Podcast
Questions and Answers
What is considered an absolute contraindication for organ donation?
What is considered an absolute contraindication for organ donation?
Which statement regarding the process of organ donation is true?
Which statement regarding the process of organ donation is true?
Which organ is the most frequently transplanted in organ donation?
Which organ is the most frequently transplanted in organ donation?
Which of the following is true about the legal status of a donor's decision to donate organs?
Which of the following is true about the legal status of a donor's decision to donate organs?
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For which type of organ donation is anesthesia services required?
For which type of organ donation is anesthesia services required?
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What is the primary impact of Cyclosporine on transplant surgery?
What is the primary impact of Cyclosporine on transplant surgery?
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Which of the following factors is NOT considered in ranking potential organ recipients?
Which of the following factors is NOT considered in ranking potential organ recipients?
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Which organ must be retrieved within 30 minutes after cardiac death to ensure viability?
Which organ must be retrieved within 30 minutes after cardiac death to ensure viability?
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Which condition is classified as an absolute contraindication to organ donation?
Which condition is classified as an absolute contraindication to organ donation?
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How does the timing of organ retrieval following cardiac death influence organ viability?
How does the timing of organ retrieval following cardiac death influence organ viability?
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What is a relative contraindication for organ donation?
What is a relative contraindication for organ donation?
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Which of the following organs are frequently transplanted, along with kidneys?
Which of the following organs are frequently transplanted, along with kidneys?
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What is the role of the United Network for Organ Sharing (UNOS) in organ transplantation?
What is the role of the United Network for Organ Sharing (UNOS) in organ transplantation?
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What is one key response of the body associated with severe rostral-caudal ischemia leading to brain death?
What is one key response of the body associated with severe rostral-caudal ischemia leading to brain death?
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Which aspect of the Uniform Anatomical Gift Act was revised to increase organ donation?
Which aspect of the Uniform Anatomical Gift Act was revised to increase organ donation?
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What physiological condition can lead to myocardial depression during brain death?
What physiological condition can lead to myocardial depression during brain death?
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Which response is part of the Cushing response observed during brain ischemia?
Which response is part of the Cushing response observed during brain ischemia?
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Who is legally empowered to consent for organ donation in the absence of a signed donor card?
Who is legally empowered to consent for organ donation in the absence of a signed donor card?
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What is a consequence of intensive catecholamine release during brain death?
What is a consequence of intensive catecholamine release during brain death?
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What has been a traditional requirement for organ donation related to family consent?
What has been a traditional requirement for organ donation related to family consent?
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What can occur as a result of medullary ischemia during brain death?
What can occur as a result of medullary ischemia during brain death?
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What is the initial management step for hemodynamic instability in organ donors?
What is the initial management step for hemodynamic instability in organ donors?
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Which medication is considered the initial drug of choice for hemodynamic support in organ donors?
Which medication is considered the initial drug of choice for hemodynamic support in organ donors?
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Which parameter is NOT part of the anesthetic management goals for organ donors?
Which parameter is NOT part of the anesthetic management goals for organ donors?
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What is the significance of maintaining plasma sodium levels ≤150 mEq/dL in organ donors?
What is the significance of maintaining plasma sodium levels ≤150 mEq/dL in organ donors?
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In the context of brain death, which treatment is most effective for bradycardia?
In the context of brain death, which treatment is most effective for bradycardia?
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Which of the following statements about colloids versus crystalloids in organ donation is true?
Which of the following statements about colloids versus crystalloids in organ donation is true?
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What physiological change occurs within the myocardium upon brain death, affecting heart rate responses?
What physiological change occurs within the myocardium upon brain death, affecting heart rate responses?
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What is the consequence of systemic inflammatory response in the context of brain death?
What is the consequence of systemic inflammatory response in the context of brain death?
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What is a common cause of dilutional coagulopathy during resuscitation?
What is a common cause of dilutional coagulopathy during resuscitation?
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Which factor must be corrected before brain death can be confirmed?
Which factor must be corrected before brain death can be confirmed?
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What are the primary criteria for diagnosing brain death?
