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Chapter 118. Brain Death and Organ Donation

Ronaldo Collo Go, MD; Roopa Kohli-Seth, MD

  • Acute CNS catastrophic event excluding acid-base, circulatory, electrolyte, hemodynamic disturbances, and no evidence of poisoning or hypothermia
  • Clinical examination: absent brainstem function; spinal cord and peripheral nerve reflexes may occur
  • Clinical exam repeated after 6 hours in patients over 1-year-old
  • Apnea test performed after second clinical examination
    • Patient disconnected from ventilator and placed on 6 L/min O2 by T-piece
    • Spontaneous respirations within 8 to 15 minutes = negative apnea test
    • No spontaneous respirations while PCO2 ≥ 60 or increase in PCO2 ≥ 20 from baseline = positive
  • Clinical examination and positive apnea test are sufficient to affirm brain death

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Tests
Confirmatory testsIf clinical exam and apnea test inconclusive
AngiogramAbsence of filling at level of internal carotids or circle of Willis
ElectroencephalographyAbsence of brain activity for 30 min
Nuclear brain scanAbsence of uptake of isotope
Somatosensory evoked potentialsAbsence of response to median nerve
Transcranial DopplerSmall systolic peak without diastolic flow
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Incidence and Types of Organ Donation
54% brain death donorlegal death; causes: cardiovascular accident, trauma, anoxia
40% living donorpreferred for kidney transplant
7 % cardiac death donorirreversible cessation of respiratory and pulmonary function, which can be controlled (expecting cardiac arrest) or uncontrolled (unexpected cardiac arrest)
Figure 118-1. Pathophysiology of Increased ICP in the Brain-Dead Patient
image
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Contraindications to Organ Donation

  • Multiorgan failure secondary to sepsis
  • Cancer except skin cancer other than melanoma, certain brain tumors, remote prostate cancer
  • Infections: bacterial, viral, fungal, parasitic, prions

Failure of Potential Donors

  • Family refuses consent
  • Hemodynamic collapse
  • Medically unsuitable according to acceptance criteria

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Work-Up and Management of the Potential Organ Donor
Identify potential donors
  • Notify local organ donor network, transplant and family coordination services
  • A second brain death examination might be warranted prior to declaration of brain death
Initial labsInfectious: HIV1, HIV2, HTLV 1, 2; hepatitis panel; CMV IgG and IgM, EBV IgM and IgG, RPR, toxoplasmosis IgG
Routine labs every 6 hCBC, ABG, AST, Liver Function Test, PT/PTT/INR, Fibrinogen, Troponin, CK, Chem7, Magnesium, Phosphorus, LDH, Amylase, Lipase
Lines
  • Arterial line (preferably left radial for heart/lung harvest)
  • Central venous catheter (preferably right IJ/subclavian)
  • Pulmonary artery catheter
  • 2 large-bore PVLs
OtherNGT, warming blanket, heater/humidifier on breathing circuit
MonitorsECG, urine output (Foley), core temperature, thermodilution CO (if PAC)
Optional
  • Echocardiogram and inotropic support if ejection fraction less than 45%
  • Electrocardiogram
  • Bronchoscopy
  • Cardiac catheterization

  • Maintain organ perfusion and oxygenation through fluid, electrolyte, and acid-base management
  • Maintain temperature between 35.5°C and 38°C
  • Rule of 100s:
    • SBP >100 mm Hg
    • U/O >100 mL/h
    • PaO2 >100 mm Hg
    • Hemoglobin >100g/L

Hypotension

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