complicating factors in patients
with significant head injury. As a result, it has been estimated that
only 1 in 20 organ donors have lungs suitable for donation due to
rapid deterioration of pulmonary function following brain death.
The avoidance of aggressive overhydration should minimize the
potential for iatrogenic damage to the lungs of potential organ
donors. Still, the shortage of available lungs for transplantation has
significantly limited progress in this field.
Abnormalities in coagulation are common in most series.
Release
of thromboplastic, fibrinolytic, and plasminogen-rich substrate from
necrotic brain is thought to cause a consumptive coagulopathy with
resultant elevations of prothrombin times and thrombocytopenia. As
a result, most potential donors require resuscitation with fresh frozen
plasma during their brain-death stay.
[48]

[19] [29]

[19]

[3]

[59]

[1] [2]

[46]

Aggressive Medical Approach

Severely brain-injured patients with a clinical examination consistent
with brain death are treated as aggressively as patients expected to
survive. As previously stated, the local OPO is notified as soon as a
lethal injury is suspected. Following completion of a clinical
examination demonstrating brain death by a neurosurgeon, an
urgent brain flow scan is obtained for confirmation. If a lack of
cerebral blood flow is documented by the radiology faculty, the
patient is immediately declared brain dead. Consent for donation is
then requested in a structured format with the aid of the OPO
representative. Several reviews suggest that the medical failures
occurring during the time leading up to actual organ procurement in
brain-dead patients may be preventable with early invasive

hemodynamic monitoring, aggressive rewarming, and liberal

transfusion therapy, all readily available in a modern critical care
setting.
An inadequate response to the dramatic hemodynamic
events described that often accompany brain death may result in
the potentially preventable loss of potential donors. Because the
heart is effectively denervated after brain death, it is atropine
resistant. Arrhythmias, such as asystole or ventricular fibrillation, are
extremely difficult to treat. The often competing management issues
regarding the optimization of different organ systems (i.e., lung
versus kidney) for successful procurement require exquisite control of
a complex resuscitation in an effort to maximize the number of organs
successfully donated per donor. This aggressive management is
extremely labor and resource intensive.
This environment
underscores the importance of moving rapidly toward a secure
diagnosis of brain death using a confirmatory test early, as in the
rapid brain death protocol outlined earlier.
[17] [22] [45]

[22] [30]

POTENTIAL DONOR EVALUATION

Absolute contraindications to donor acceptance include extracerebral
malignancy (except for local skin neoplasms and carcinoma in situ of
the cervix); uncontrolled sepsis and active viral infections, such as
hepatitis A or B; cytomegalovirus; herpes simplex virus; and AIDS.
The presence of HIV antibody is also a contraindication to organ
donation. When possible, organs from a hepatitis C-positive donor
may be used in a hepatitis C-positive recipient.
Given the severe shortage of donor organs, the criteria for donor
acceptance have been expanded. In 1998, the number of cadaveric
donors increased 5.6% from 1997 data according to United Network
for Organ Sharing (UNOS). Although donors increased in all age
ranges, the largest increase was in older donors. Donors aged 60 or
more increased by 10.7%; donors aged 40 to 59 years increased by
9.6%; those 20 to 39 years increased by only 2.4%, and 0 to 19 by
only 1.6%.
Non-heart-beating donors accounted for 1% of all cadaveric donors
from 1994 to 1996 as this form of organ donor is becoming more
recognized. In this scenario, the family consents to organ donation
to occur following the removal of life support. The consent is given
before the removal of life support when irrefutable evidence shows
devastating injury with no chance for a meaningful recovery. Life
support may be withdrawn in the intensive care setting, and the
donor is then transported to the operating room for donation, or the
entire process may be performed in the operating room to reduce
warm ischemia time. Experience with this technique has been more
extensive in Europe and especially Japan,
where access to
heart-beating, brain-dead donors has been limited. The results of
transplant organ (kidney and liver) function from non-heart-beating
donors have been encouraging.
[67]

[8]

[74]

[27] [33] [41] [64]

[7] [10] [11] [56]

Noncadaveric sources for organ donation are also being increasingly

used. The number of living donors has increased 95%, from 1825 in
1988 to 3553 in 1996 as transplant surgeons stretch their ability and
imaginations to procure organs in a responsible fashion to cope with
the severe shortage in availability.

