Support of the Organ Donor



Support of the Organ Donor


Patrick K. Kim

Matthew V. Benns

Patrick M. Reilly

C. William Schwab



I. Introduction

Organ availability is the major limitation to increasing the benefit of organ transplantation. In the United States, the number of people awaiting organ transplantation has doubled over 10 years, whereas the organ supply has only increased by one-third. Thus, median waiting times for transplants have increased and more people die waiting for organs than ever receive an organ transplant.



  • Organs that can be transplanted include the heart, lung, liver, kidney, pancreas, and small bowel. Other tissues that can be transplanted include bone, bone marrow, cartilage, cornea, fascia, heart valves, and skin.


  • Trauma, especially severe head injury, is the second most common source of organ donors (after stroke) and provides more organs per donor. Currently one-third of available organs for transplant come from patients sustaining lethal injury. All professionals involved with trauma care must be knowledgeable of and involved with the organ procurement approaches. One large challenge for increasing the pool of donor organs is the high refusal rate by the public to proceed with donation (only 15% to 20% of the potential donor pool proceeds to donation). Enhanced strategies to increase the percentage of actual donors play a critical role in securing organ availability.


  • The failure to procure potential organs is multifactorial and includes family refusal, the lack of awareness by the treating physician, and the inadequate resuscitation of the potential organ donor (Table 41.1). According to the Federal Conditions of Participation of the Centers for Medicare and Medicaid Services, hospitals must contact their local organ procurement organization (OPO) in a timely manner if a patient is expected to die. The trauma practitioner plays the key role in identifying potential donors, contacting the OPO, and maintaining normal physiologic in the potential donor.



    • The OPO should be notified early in the evaluation of all potential donors. Once involved, the OPO and transplant team, not the ED or trauma staff, should assess the suitability of a potential donor. In addition, the OPO is skilled in approaching the family of potential donors and can be a resource in the diagnosis and mechanics of the confirmation of brain death. When the OPO provides the initial approach to the family regarding organ donation, families are more likely to proceed to organ donation than contact started by physicians or staff involved in the care of the potential donor.








      Table 41-1 Failure to Donate: Causes and Remedial Strategies










      Causes Remedial strategies


      1. Failure to recognize potential organ donors
      2. Family refusal

        • – Family approached about organ donation by the primary care team (perceived conflict of interest)
        • – Family informed of death and approached about organ donation at the same time (perceived conflict of interest)
        • – Low acceptability of organ donation by minorities

      3. Failure to expedite diagnosis of brain death
      4. Failure to maintain organ homeostasis

      • Provide continuous education
      • Develop a hospital-based organ donation team (social workers, ministers, OPO, ICU staff)
      • Primary service informs family of death
      • OPO approaches family
      • Temporally separate the discussion of death and the request for donation
      • OPO should approach the family regarding donation
      • Understand cultural diversity
      • Create clear guidelines for the diagnosis of brain death
      • Optimize organ perfusion (volume first followed by pressors as needed)
      • Use lung protective ventilatory strategies
      • Anticipate and treat endocrine abnormalities
      OPO, organ procurement organization; ICU, intensive care unit.


II. Potential Organ Donors

The legal framework for modern organ transplantation is largely based on two Uniform Acts and their subsequent revisions: The Uniform Anatomical Gift Act of 1968 and The Uniform Determination of Death Act of 1981. These acts provided:

(a) An individual with the legal right to donate organs or tissue after death and

(b) included a neurologic basis for the definition of death: “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead.” The majority of current organ donors are comprised of patients who have been declared dead on the basis of their neurologic function. However, an increasing proportion of donors are declared dead on the basis definitions of circulatory and respiratory arrest.




