Anesthesia Care of the Organ Donor

Types of Organ Donation

DBD^1,2

• DBD is the most common donation pathway and involves irreversible cessation of all brain and brainstem function.
• Diagnosis must meet the following conditions: persistent coma, absence of brainstem reflexes, and apnea.
  • Ancillary tests (computed tomography angiography, computed tomography perfusion, radionuclide perfusion studies, electroencephalogram) are used when the exam or apnea test cannot be completed.
• Please see the OA summary: Organ Donation: Donation After Brain Death and Donation After Cardiac Death for more details. Link
  • Hemodynamic changes after brain death include:
  • Reflex hypertension and bradycardia (Cushing’s reflex)
  • Catecholamine storm (hypertension, tachycardia, and increased afterload)
  • Myocardial stunning
  • Vasoplegia
  • Loss of sympathetic tone
  • Hypothermia
  • Diabetes insipidus (DI)
  • Low cortisol
  • Thyroid dysfunction

DCD³

• DCD is used when patients do not meet criteria for brain death but undergo withdrawal of life-sustaining therapy (WLST) due to irreversible illness.
• Death is confirmed via cardiorespiratory criteria (cardiac arrest) and a mandatory “no-touch” standoff period following WLST.
• The transplant team cannot be involved in decisions related to patient prognosis, withdrawal of ventilatory or organ-perfusion support, or determination of death, as each would represent a conflict of interest.
• Informed consent is obtained from the patient’s legal decision maker(s), which is obtained after the decision is made to withdraw support.
• The possibility that the patient may not die or may not provide transplanted organs must be communicated to the consenter.
• Warm ischemia during the agonal phase represents the principal threat to organ viability. Therefore, the anesthetic approach focuses on non-interference with the dying process while preparing for rapid organ recovery once death is declared.

Care of the Organ Donor^4-6

Hemodynamic Management

• The primary goals are to preserve end-organ perfusion, avoid tachycardia and excessive vasoconstriction, and support myocardial function.
• Maintain heart rate 60-120 bpm, mean arterial pressure (MAP) greater than 65 mmHg, central venous pressure 6-10 mmHg, and urine output 1-3 mL/kg/hr.
• Esmolol may be used to treat tachycardia or hypertension.
• Anticholinergic agents may not work for bradycardia if the vagal nerve has been compromised. Direct-acting agents such as isoproterenol is preferred.
• Avoid excessive fluid administration. Balanced crystalloids (e.g, Lactated Ringer’s, Plasma-Lyte) are preferred. If lung procurement is planned, colloids are preferred.
• DCD often requires vasopressors due to vasoplegia.
  • First-line treatment is norepinephrine, followed by vasopressin (especially if DI is present).
• Myocardial stunning is common and often reversible.
  • Optimize preload and afterload before excluding the heart for transplantation.

Respiratory Management

• Lung-protective ventilation strategies have been shown to improve organ yield and graft function.
• Maintain tidal volumes 6-8 mL/kg of ideal body weight (ideal body weight), positive end-expiratory pressure 5-8 cm H₂O, plateau pressures less than 30 cm H₂O, and PaO₂ greater than 100 mmHg.

Endocrine and Hormonal Management

• DI
  • DI occurs in up to 80% of donors due to posterior pituitary failure.
  • Symptoms include urine output more than 3–4 mL/kg/hr, low urine osmolality, and hypernatremia.
  • Treatments include vasopressin infusion or DDAVP and aggressive free-water replacement to maintain Na less than 155 mEq/L.
• Thyroid hormone dysfunction
  • Low T3 levels and impaired conversion contribute to myocardial dysfunction.
• Corticosteroids
  • Steroids reduce inflammatory cytokines, improve oxygenation in lung donors, and treat adrenal insufficiency.
  • Methylprednisolone 15 mg/kg improves oxygenation, reduces inflammatory mediator levels, and increases the likelihood of lung procurement.
• Glucose management
  • Hyperglycemia results from insulin resistance and endocrine collapse.
  • Maintain glucose less than 180 mg/dL with an insulin infusion.

Temperature Regulation

• Hypothermia is common due to hypothalamic failure and peripheral vasodilation. Temperature preservation improves organ quality and reduces coagulopathy.
• Maintain core body temperature between 35.8°C and 37.8°C using forced-air warming, increased room temperature, and warmed intravenous fluids.

Coagulopathy and Hematology Management

• Maintain hemoglobin levels not less than 8 g/dL (10 or more for heart donors), platelet count greater than 50,000/µL, and international normalized ratio less than 1.5.
• Correct coagulopathy with fresh frozen plasma or cryoprecipitate to prevent intraoperative bleeding.

Infection Prophylaxis

• Administer broad-spectrum antibiotics due to the risk of ventilator-associated pneumonia and bloodstream infections.

Types of Organ Donation

Phases of Organ Procurement and Intraoperative Management^5,6

• The intraoperative course of organ procurement can be divided into several phases, each associated with specific anesthetic responsibilities to preserve organ function and maintain surgical conditions.
• Initial Phase
  • Spinal reflexes may cause hypertension or movement despite confirmed brain death.
  • Low-dose volatile anesthetics may be used to blunt reflex hypertension and facilitate surgical exposure.
  • Neuromuscular blockade may be administered to prevent spinally mediated movement.
  • Maintain adequate MAP to ensure continued organ perfusion until the aortic cross-clamp.
• Aortic Cross-Clamping
  • Aortic cross-clamping results in the abrupt cessation of organ blood flow and a rapid decline in venous return, MAP, and end-tidal CO₂.
  • This marks the shift from maintaining physiologic stability to supporting surgical conditions only.
• Cold Perfusion and Organ Preservation
  • Preservation solutions (e.g., University of Wisconsin solution) are infused immediately after cross-clamping to rapidly cool organs and minimize ischemic injury.
  • Hemodynamic support and ventilation are typically discontinued once cold perfusion is established.
  • Anesthetic responsibilities are now focused on assisting with surgical workflow and equipment management.