SUMMARY
The shortage of organ donors has become a serious problem in
modern medicine. Room for improvement exists in our ability to
convert potential donors to actual donors based on the available
numbers and a significant amount of recent research. A significant
percentage of the potential donors represent head-injured patients, so
a significant amount of responsibility falls on surgeons to optimize the
opportunity for donation.
There are clear steps along the pathway from potential to actual
donor where physicians can have a significant effect on the rate of
successful donation:
1. Identify all potential donors and institute a review system to verify that all
potential donors are being identified in your area.
2. Establish an acceptable method to rapidly and accurately determine brain death
in potential donors using the local available services.
3. Approach all potential donor families for consent, decouple death notification
and consent request, use a member of the hospital team and an OPO
representative to approach the family, and make the request in a private setting.
4. Use an aggressive, proactive approach to the medical management of the
potential donor using the techniques described to limit the number of medical
failures and maximize the number of organs donated per donor. Institute a
review process to evaluate any medical failures that occur.
Given the difference between the numbers of potential versus actual
donors, the authors' significant contact with potential donors, and the
clear opportunities for improvement in their approach, the surgical
community must address these issues surrounding the optimal
management of potential donors and their families.
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El volumen 80 o Number 3 o el 2000 de junio

Registre la propiedad literaria de 2000 W. la B. Saunders Compaa
Los nicos Desafos
LOS PROBLEMAS EN LA DIRECCIN DE DONADOR DE RGANO
POTENCIAL
TAREK RAZEK 1 MD
Kim Olthoff 2 MD
El Patrick M. Reilly 1 MD
1 divisiones de Trauma y el Cuidado Crtico Quirrgico (TR, PMR)
2 Ciruga del trasplante (KO),
La seccin de Ciruga, el Hospital de la Universidad de Pennsylvania, Filadelfia,
Pennsylvania,
Las demandas de reimpresin de direccin a
El Patrick M. Reilly, MD,
La divisin de Trauma y el Cuidado Crtico Quirrgico
El hospital de la Universidad de Pennsylvania
3440 Calle del mercado, Primero el Suelo,
Filadelfia, PAP 19104,
A partir del 1999 de septiembre, 65,793 pacientes estaban en el trasplante americano
lista de espera que contina creciendo a una media proporcin de 16% por ao. [70]
[71] en el contraste, la disponibilidad de donadores del rgano cadavricos ha
permanecido relativamente estancado. En 1998, el nmero de donadores cadavricos
aument la primera vez para desde 1995, pero el aumento modesto de 5.6% no guard
el paso con el aumento de pacientes que esperan los rganos para el trasplante. [70] [71]
Un estim 12,500 a 27,000 donadores del rgano potenciales se mueren cada ao en los
Estados Unidos. [6] [15] [68] a pesar de lo que parece ser una piscina del donador
adecuada, slo 15% a 20% de donadores potenciales se vueltos los donadores reales. [4]
[69] como resultado, en 1998, 4855 pacientes se murieron mientras en la lista de espera
para el trasplante. [70] una revisin de donadores potenciales en una rea de la
captacin que sirve una poblacin de 22 milln por el Gortmaker et al [19] mostr que
las causas mayores de muerte entre los donadores potenciales eran el trauma de cabeza
(49%) y eventos del cerebrovascular (33%). [19]
Un acercamiento ms estructurado a y elev el conocimiento de donadores del rgano
potenciales puede mejorar el nmero de donadores. Con una proporcin significante de
donadores potenciales que vienen del trauma que pone y trat en ICUs, el trauma y los
equipos del cuidado crticos deben darse cuenta de la importancia de procuracin del
rgano y experimentado perfeccionando la donacin de los donadores potenciales.
Varios pasos distintos existen en el camino de un donador potencial a un donador real.
Estos pasos se han definido claramente, y las estrategias para aumentar al mximo las
proporciones de la donacin reales examinadas en la literatura durante la ltima dcada

han mostrado los resultados impresionantes. Desgraciadamente, estos pasos, y los

mtodos por llevarlos a cabo, no se practica ampliamente. Como resultado, los restos de
donacin de rgano cadavricos inadecuado a pesar de una poblacin de donador de
rgano potencial grande. Identificando a todos los donadores potenciales, determinando
la muerte del cerebro en un rpido y el mtodo fiable, acercndose a todas las familias
del donador potenciales para el consentimiento, y manejar problemas mdicos de todos
los donadores potenciales agresivamente todos son los elementos importantes necesario
comprender las proporciones de la donacin reales mejoradas. [22] [31] este artculo
examina los acercamientos prcticos a estos pasos en un esfuerzo aumentar el
conocimiento y mejorar las proporciones de procuracin de rgano.
LA MUERTE DEL CEREBRO
La historia
La introduccin de trasplante del rin exitoso en los aos cincuenta llevado al
concepto de uso del rgano de "corazn-pegando los cadveres". En 1968, el Comit ad
hoc del Harvard la Escuela Mdica para Examinar la Definicin de Muerte del Cerebro
fue creada regularizar la definicin de muerte del cerebro y resolverse algunas de las
controversias crecientes la procuracin del rgano circundante para el trasplante de
corazn-pegar a los donadores. Las resoluciones de este comit estn conocido como el
Criterio de Harvard de Muerte del Cerebro [5] (vea la caja debajo).

