Organ Donation

Chapter 86 Organ Donation



Benjamin T. Suratt, MD , Kapil Patel, MD




1 Who governs the rules and regulations for organ donation?




image The Organ Procurement and Transplantation Network (OPTN) is a system for operating and monitoring the unbiased allocation, through established medical criteria, of organs donated for transplantation and maintaining a recipients’ waiting list (including the listing and delisting of recipients).


image The United Network for Organ Sharing (UNOS) is a nonprofit organization awarded the contract by the Department of Health and Human Services in 1986 to implement the OPTN.


image Organ Procurement Organizations (OPO) serve specific regions in the country for clinical services including working with hospital staff to maintain donor-organ function, working with UNOS to match donor organs with recipients, coordinating organ recovery surgery, and giving compassionate and professional support to donors’ families.



2 Who can be a potential organ donor?


Potential for organ or tissue donation has few absolute contraindications: human immunodeficiency virus infection, active hepatitis B virus infection, active visceral or hematologic neoplasm, or active bacterial infection, with no age limitation. Appropriateness for donation is assessed when the occasion arises. The majority of cases that are considered for organ donation occur within the intensive care unit (ICU). Despite severe organ shortage, no set universal protocol exists for organ donation. It is at the discretion of the intensivist to consider cases for organ donation. If a case is considered, then the next step is to notify the local OPO, which will then gather data and discuss the critical care management with the regional organ donation specialist, usually an intensivist.


The general rule for the possibility for organ donation is that there should be no evidence of end-organ damage (e.g., acute tubular necrosis, myocardial depression, or pneumonia), with the final decision per the accepting transplant center.



3 Which organs can be donated?




image Organs: kidney, heart, lung, liver, pancreas, and the intestines. Of note, combined organ transplantations (kidney-pancreas, heart-lung, other transplant) can be performed.


image Tissue: corneas, the middle ear, skin, heart valves, bones, veins, cartilage, tendons and ligaments.



4 What is the current standard for organ donation?


Organ donation is possible in patients who are declared brain dead. New brain death guidelines have been published (see Box 86-1). Despite efforts to promote organ donation, an enormous shortage of available organs for transplant continues to exist. As a result, efforts have been undertaken to expand the settings in which organs may become available (i.e., donation after cardiac death (DCD); see later). See Boxes 86-2, 86-3, and 86-4 and Tables 86-1 and 86-2.



Box 86-1 Brain death criteria




image Unresponsiveness or coma


image Core body temperature (≥ 32° C)


image Absence of cerebral motor responses to pain in all extremities


image Absence of brainstem reflexes, that is, pupillary, oculocephalic (doll’s eyes), vestibuloocular (cold calorics), corneal, gag, and cough reflexes


image Apnea test (see Boxes 86–2, 86–3, and 86–4)


image Exclusion of conditions that may confound clinical assessment of brain death, that is, metabolic or endocrine abnormality or drug intoxication


Table 86-1 Confirmatory brain death testing





















Electroencephalography No electrical activity for a period of 30 minutes
Cerebral angiography No intracerebral filling at the level of the carotid bifurcation or circle of Willis
Patent external carotid circulation
Transcranial Doppler sonography No diastolic or reverberating flow
Systolic-only or retrograde diastolic flow
Small systolic peaks in early systole
Somatosensory evoked potential Bilateral absence of response to medial nerve stimulation
Cerebral scintigraphy (technetium Tc 99m brain scan) No uptake of radionuclide in brain parenchyma (hollow skull phenomenon)
Magnetic resonance imaging Not yet determined

Table 86-2 Comparison of donation after brain death and donation after cardiac death







































  Donation after brain death Donation after cardiac death
Cause of illness (e.g., anoxic, trauma, stroke) Severe irreversible brain injury
Does meet criteria of brain death		 Severe irreversible brain injury
Does not meet criteria of brain death
Organ procurement process Physician (non–transplant team) declares brain death Family elects withdrawal of life support
  Referral to OPO Referral to OPO
  Await OR time for organ procurement Withdrawal of life support in the OR or ICU
  Transplant team retrieves organs Physician (non–transplant team) declares cardiac death
  Heart, lungs, kidneys, liver, pancreas, and/or intestines are transplantable Transplant team waits 5 minutes after cardiac death is declared before procuring organs
    Transplant team retrieves organs
    Kidney, pancreas, and liver are generally transplantable

OR, Operating room.


Modified from Organ Donation After Cardiac Death. Madison, Wis., University of Wisconsin Organ Procurement Organization, 2009.



Box 86-2 Prerequisites for performing the apnea test




Core body temperature ≥ 36.5° C


Systolic blood pressure ≥ 90 mm Hg (may use intravenous fluids or dopamine to achieve)


Eucapnia (PaCO2 approximately 40 mm Hg) if possible


Normoxemia (PaO2 ≥ 200 mm Hg) if possible (typically 10 minutes at an FiO2 of 1.0 will achieve)

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Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on Organ Donation

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