  • All patients identified to have a fatal disease process are potential organ/tissue donors, even if they have severe pre-existing disease in one or more organ systems. Exceptions to donation include:



    • Viral infections: Human immunodeficiency virus (HIV) infection, human T-cell leukemia–lymphoma virus, systemic viral infections (e.g., measles, rabies, adenovirus, enterovirus, parvovirus), and herpetic meningo-encephalitis


    • Viral hepatitis: Hepatitis-positive patients, however, can donate to hepatitis-positive recipients


    • Tuberculosis


    • Untreated septicemia: The presence of bacteremia or fungemia, is not an absolute contraindication. Patients who receive organs from infected donors do not do worse than those who receive organs from non-infected donors


    • Extracranial malignancies: Exceptions include non-melanoma skin cancers


    • Intravenous drug abuse


    • Known prion-related diseases








Table 41-2 Steps in the Organ Donation Process (Brain Injured Patients)






  1. Determine severity of head trauma.
  2. Determine the likelihood of reversing the patient’s disease process.
  3. Notify the OPO.
  4. Inform the family of the patient’s condition and prognosis.
  5. Optimize organ function, perfusion, and oxygen transport. Maintain homeostasis.
  6. Determine irreversibility of brain injury. Perform first brain death clinical examination.
  7. Family approached by OPO regarding the possibility of organ donation.
  8. Second brain death clinical examination, laboratory evaluations, and secondary investigational studies (e.g., nuclear medicine flow study).
  9. Consent.
  10. Donation laboratory studies, echocardiogram, and bronchoscopy (if needed).
  11. Organ procurement.


III. Determination of Brain Death (Table 42-2)

The majority of trauma patients who proceed to organ donation will do so because of lethal brain injury. It is therefore essential that the trauma team and practitioner have knowledge of the process to establish brain death.



  • Brain death is a clinical diagnosis. The practical steps and technical determination of brain death may vary between institutions, but the usual criteria are as follows:



    • Documentation of coma


    • No motor response to painful stimuli


    • No brainstem reflexes



      • Pupils are nonreactive to a bright light


      • Ocular movements are absent; there is no response to head turning or tympanic caloric testing with ice water


      • Corneal, laryngeal, and tracheal reflexes are absent









      Table 41-3 Apnea Test






      1. Prerequisites

        • – Core temperature >36.5C
        • – Systolic blood pressure (SBP) >90 mm Hg
        • – Euvolemia
        • – Normal PaCO2
        • – Normal PaO2
        • – No paralytics, sedation, or drug intoxication
        • – Normal electrolyte and acid–base status

      2. Pre-oxygenate with 100% FiO2 for 20 minutes
      3. Normalize PaCO2 and draw a baseline ABG
      4. Connect pulse oximeter and disconnect ventilator
      5. Deliver 100% oxygen, 8–12 L/min, into the trachea
      6. Look closely for respiratory movements
      7. Measure arterial PO2, PCO2, and pH after 5 and 10 minutes and reconnect to the ventilator

        • – If respiratory movements are absent and PaCO2 increases to ≥60 mm Hg, apnea is present and the diagnosis of brain death is supported
        • – If respiratory effort is seen, the diagnosis of brain death is not supported

      8. Abort the test if:

        • – Hemodynamic instability (i.e., decrease in SBP <90 mm Hg) or ventricular arrhythmia
        • – Oxygen desaturation (<90%)


    • Apnea: The absence of respiratory movements with an increase in PaCO2 >60 mm Hg in the setting of Normal PaO2 (Table 41-3)


    • No increase in heart rate following intravenous administration of 2 mg atropine


    • The brain death examination should be completed at least twice at different time intervals (traditionally 2 to 12 hours apart) by two different qualified physicians who are not part of the transplant team.


  • A number of tests can aid in confirming clinical brain death. They are useful when a complete clinical evaluation cannot be done (i.e., in the setting of uremia or encephalopathy, the presence of central nervous system [CNS] depressants, or the inability to assess pupillary response secondary to ocular trauma). The tests include electroencephalography (EEG), cerebral angiography, transcranial Doppler ultrasonography, nuclear medicine or xenon flow studies, and somatosensory-evoked potentials. EEG, Doppler studies, and evoked potentials can be difficult to interpret and lack specificity for brain death. Although angiography is an option, it requires an invasive procedure. For these reasons, most centers currently utilize brain flow studies for additional confirmation of brain death.

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Oct 17, 2016 | Posted by in CRITICAL CARE | Comments Off on Support of the Organ Donor

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