El Criterio de Harvard para la Muerte del Cerebro * 1. Ningn movimiento o

respirando. Las observaciones de por lo menos 1 hora por mdicos para satisfacer el
criterio de ningn movimiento muscular espontneo o respiracin espontnea o
contestacin a los estmulos. La ausencia de respiracin espontnea puede establecerse
apagando el respirador durante 3 minutos, tambin proporcion que el paciente haba
sido el aire del cuarto respiratorio durante por lo menos 10 minutos antes del ensayo. 2.
ningn reflejo. La ausencia de reflejos del elicitable. Los alumnos son fijos y dilatados y
no responden para encender. El movimiento ocular (para encabezar volvindose e
irrigacin de las orejas con el agua de hielo) y pestaear estn ausentes. Ninguna
evidencia de actividad del postural est presente. La crnea y los reflejos farngeos estn
ausentes. Como una regla, los reflejos de tendn de estiramiento no pueden sacarse. 3.
el electroencefalograma llano (EEG). De gran valor del confirmatory el piso o
isoelectric son EEG.
Aunque esto represent un paso significante adelante en el momento, stos el criterio de
Harvard es considerado ahora ms severo que necesario.
El criterio del cerebro-muerte en los Estados Unidos es basado en el Informe de los
Consultores Mdicos en el Diagnstico de Muerte a la Comisin del Presidente en el
Estudio de Problemas ticos en la Medicina y la Investigacin Biomdica y Conductual
de 1981 [60] (vea la caja debajo).
Las pautas para la Determinacin de Muerte del Cerebro * 1. la Cesacin se reconoce
cuando la evaluacin descubre: un. las funciones Cerebrales estn ausentes; "el
unresponsivity cerebral y unreceptivity" estn presentes, y b. las funciones de tallo de
Cerebro estn ausentes; stos incluyen luz del pupillary, crnea, oculocephalic,
oculovestibular, oropharyngeal, y los reflejos respiratorios; el apnea se prueba con una

cnula nasal que entrega oxgeno y demostrando fracaso de esfuerzo respiratorio con el
Pap CO2 de ms de 60 mm Hg; los reflejos del cordn espinales pueden persistir
despus de la muerte; verdaderos decerebrate o posturing del decorticate o cogida son
incoherentes con el diagnstico de muerte. 2. Irreversibility se reconoce cuando la
evaluacin descubre: un. La causa de coma se establece y es suficiente a la cuenta para
la prdida de funcin del cerebro, y b. La posibilidad de recuperacin de cualquier
funcin del cerebro se gobierna fuera, y c. La cesacin de todas las funciones del
cerebro persiste para un periodo apropiado de observacin o terapia del ensayo; la
confirmacin de resultados clnicos por EEG es deseable cuando la documentacin
objetiva se necesita probar los resultados clnicos; la cesacin completa de la circulacin
al normothermic el cerebro adulto para ms de 10 minutos es incompatible con la
supervivencia de tejido del cerebro; el flujo de sangre cerebral ausente, junto con la
determinacin clnica de cesacin de todo el cerebro funciona durante por lo menos 6
horas, es diagnstico de muerte d. Complicating las condiciones e. la Droga y la
intoxicacin metablica f. la Hipotermia (<32.2C) g. la edad Joven (es decir, nios) h.
el Susto
La Comisin del Presidente requiere:
1. la prdida de funcin de tallo de cerebro
2. la prdida de funcin cortical
3. que la condicin es irreversible
Usando estas pautas, un donador del rgano potencial se identifica despus de
establecer un diagnstico que es probable producir el neurologic severo, irreversible
dae (por ejemplo, trauma de cabeza severo o los intracerebral macizos hemorragian).
Varios factores confundiendo deben gobernarse fuera, mientras incluyendo: la
hipotermia (<32C), asuste, intoxicacin de droga, descomposicin metablica severa, y
los efectos de asedio del neuromuscular. [13] [47] la ausencia de funcin de tallo de
cerebro se documenta probando para la contestacin del pupillary (el nervio craneal
[CN] yo, III), el reflejo corneal (CN V, VII), oculocephalic y reflejos del oculovestibular
(CN VIII). la Prdida de funcin medular se demuestra con una prueba del apnea.
Aunque manteniendo la oxigenacin adecuada con la oxigenacin del endotracheal, los
pacientes estn alejados del ventilador hasta el Pap que CO2 alcanza 60 mm Hg. Una
ausencia de respiraciones espontneas con este estmulo es consistente con la prdida de
funcin de tallo de cerebro. [62] la prdida de funcin cortical implica prdida de
sensibilidad y receptivity. La documentacin de una falta de funcin cortical con un
isoelectric EEG es optativo.
Un cambio significante del criterio de Harvard es el reconocimiento que espinal y los
reflejos del tendn son en conserva en la muerte del cerebro, y el intervalo entre repita
los exmenes pueden ser tan cortos como 6 horas. Aunque el diagnstico es
principalmente clnico, se recomiendan las pruebas del confirmatory, sobre todo si el
periodo entre los exmenes est menos de 12 horas y en los nios menos de 5 aos de
edad.
Los Estudios auxiliares
El diagnstico de muerte del cerebro es clnico. Ninguna pauta exige a cualquier prueba
auxiliar confirmar la impresin clnica; sin embargo, la documentacin objetiva de los
resultados clnicos puede ser un adjunto til al diagnstico, sobre todo en los casos
difciles (el ej., infantes o pacientes con el trauma facial severo). Con suerte, un estudio
del confirmatory proporciona confirmacin objetiva de los resultados del examen
clnicos con precisin y rpidamente para que una declaracin segura de muerte del
cerebro pueda hacerse ms rpidamente.