What are the primary criteria for diagnosing brain death?
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What is the primary goal for maintaining hemodynamic parameters in organ donors?
What is the primary goal for maintaining hemodynamic parameters in organ donors?
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What confirmatory tests may be performed for brain death diagnosis?
What confirmatory tests may be performed for brain death diagnosis?
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Which factor contributes to neurogenic pulmonary edema following brainstem death?
Which factor contributes to neurogenic pulmonary edema following brainstem death?
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What is a likely consequence of thyroid dysfunction in brain death?
What is a likely consequence of thyroid dysfunction in brain death?
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Which treatment is indicated for managing diabetes insipidus in brain-dead patients?
Which treatment is indicated for managing diabetes insipidus in brain-dead patients?
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What is the ideal target arterial oxygen pressure (PaO2) for pulmonary management during organ procurement?
What is the ideal target arterial oxygen pressure (PaO2) for pulmonary management during organ procurement?
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Which physiological condition is associated with profound hypothermia in brain-dead patients?
Which physiological condition is associated with profound hypothermia in brain-dead patients?
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What is a major complication associated with the inflammatory response in lung damage during organ procurement?
What is a major complication associated with the inflammatory response in lung damage during organ procurement?
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Which component is vital for correcting hypovolemia in patients experiencing diabetes insipidus during organ procurement?
Which component is vital for correcting hypovolemia in patients experiencing diabetes insipidus during organ procurement?
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Which aspect of pulmonary management aims to minimize lung trauma in organ donors?
Which aspect of pulmonary management aims to minimize lung trauma in organ donors?
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Which reflex remains intact in brain death despite the absence of specific motor responses?
Which reflex remains intact in brain death despite the absence of specific motor responses?
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What is the primary indication of brain death during the apnea test?
What is the primary indication of brain death during the apnea test?
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Which of the following drugs does NOT influence the pupillary response in cases of brain death?
Which of the following drugs does NOT influence the pupillary response in cases of brain death?
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Which laboratory test is essential for evaluating potential organ donors?
Which laboratory test is essential for evaluating potential organ donors?
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In what way does the oculovestibular reflex present in a patient with brain death?
In what way does the oculovestibular reflex present in a patient with brain death?
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What common response occurs in patients experiencing hypoxia during apnea testing?
What common response occurs in patients experiencing hypoxia during apnea testing?
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Which condition must be corrected before confirming brain death?
Which condition must be corrected before confirming brain death?
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What is the primary characteristic of diabetes insipidus (DI) as indicated by its symptoms?
What is the primary characteristic of diabetes insipidus (DI) as indicated by its symptoms?
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Which management approach is ineffective for nephrogenic DI?
Which management approach is ineffective for nephrogenic DI?
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What is a potential effect of using sedatives on brain death diagnosis?
What is a potential effect of using sedatives on brain death diagnosis?
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In the context of organ donors, what role do steroids play during preoperative management?
In the context of organ donors, what role do steroids play during preoperative management?
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How is the diagnosis of central DI confirmed?
How is the diagnosis of central DI confirmed?
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Which factor is NOT associated with causing nephrogenic diabetes insipidus?
Which factor is NOT associated with causing nephrogenic diabetes insipidus?
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Which fluid management step is crucial during the diagnosis of diabetes insipidus?
Which fluid management step is crucial during the diagnosis of diabetes insipidus?
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What additional dosage of methylprednisolone may be required to protect organs before procurement?
What additional dosage of methylprednisolone may be required to protect organs before procurement?
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What monitoring is essential for a donor with diabetes insipidus?
What monitoring is essential for a donor with diabetes insipidus?
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What is the recommended observation period to ensure lack of cardiac reanimation in a DCD donor?
What is the recommended observation period to ensure lack of cardiac reanimation in a DCD donor?
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Which solution is used to decontaminate the intestinal tract during organ retrieval for liver and pancreas?
Which solution is used to decontaminate the intestinal tract during organ retrieval for liver and pancreas?
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What is the main purpose of administering heparin to a DCD donor?
What is the main purpose of administering heparin to a DCD donor?
