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INTRODUCTION

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The major obstacle to saving more lives through transplantation is the limited supply of donor organs available. Organ donation occurs via three main avenues: cadaveric donation, non-heart-beating donors and live donor donation. In 2014, there were 123,934 patients waiting on all organ lists combined, while only 19,426 patients were transplanted from 9512 donors. Further, only 5658 donors were deceased, while the remaining 3854 were live donors. To make matters worse, there are at least twice as many potential brain-dead organ donors every year in the United States that for multiple reasons do not make it to actual donation. It is therefore imperative that physicians learn how to both recognize and effectively manage the brain-dead organ donor to maximize the number of organs available for transplantation, and thus the number of lives saved.

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DIAGNOSIS OF BRAIN DEATH

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The Uniform Determination of Death Act, jointly drafted by the American Bar Association and the American Medical Association in 1981, states that “an individual is dead if there is irreversible cessation of circulatory and respiratory functions, or if there is irreversible cessation of all functions of the entire brain, including the brainstem.” This act paved the way for the concept of brain death and the ability to proceed with organ donation from such individuals. It also led to the establishment of specific criteria for brain death (Table 190-1). The diagnosis of brain death is not always easy since several conditions may also confound the evaluation (Table 190-2).

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TABLE 190-1Criteria for Whole-Brain Death
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TABLE 190-2Conditions that Confound the Diagnosis of Brain Death
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Irreversible brain death is assumed if the cause of brain death is known and accepted to be sufficient to account for death. Further, irreversibility is assumed if the neurologic examination results in the diagnosis of brain death, and the results do not change on repeat examination within a 2–12 hour period. The actual time period between exams varies between institutions. Additionally, in the case of anoxic brain damage, it is generally accepted to wait 24 hours between examinations. There are several confirmatory tests for brain death but the ...

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