El EEG slo era incluido en el criterio de Harvard severo para su "los granes
confirmatory valoran" pero no se vio como un criterio necesario para el diagnstico de
muerte del cerebro. Su valor en la prognosis de lesin del cerebro severa se reconoci
ya en 1969 [65]; sin embargo, los tcnicos buenos y las lecturas exactas son difciles de
acceder horas en absoluto en la mayora de las instituciones.
La demostracin de una falta del flujo de sangre al cerebro puede ser un adjunto
importante al diagnstico de muerte del cerebro. Un angiogram del cuatro-vaso es
considerado la norma del oro pero es caro, involucra una carga del tinte, y requiere el
transporte a la coleccin del angiografa. [44] una alternativa es el flujo de cerebro de
medicina nuclear examine--una prueba exacta, barata que puede realizarse al lado de la
cama. [12] [35] [73] [75] Transcranial que la Doppler sangre-flujo medida tambin
puede realizarse al lado de la cama, es barato, y se ha informado para ser exacto. [61]
La Determinacin de Muerte de Cerebro rpida
Regularizar la definicin de muerte del cerebro, la variacin considerable existe entre
las instituciones, estados o provincias, y pases en el modelo de determinacin del
cerebro-muerte a pesar de los esfuerzos. [24] [30] [68] [72] la poltica en el Hospital de
la Universidad de Pennsylvania (HUP) para la determinacin del cerebro-muerte se
resume en Mesa 1 y sigue estatutos de la Comunidad de naciones legislados por la
Comunidad de naciones de Pennsylvania. [28]

MESA 1--LOS MTODOS DE DETERMINACIN DE MUERTE DE CEREBRO EN

EL HOSPITAL DE LA UNIVERSIDAD DE PENNSYLVANIA
El mtodo el ClinicalExamination ApneaTest Intervalo la Prueba de Confirmatory
Un S S 12 h Second el examen clnico
B S S 6 h Second el electroencefalograma del examinationand clnico
C S S el estudio de flujo de sangre Cerebral Mnima
Modificado de Jenkins DH, Reilly PM, Schwab CW,: Mejorando el acercamiento a la
donacin del rgano: Una revisin. J mundial Surg 23:644, 1999,; con el permiso.
Complicaciones relacionadas al cuidado a favor prolongado, a menudo como
consecuencia de los retrasos en el diagnstico de muerte del cerebro, reducen la
disponibilidad y conveniencia de rganos potencialmente trasplantables. Un estim 17%
a 25% de donadores potenciales estn perdidos debido al fracaso mdico mientras
esperando la declaracin formal de muerte del cerebro. [36] en un esfuerzo mejorar la
procuracin del rgano est a la institucin de los autores, la Divisin de Trauma y el
Cuidado Crtico Quirrgico a HUP evalu una Determinacin de Muerte de Cerebro
Rpida (RBD) el Protocolo. [30] siguiendo un examen clnico consistente con la muerte
del cerebro (es decir, ningn cortical o funcin de tallo de cerebro, irreversibility, y
ninguna condicin complicando) un flujo de cerebro de medicina nuclear examina se
obtiene para confirmar la muerte del cerebro. El uso de cerebro que examina como una
prueba del confirmatory para la muerte del cerebro se ha descrito bien. [12] [35] [73]
[75] el protocolo de RBD el tiempo significativamente reducido a la declaracin de
muerte del cerebro (de 12.4 a 3.4 horas) y los cargos asociados ($16,645-$6125) para
los donadores potenciales a HUP. [30] dado el deterioracin del physiologic obicuo de
donadores del cerebro-muerto, una determinacin ms rpida, exacta de muerte del
cerebro podra tener un impacto significante en el nmero de donadores reales y el
nmero de rganos por el donador a travs de una disminucin en la incidencia de

fracaso mdico. Los autores han comprendido que cosas as aumenta a HUP y ahora
promedia ms de 4.5 rganos slidos por el donador. [30] [31]