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Which organ is typically removed first in the process of organ procurement due to its susceptibility to ischemia?
Which organ is typically removed first in the process of organ procurement due to its susceptibility to ischemia?
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What criteria must be met regarding blood pressure and hematocrit for a DCD donor?
What criteria must be met regarding blood pressure and hematocrit for a DCD donor?
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What action is taken in the case of premature cardiac arrest during organ retrieval?
What action is taken in the case of premature cardiac arrest during organ retrieval?
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What medications are typically administered to a DCD donor to relieve suffering without hastening death?
What medications are typically administered to a DCD donor to relieve suffering without hastening death?
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In which order are organs removed during organ procurement based on their susceptibility to ischemia?
In which order are organs removed during organ procurement based on their susceptibility to ischemia?
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What is the long-term survival rate for heart-lung transplant recipients?
What is the long-term survival rate for heart-lung transplant recipients?
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Which statement is true regarding the responsibilities of healthcare providers in the organ donation process?
Which statement is true regarding the responsibilities of healthcare providers in the organ donation process?
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How does the survival of DCD (Donation after Cardiac Death) kidney grafts compare to DBD (Donation after Brain Death) kidney grafts?
How does the survival of DCD (Donation after Cardiac Death) kidney grafts compare to DBD (Donation after Brain Death) kidney grafts?
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What limitation exists with a signed driver's license or organ donor card compared to an informed surgical consent?
What limitation exists with a signed driver's license or organ donor card compared to an informed surgical consent?
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What major concern may families have regarding healthcare providers involved in organ donation?
What major concern may families have regarding healthcare providers involved in organ donation?
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What is the primary responsibility of the Organ Procurement Organization (OPO)?
What is the primary responsibility of the Organ Procurement Organization (OPO)?
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Which organ transplant has the highest one-year survival rate among recipients?
Which organ transplant has the highest one-year survival rate among recipients?
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What criticism may anesthetists face during organ procurement procedures?
What criticism may anesthetists face during organ procurement procedures?
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Study Notes
Organ Donation Legalities
- A driver's license or donor card signature is legally binding for organ donation, overriding family consent.
Contraindications for Donation
- Age over 80 years
- HIV infection
- Active metastatic cancer
- Prolonged hypotension or hypothermia
- Active infection
- Disseminated intravascular coagulation (DIC)
- Sickle cell anemia or other hemoglobinopathy
Donor Management
- Aggressive donor management enhances the number and quality of retrieved organs, improving transplant outcomes.
Organ Transplantation Statistics
- The kidney is the most transplanted organ.
- The lung is the least transplanted organ.
Anesthesia for Donation
- Anesthesia is necessary for organ donation after brain death (DBD).
- Anesthesia is not required for donation after cardiac death (DCD).
History of Organ Transplantation
- First solid organ transplant: kidney between identical twins (1954)
- Liver, lung, heart, pancreas transplants began in the 1960s
- Cyclosporine (1978) significantly improved transplant success by reducing rejection
Organ Types and Transplant Statistics
- Transplantable organs include: heart, kidneys, lungs, pancreas, liver, intestines, corneas, skin, tendons, bone, and heart valves
- Most frequently transplanted: kidney and liver (whole or segmental)
Organ Procurement and Allocation
- United Network for Organ Sharing (UNOS): links organ procurement and transplant centers in the US
- Matching and Ranking: based on blood type, tissue match, time on waiting list, immune status, and geographic distance
- Other factors considered: pediatric patients, payback agreements, dual-organ recipients, organ failure following recent transplant, and medical urgency (heart, liver, intestines)
Contraindications for Organ Donation
- Absolute: age >80 years, HIV, active metastatic cancer, prolonged hypotension or hypothermia, active infection, DIC, hemoglobinopathy
- Relative: non-CNS or skin malignancy in remission, hypertension, diabetes, age >70 years, hepatitis B/C, smoking history
Donor Organ Viability
- Donor health at death determines viability of organs
- Organs deteriorate faster after cardiac arrest
- Tissues like bone, skin, heart valves, and corneas can be retrieved up to 24 hours after death
Minimizing Ischemic Time (Warm Ischemic Time)
- Time between cardiac death and organ preservation impacts viability
- Goal: Minimize warm ischemic time
- Organ-specific time limits:
- Heart and liver: 30 minutes
- Kidneys and pancreas: 60 minutes
Organ Procurement: Consent and Legal Considerations
- Organ donation can be documented through various methods like driver's license, donor card, living will, or verbal communication with family.
