Donor Management

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

2. 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

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

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

5. 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

6. 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% Goal of management

7. Hypertension Hypotension Hypovolemia Decreased vascular resistance Cardiovascular support

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

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

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

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

12. 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 Respiratory support

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

14. Urine output > 500 ml/hr Serum sodium > 155 mEq/L Urine specific gravity < 1.005 Serum osmolarity > 305 mOsm/L Central diabetes insipidus

15. 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 Effect of hypernatremia

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

17. 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 Endocrine therapy

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

19. 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

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

21. 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 Ideal cadaver donor

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

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

24. พบผู้ป่วยที่อาจเป็นผู้บริจาคอวัยวะพบผู้ป่วยที่อาจเป็นผู้บริจาคอวัยวะ ยืนยันภาวะสมองตาย แพทย์แจ้งข่าวสมองตายแก่ญาติ ผู้ประสานงานขอบริจาคจากญาติ แจ้งศูนย์รับบริจาคอวัยวะสภากาชาดไทย ตรวจยืนยันภาวะสมองตายและความเหมาะสมในการเป็นผู้บริจาค ขั้นตอนการขอรับบริจาค

25. Care of potential donor Diagnosis of brain death Documentation of brain death Consentform Preparation for organ retrieval Operative injury Packaging Pitfall

26. Drug Hypothermia Decorticate Decerebrate Spinal cord injury Diagnosis of brain dead

27. Documentation of brain death

28. Thank you.