LA IDENTIFICACIN Y CONSENTIMIENTO
La desigualdad entre los donadores del rgano potenciales y los donadores del rgano
reales no han escapado el ojo de fabricantes de la poltica gubernamentales. El 1986
Acto de Conciliacin de mnibus, seccin 1138, requiere que todos los hospitales que
participan en Seguro mdico del Estado y programas de Medicaid se refieren a todos los
donadores del rgano potenciales a su organizacin de la rgano-procuracin local
(OPO) y que las familias de todos los donadores del rgano potenciales se dadas cuenta
de su opcin donar. El acto se complementa por la legislacin de la demanda requerida
que los mandatos que los hospitales les piden a todas las familias de pacientes difuntos
que consideren la donacin del rgano. Ms de 40 los estados han promulgado la
legislacin similar. [22] [63] a pesar de stos los esfuerzos de la pblico-poltica, el
efecto en la disponibilidad del rgano ha estado limitado.
Aun cuando todos los donadores potenciales se identifican y se acercaron sobre la
donacin, la escasez de rganos ser difcil dirigirse con tal de que las proporciones de
consentimiento permanezcan en el 40% rango. [19] [66] las investigaciones han
mostrado que, organizando el proceso de consentimiento tal esa notificacin de muerte
y la demanda de consentimiento es el decoupled, personal del hospital y el coordinador
de OPO participan en el proceso de consentimiento, y la demanda tiene lugar en una
escena privada, la proporcin de consentimiento puede ser tan alta como 74%. [19] [66]
Aplicando este acercamiento simple, organizado a todas las situaciones del donador
potenciales pueden mejorar las proporciones del donador significativamente.
En Espaa, un acercamiento favorablemente estructurado a la donacin del rgano se ha
establecido con la designacin y el entrenamiento formal de coordinadores de la
donacin en cada hospital con los donadores potenciales. [39] [40] Espaa tiene una de
las proporciones de la donacin ms altas (20.2 por milln) en el mundo. Un
embrollador potencial es esa Espaa ha presumido leyes de consentimiento que
mantienen donacin rutinaria de rganos en el momento de muerte a menos que los
registros individuales una oposicin del premortem a la donacin del rgano. Aunque
algunos de los 13 pases europeos que usan el consentimiento presunto tienen que la
donacin ms alta tasa que haga los pases sin el consentimiento presunto, otros no
hacen, y ningn pas tiene los rganos suficientes para encontrarse las demandas de esos
esperar por el trasplante. [34] [43]
A HUP, cuidado agresivo que usa el acercamiento del equipo y la determinacin de
muerte del cerebro que usa un solo examen clnico realizado por neurocirujanos del
consultor y los estudios de flujo de medicina nucleares ha aumentado la proporcin de
consentimiento significativamente a la donacin del rgano y el nmero de rganos
procurados de los donadores elegibles (Mesa 2). [31] [32] aunque las razones para estos
aumentos son los multifactorial probables, el protocolo descrito parece proporcionar la
resurreccin apropiada y mantener a los donadores del rgano potenciales hasta una
decisin en el consentimiento puede alcanzarse. La objetividad de medicina nuclear
examina se unido al "decoupled" que el equipo de la procuracin parece influir en la
decisin de familias positivamente para donar. El aumento en rganos no slo donados
por el donador elegible es causado por la proporcin de consentimiento aumentada pero
tambin es reflexivo del cuidado agresivo de donadores potenciales emprendido para

minimizar los fracasos mdicos. Teniendo un estudio definitivo, como un flujo nuclear
examine, confirmar el diagnstico de muerte del cerebro pueden ayudar a las familias
con la comprensin y aceptacin de muerte del cerebro. [31]
MESA 2--EL EFECTO DE CEREBRO MUERTE DETERMINACIN PROTOCOLO
RPIDO
Poste-RBD el Protocolo de Pre-RBD Protocolar
Los donadores 141 16 potenciales
La proporcin de fracaso mdica 13% 0%
Otra inadecuacin 7% 0%
El donador de Organ/potential 1.5 0.2 3.3 0.6 *
Los donadores 113 14 elegibles
La negativa 63 familiar (56%) 4 (29%)
Consienta 50 (44%) 10 (71%)
El donador de Organ/eligible 1.8 0.2 3.4 0.6 *
RBD = la muerte del cerebro rpida
Modificado de Jenkins DH, Reilly PM, Schwab CW,: Mejorando el acercamiento a la
donacin del rgano: Una revisin. J mundial Surg 23:647, 1999,; con el permiso.
* P <0.05 contra el protocolo del pre-RBD.
P <0.01 contra el protocolo del pre-RBD.