- States with first-person consent laws make an individual's signature legally binding, eliminating the need for family consent.
- The Uniform Anatomical Gift Act (UAGA) empowers OPOs to seek consent for organ donation, even in the absence of family permission.
- The National Organ Transplant Act (1984) prohibits the sale of organs for transplantation.
Physiological Responses Associated with Brain Death
- Brain death results from severe rostral-caudal ischemia, triggering a cascade of physiological responses.
- Intense sympathetic activity is the initial response, aiming to maintain cerebral perfusion pressure.
- Medullary ischemia leads to loss of thermoregulatory control and endocrine dysfunction due to hypothalamic and pituitary impairment.
- Brainstem herniation is associated with cardiovascular instability, pulmonary complications, and potential cardiopulmonary arrest.
- A systemic inflammatory response occurs in brain death, affecting vascular resistance and potentially increasing immune sensitivity after transplantation.
Preoperative Management of Organ Donors
- Hemodynamic instability poses a significant challenge for organ donors, requiring aggressive fluid resuscitation and cardiovascular support.
- Colloids are preferred over crystalloids to prevent pulmonary edema and organ congestion.
- Inotropic medications like dopamine, dobutamine, norepinephrine, or epinephrine are commonly used to maintain perfusion pressures.
- Anesthetic management aims to achieve optimal hemodynamic parameters, including MAP >60 mm Hg, CVP 12 mm Hg, SVR 800 to 1200 dynes/cm', SBP > 100 mm Hg, and CI > 2.5.
- Bradycardia is effectively treated with isoproterenol, epinephrine, or cardiac pacing due to the limited effect of atropine in brain death.
- Electrolyte monitoring is crucial to maintain optimal levels of sodium and potassium.
- Lung function is significantly compromised in brain death, with limited recovery potential.
Pulmonary Complications Associated with Brain Death
- Neurogenic pulmonary edema is caused by elevated systemic vascular resistance (SVR), left atrial and pulmonary capillary pressure.
- The inflammatory response contributes to lung damage due to the release of proteases, cytokines, and leukotrienes.
- Coagulopathy may lead to pulmonary micro emboli
- Decreased SVR after brain death increases ventilation/perfusion mismatch
- Additional factors affecting pulmonary function include aspiration, pulmonary contusion, excessive fluid resuscitation, atelectasis, and barotrauma.
- Pulmonary management includes:
- Large tidal volumes (12 to 15 mL/kg)
- Low peak inspiratory pressure (PIP), ideally 90%
- Arterial oxygen pressure (PaO2) >60 mm Hg
- Arterial carbon dioxide pressure (PaCO2) 30 to 35 mm Hg
- Arterial pH 7.35 to 7.45
- Other measures:
- Careful fluid management
- Chest physiotherapy
- Frequent suctioning
- Administration of antibiotics (cefazolin or equivalent)
Endocrine Dysfunction
- Diabetes insipidus (DI) is caused by a lack of antidiuretic hormone (ADH) production or release due to damage to the hypothalamus or pituitary gland. Treatment includes vasopressin or desmopressin acetate (DDAVP [1-deamino-D-arginine vasopressin]).
- Hypovolemia associated with DI is corrected with hypotonic saline or dextrose and water and electrolyte replacement.
- Thyroid Dysfunction is characterized by low triiodothyronine (T3), a result of decreased thyroid-stimulating hormone (TSH) secretion and reduced conversion of thyroxine (T4) to T3.
- Hyperglycemia is caused by sympathetically mediated hyperglycemia and depletion of insulin stores and is best managed with an insulin infusion.
- Prolonged hypothermia is associated with cardiac depression, cold diuresis, coagulopathy, and reduced tissue oxygenation.