EL CUIDADO DEL DONADOR DEL RGANO POTENCIAL

Las Complicaciones Mdicas mayores
Las descomposiciones del physiologic severas son comnes en los donadores
potenciales cerebro-muertos y pueden presentar los desafos mdicos significantes en su
direccin. Los donadores potenciales manifiestan anormalidades hemodinmicas y
metablicas profundas que pueden producir una prdida de valiosos rganos. [14] [23]
[25] [55]
La inestabilidad de Autonomic e hipotensin ocurren en 80% a 85% de donadores. [25]
[55] Hypovolemia de agentes osmticos dados para tratar el intracranial alto presionan
(ICP), el insipidus de la diabetes pobremente tratado, y la prdida de sangre traumtica
que todos pueden contribuir al hipotensin. Un aumento sbito en ICP puede causar
hipotensin y el bradyarrhythmia severo debido al estmulo del parasympathetic del
dural estire que normalmente se sigue por el reflejo de Cushing. En un esfuerzo por
compensar para la hipertensin del intracranial, la hipertensin sistmica severa ocurre.
Esto marcado el aumento en la resistencia vascular puede asociarse con las seales de
ischemia del myocardial.
Los modelos animales han demostrado el vasoconstriction sistmico y pulmonar
profundo con un aumento sistmico macizo en el catecholamine nivela, tormenta de
autonomic de termed. Experimentalmente, la magnitud de descargo de catecholamines y
sus efectos depende de la proporcin de aumento ICP, la tcnica de produccin de
muerte del cerebro, y las especies animales examinaron. [9] [26] [54] [57] [58] esto "los
autonomic atacan" se sigue por un cambio transente de volumen del intravascular
sistmico a los pulmones. El rendimiento cardaco (CO) las disminuciones y la presin

del atrial izquierda pueden exceder la presin de la arteria pulmonar. Esto puede
producir la ruptura del capilar-pared y el goteo de fluido protena-rico en el interstitium
pulmonar, mientras produciendo el edema pulmonar. [53]
Una reduccin profunda en la salida simptica sigue, mientras ocurriendo durante un
tiempo inconstante cuando cerebral cortical y la funcin de tallo de cerebro est perdida.
[1] [21] [52] Inotropic y chronotropic controlan del corazn se daa y disminuciones de
CO ms all. La prdida de influencia del hypothalamic y el tono simptico se
caracteriza por una disminucin progresiva en el norepinephrine de suero y una
disminucin en la resistencia vascular sistmica. Esto es anlogo a un transection del
cordn espinales cervicales altos.
>, GELB AW,: Catecholamine nivela en un modelo de muerte de cerebro. Pecho
98(suppl):63, 1990 lo abstracto,
2. Ali MJ, Madera G, Gelb AW,: Los problemas de donador de rgano y su direccin:
Una cuatro revisin del ao de un centro del trasplante canadiense [abstracto]. la Lata J
Anaesth 39:125, 1992,
3. ALI MJ: Essentials de problemas de donador de rgano y su direccin. El Anesth
Clin Norte Es 12:655, 1994 [67] como resultado, los donadores del rgano ms
potenciales les exigen a agentes del vasoactive que mantengan la presin de sangre.
El fracaso de Neuroendocrine como una causa de hipotensin en los donadores ha
recibido mucha atencin. La mayora de los investigadores acepta un eslabn entre la
muerte del cerebro y el trastorno del eje hypothalamic-pituitario. [16] [37] [38] [42] este
trastorno lleva al insipidus de diabetes de neurogenic y una marcada disminucin en los
niveles de hormona tiroidea y cortisol en modelos del animal. En la ausencia de niveles
de la tiroides normales, los mitochondria se inhiben, mientras produciendo el
vaciamiento de fosfato de alto-energa, metabolismo anaerobio, inestabilidad
hemodinmica, y deterioracin de funcin del rgano. [48] [49] [50] [51] las
variaciones anchas en la temperatura del cuerpo tambin pueden ser el resultado del
dysregulation central. [18] se ha invertido este vaciamiento de tiendas de alto-energa y
las descomposiciones del physiologic subsecuentes con xito con una combinacin de
thyroxine (T3), cortisol, y administracin de insulina, sugiriendo que la causa de
cambios hormonal estos efectos. [48]
Algunos investigadores, sin embargo, han demostrado que slo neuroendocrine mnimo
cambia en los humanos. [19] [29] la muerte del cerebro necesariamente no lleva al
fracaso endocrino; la hormona funcional suficiente nivela puede conservarse en muchos
donadores para los periodo extendidos. [19] estos resultados hacen pensar en alguna
funcin residual y perfusion del eje hypothalamic-pituitario. Esto es, sin embargo, no
inesperado porque el pituitario anterior recibe el suministro de una sangre dual. La
arteria del hypophysial inferior se levanta el extradurally de la arteria cartida interior y
se protege por consiguiente relativamente de los efectos de ICP alto. Estas diferencias
entre los resultados experimentales y clnicos no son sorprendentes dado el ambiente
controlado del anterior y la variedad de mecanismos de muerte del cerebro encontr en
una escena clnica. El papel que las anormalidades endocrinas juegan en el estado de
donadores puede variar entre los donadores dependiente en el guin clnico. Por
consiguiente, tambin se espera la eficacia de reemplazo de la hormona variar. Un
ensayo probable, controlado riguroso se exige entender bien el papel de reemplazo
hormonal en la direccin de donadores del rgano.

La neumonitis de aspiracin, las contusiones pulmonares, el neurogenic el edema

pulmonar, y la pulmona es los factores complicando comnes en los pacientes con la
lesin de cabeza significante. Como resultado, se ha estimado que slo 1 en 20 los
donadores del rgano tienen los pulmones conveniente para la donacin debido al
deterioracin rpido de funcin pulmonar la muerte del cerebro siguiente. [3] la
anulacin de overhydration agresivo debe minimizar el potencial para el iatrogenic dae
a los pulmones de donadores del rgano potenciales. [59] todava, la escasez de
pulmones disponibles para el trasplante ha limitado el progreso significativamente en
este campo.
Las anormalidades en la coagulacin son comnes en ms serie. [1] [2] se piensa que el
descargo de thromboplastic, fibrinolytic, y el substrate plasminogen-rico del cerebro del
necrotic causa un coagulopathy tsico con las elevaciones del resultante de tiempos del
prothrombin y thrombocytopenia. [46] como resultado, ms ms de los donadores
potenciales requiera la resurreccin con el plasma helado fresco durante su estancia del
cerebro-muerte.
El Acercamiento Mdico agresivo
Severamente los pacientes del cerebro-herido con un examen clnico consistente con la
muerte del cerebro se trata tan agresivamente como los pacientes esperaron sobrevivir.
Como previamente declar, el OPO local se notifica en cuanto una lesin letal sea
sospechosa. La realizacin siguiente de un examen clnico que demuestra la muerte del
cerebro por un neurocirujano, un flujo del cerebro urgente examina se obtiene para la
confirmacin. Si una falta del flujo de sangre cerebral es documentada por la facultad de
la radiologa, el paciente se declara el muerto del cerebro inmediatamente. El
consentimiento para la donacin se pide entonces en un formato estructurado con la
ayuda del representante de OPO. Varias revisiones sugieren que los fracasos mdicos
que ocurren durante el tiempo que lleva a a la procuracin del rgano real en los
pacientes del cerebro-muerto puedan ser evitables con el invasive temprano el
supervisando hemodinmico, rewarming agresivo, y la terapia de la transfusin liberal,
todos prontamente disponible en una escena del cuidado crtica moderna. [17] [22] [45]
una contestacin inadecuada a los eventos hemodinmicos dramticos descritos a
menudo eso acompaa la muerte del cerebro puede producir la prdida potencialmente
evitable de donadores potenciales. Porque el corazn es eficazmente el denervated
despus de la muerte del cerebro, es la atropina resistente. Las arritmias, como asystole
o el fibrilacin ventricular, son sumamente difciles tratar. Los problemas de direccin a
menudo compitiendo con respecto a la optimizacin de sistemas del rgano diferentes
(es decir, pulmn contra el rin) para la procuracin exitosa requiera mando exquisito
de una resurreccin compleja en un esfuerzo aumentar al mximo el nmero de rganos
donado por el donador con xito. Esta direccin agresiva es sumamente la labor y
recurso intensivo. [22] [30] este ambiente subraya la importancia de acercarse
rpidamente a un diagnstico seguro de muerte del cerebro que usa una prueba del
confirmatory temprano, como en el protocolo de muerte de cerebro rpido perfilado
antes.
LA EVALUACIN DEL DONADOR POTENCIAL
Las contraindicaciones absolutas a la aceptacin del donador incluyen la malignidad del
extracerebral (salvo los neoplasma superficiales locales y carcinoma en el situ de la
cerviz); los sepsis desenfrenados y las infecciones virales activas, como las hepatitis UN
o B; el cytomegalovirus; el virus de simplex de herpes; y AYUDAS. La presencia de
anticuerpo de HIV tambin es una contraindicacin a la donacin del rgano. [67]