Coagulation Abnormalities
- Coagulation abnormalities occur due to the release of thromboplastin, tissue plasminogen, and fibrinogen from necrotic brain tissue and reduced platelet aggregation secondary to hypothermia.
- A dilutional coagulopathy can occur due to the excessive use of crystalloids for resuscitation.
- Blood products like fresh frozen plasma (FFP), platelets, and cryoprecipitate are used to correct coagulation abnormalities.
- Immediate organ retrieval is recommended for severe fibrinolysis resistant to therapy.
Hypovolemia
- Contributing factors to hypovolemia include fluid restriction for cerebral edema treatment, DI, hemorrhage, hyperglycemic osmotic diuresis, cold diuresis, and decreased SVR.
- Treatment involves administering crystalloids, colloids, and red blood cells to maintain a systolic blood pressure ( SBP) >100 mm Hg, urine output > 1 mL/kg/ hr, and hematocrit >30%.
Brain Death Criteria
- Diagnosis of brain death is primarily based on the absence of brainstem reflexes and respiratory effort.
- Optional confirmatory tests:
- Electroencephalogram (EEG)
- Cerebral blood flow studies
- Brain-stem auditory-evoked responses (BAER)
- Potentially reversible causes of coma should be ruled out before confirming brain death. These include hypothermia, metabolic disturbances, medications, hypoxia, or hypocarbia.
- The Glasgow Coma Scale (GCS) is used to assess the status of the central nervous system (CNS) and provides an objective and reliable method.
Brain death and Spinal Automatism
- Spinal automatism (Lazarus sign) includes limb flexion, gasping motions, and head-turning.
- Spinal automatism occurs at the spinal cord level, not brain activity.
- Spinal automatism is more common in young adults.
Brainstem Reflexes
- Absent Pupillary Light Reflex: Pupils are mid-sized (4-6mm) but do not constrict when light is shone on them.
- Absent Oculocephalic Reflex (Doll's Eyes): Eyes remain fixed when the head is turned from side to side.
- Absent Oculovestibular Reflex (Caloric Reflex): No eye movement occurs when iced saline is irrigated into the ear canal.
- Absent Corneal Reflex (Blink Reflex): No eyelid closure occurs when the cornea is stimulated.
-
Apnea Test:
- After ventilation with 100% O2, the patient is disconnected from the ventilator while receiving continuous positive airway pressure (CPAP).
- Respiratory effort is observed for 10 minutes.
- Brain death is confirmed if there is no spontaneous breathing and PaCO2 is greater than 55-60 mmHg.
Laboratory Evaluation of Organ Donors
- Requires a variety of tests for both DBD (Donation after Brain Death) and DCD (Donation after Cardiac Death) donors.
- Blood: CBC, glucose, electrolytes, BUN, creatinine, ABG, ABO and HLA typing, blood cultures, VDRL, HIV, EBV, CMV, HTLV-1, Hepatitis B and C serologies.
- Other: Sputum and urine cultures.
- Heart Donors: ECG, CXR, echocardiogram, CK, CK-MB, troponin levels.
- Lung Donors: Serial ABGs, CXR, bronchoscopy.
- Pancreas Donors: Serial blood glucose, amylase, and lipase levels.
- Liver Donors: LFTs, PTT, PT.
Diabetes Insipidus (DI)
- ADH is produced by the hypothalamus and stored and released from the posterior pituitary.
- ADH increases water permeability, leading to water reabsorption in the renal collecting ducts and distal convoluted tubule.
-
Central DI:
- Deficiency of ADH due to autoimmune disease, malignancy, head trauma, intracranial tumor, infection, renal disease, or vascular disease.
- Signs include:
- Polyuria (urine output ≥ 25 mL/kg/hr) with a specific gravity of ≤ 1.005.
- Lethargy, excessive thirst, hypernatremia, tachycardia, hypotension, fatigue, vomiting, and seizures.
-
Nephrogenic DI:
- The kidney fails to respond to ADH.
- Causes: Lithium, amphotericin B, demeclocycline, hypercalcemia.