cuando posible, rganos de un hepatitis el donador C-positivo puede usarse en un

hepatitis el destinatario C-positivo.
Dado la escasez severa de rganos del donador, el criterio para la aceptacin del
donador se ha extendido. El nmero de donadores cadavricos aument 5.6% de 1997
datos segn la Red Unida para rgano que Comparte en 1998, (UNOS). Aunque los
donadores aumentaron en todos los rangos de edad, el aumento ms grande estaba en
los donadores ms viejos. Los donadores envejecieron 60 o ms aumentado por 10.7%;
los donadores envejecieron 40 a 59 aos aumentados por 9.6%; esos 20 a 39 aos
aumentados por slo 2.4%, y 0 a 19 por slo 1.6%.
Non-corazn-pegando a donadores considerados para 1% de donadores todo
cadavricos de 1994 a 1996 como esta forma de donador del rgano est volvindose
ms reconocido. [8] en este guin, los consentimientos familiares a la donacin del
rgano para ocurrir, siguiendo el levantamiento de apoyo de vida. El consentimiento se
da antes del levantamiento de apoyo de vida cuando la evidencia irrefutable muestra
devastando la lesin sin la oportunidad para una recuperacin significante. Puede
retirarse el apoyo de vida en la escena del cuidado intensiva, y el donador se transporta
entonces a la sala de operaciones para la donacin, o el proceso entero puede realizarse
en la sala de operaciones para reducir el tiempo del ischemia caluroso. Experimente con
esta tcnica ha sido ms extenso en Europa [74] y sobre todo Japn, [27] [33] [41] [64]
donde accede a corazn-pegar, los donadores del cerebro-muerto han estado limitados.
Los resultados de rgano del trasplante (el rin y hgado) la funcin de non-coraznpegar a los donadores ha estado animando. [7] [10] [11] [56]
Tambin estn usndose cada vez ms fuentes de Noncadaveric para la donacin del
rgano. El nmero de donadores vivientes ha aumentado 95%, de 1825 en 1988 a 3553
en 1996 como cirujanos del trasplante su habilidad e imaginaciones estiran para
procurar los rganos en una moda responsable cubrir con la escasez severa en la
disponibilidad.
EL RESUMEN
La escasez de donadores del rgano se ha vuelto un problema serio en la medicina
moderna. El cuarto para la mejora existe en nuestra habilidad de convertir a los
donadores potenciales a los donadores reales basada en los nmeros disponibles y una
cantidad significante de reciente investigacin. Un porcentaje significante de los
donadores potenciales representa a los pacientes del cabeza-herido, para que una
cantidad significante de cadas de responsabilidad en cirujanos perfeccione la
oportunidad para la donacin.
Hay pasos claros a lo largo de la senda del potencial a donador real dnde mdicos
pueden tener un efecto significante en la proporcin de donacin exitosa:
1. identifique a todos los donadores potenciales e instituye un sistema de la revisin
para verificar que todos los donadores potenciales estn identificndose en su rea.
2. establezca un mtodo aceptable rpidamente y con precisin a determine la muerte
del cerebro en donadores potenciales que usan los servicios disponibles locales.
3. el acercamiento todas las familias del donador potenciales para el consentimiento,
notificacin de muerte de decouple y demanda de consentimiento, use a un miembro del
equipo del hospital y un representante de OPO para acercarse a la familia, y haga la
demanda en una escena privada.
4. use un agresivo, los proactive se acercan a la direccin mdica del donador potencial
que usa las tcnicas descrita limitar el nmero de fracasos mdicos y aumentar al
mximo el nmero de rganos donada por el donador. Instituya un proceso de la
revisin para evaluar cualquier fracaso mdico que ocurre.

Dado la diferencia entre los nmeros de potencial contra los donadores reales, el
contacto significante de los autores con los donadores potenciales, y las oportunidades
claras para la mejora en su acercamiento, la comunidad quirrgica debe dirigirse estos
problemas que rodean la direccin ptima de donadores potenciales y sus familias.
Las referencias
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riones cadavricos para el trasplante. Trasplante 31:383-387, 1981 lo abstracto,
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irreversible: El informe del Comit ad hoc del Harvard la Escuela Mdica para
Examinar la Definicin de Muerte del Cerebro. JAMA 205:337-340, 1968,
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muerte del cerebro: La superioridad de estudios del perfusion con 99m Tc-HMPAO
encima del radionuclide convencional el angiografa cerebral. Br J Radiol 65:289, 1992
lo abstracto,
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el Cuidado 23:37 Intensivo, 1995 cita,
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cerebro para la donacin del rgano. Enlate J Anaesth 37:806, 1990 lo abstracto,
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