- Diagnosis: Restrict fluids and monitor plasma and urine sodium, urine specific gravity, and ADH levels.
-
Treatment:
- Central DI: Chlorpropamide, carbamazepine, clofibrate (stimulate ADH production).
- Nephrogenic DI: Indomethacin, hydrochlorothiazide, or amiloride.
-
DI in Organ Donors: Occurs in 70-80% of DBD donors.
-
Treatment:
- Vasopressin (if hemodynamically unstable).
- Desmopressin (if hemodynamically stable).
- Frequent electrolyte monitoring.
-
Treatment:
Role of Steroids in Organ Donor Management
- Increase tissue oxygenation.
- Attenuate the effects of proinflammatory cytokines.
- Improve donor organ function.
- Increase the number of organs transplanted from each donor.
- Improve graft survival, especially in heart and lung recipients.
-
Dosage: Methylprednisolone 15-30 mg/kg every 24 hours.
- Additional 30 mg/kg 1-2 hours before organ procurement to protect the heart and lungs.
Declaring Death in a DCD Donor
- DCD donor: A potential donor who is expected to expire within 60 minutes after extubation.
- Observation Period: 5 minutes to confirm lack of cardiac reanimation.
- Cardiac Reanimation Criteria: Flat ECG tracing, flat pressure arterial line tracing, absence of carotid pulse.
- Hemodynamic Criteria: Systolic blood pressure < 100 mmHg, and hematocrit > 30%.
- Fluid Management: Colloids are preferred for lung and pancreas donors to increase organ viability.
- Electrolyte Monitoring: Serial evaluation of electrolytes, glucose, hemoglobin, hematocrit, and ABGs is crucial for heart and lung donors.
- Intestinal Decontamination: A Betadine and amphotericin B solution is inserted via a nasogastric tube to decontaminate the intestinal tract.
- Organ Procurement Sequence: Organs are removed in order of their susceptibility to ischemia, with the heart first and the kidneys last.
- Anesthesia Termination: Anesthesia care is terminated when the aorta is cross-clamped and the heart removed.
- CPR and Organ Viability: CPR can preserve the viability of some organs in case of premature cardiac arrest.
- Maximum Transplantation Time: Varies according to organ type, ranging from 5 hours for the heart to 3 days for kidneys.
Organ Transplant Survival Rates
- Over 163,000 individuals in the United States are living with a functioning organ transplant
- The highest one-year survival rates are for kidney and pancreas recipients (95% to 98%)
- One-year survival rates for liver, intestine, lung, and heart recipients range from 81% to 91%
- The lowest survival rate (75%) is seen with heart-lung recipients
- DCD kidney graft survival is similar to DBD kidney, but DCD liver graft survival is significantly lower than DBD liver
Professional Conflicts with Organ Donation
- While most health care providers support organ donation, some may experience conflict when shifting focus from donor to recipient
- Families may question the ability of health care providers to provide quality end-of-life care
- Physicians and nurses should focus on quality end-of-life care for the donor and not be involved in the organ procurement or transplant process
- The OPO is responsible for evaluating the donor, obtaining consent, coordinating procurement and transplantation, and supporting the family during bereavement
- The treating physician declares death using brain or cardiac criteria; the transplant team cannot participate in end-of-life care or the declaration of death
- Anesthetists providing anesthesia for organ procurement are required to withdraw life support, which may contradict professional standards
Surgical Consent vs Driver's License or Donor Card
- Surgical consent informs the patient about the procedure, risks, benefits, and alternative options
- A signed driver's license or donor card is a limited informed consent, lacking detailed explanation of risks and benefits
- Most donors do not know that their end-of-life care may be significantly altered and managed by the OPO, not their treating physician
- The OPO can dictate premortem medications and procedures (heparin, catheters, cannula), as well as when to discontinue mechanical ventilation
- To restrict end-of-life care to their personal physician, voluntary donors must specify this directive in a living will
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Explore the essential legalities and management practices surrounding organ donation. Learn about the contraindications, statistical insights, and the role of anesthesia in both brain and cardiac death. This quiz will enhance your understanding of the complexities of organ transplantation.
