1. Management of a Brain dead donor until retrieval of organs
ISCCM FOUNDATION DAY

2. General approach to these issues
Practice ‘good house-keeping’
Use [your] standard approaches to issues
Maintain [extracranial] organ perfusion
Prevent adverse sequelae of brain death
Correct abnormal physiology if necessary to facilitate clinical brain death testing
Exclude contraindications to donation
Consult Organ Donation agency at any time for advice

3. Physiological support before brain death
Brain oriented intensive treatments
Ventilation, MAP and CPP support, osmolar control, temperature control, CSF drainage
Assessment of CNS function
Investigations and clinical assessment
Requires absence of CNS-active agents
Withdrawal of brain-oriented treatments
After reliable prognosis and consensus
May include continuation of ventilation and MAP support for extra-cranial organ function

4. Physiological support after brain death
Why do this?
To preserve best possible function of all organs that might be donated and transplanted
How is this done?
ISCCM Donor Management Guidelines, consultation with Organ Donation Agency
Ventilation, fluids and inotropes, DDAVP, warming …
Usual basic treatments for a critically ill patient (turns, suction, surveillance, infection control)
Monitoring and investigations

5. ISCCM Statement 2017
Indian J Crit Care Med 2017;21:

6. Overview of specific issues
Respiratory care:
Routine suctioning, positioning and turning, ventilatory techniques that reduce atelectasis (e.g. PEEP, recruitment manoeuvres) and avoidance of interstitial fluid overload help to maintain adequate oxygenation and oxygen delivery to organs
Such an approach is vital for optimising lung utilisation and for successful lung transplantation outcomes

7. Overview of specific issues
Management of the circulation:
Autonomic storm is transient. Use only short-acting agents (e.g. esmolol, sodium nitroprusside)
Arrhythmias – Electrolytes, Volume, Temperature and drugs
Bradycardia resistant to atropine; adrenaline, isoprenaline may be effective
In cardiac arrest, CPR may result in recovery of cardiac function and successful transplantation

8. Overview of specific issues
Management of the circulation
Hypovolaemia – Volume state should be optimised by the administration of intravenous (IV) fluids.
Competing requirements for optimising organ function may produce conflicting strategies for fluid replacement.
Identifying early which organs are suitable for transplantation makes it possible to develop focused medical management strategies

9. Overview of specific issues
Management of the circulation
Hypotension and/or low cardiac output – An adequate perfusion pressure should be targeted (e.g. MAP > 70 mmHg) by optimising volume state and use of inotropic agents.
>90% need inotropic support
~ 85% receive Noradrenalin

10. Overview of specific issues
Management of the circulation
Hormonal resuscitation – There is no Level I or Level II evidence to endorse the use of hormonal resuscitation
Recommended if persistent hemodynamic instability/ EF <45%
T3- 4 mcg IV , then 3 mcg/hour
Steroids
Methylprednisolone 15 mg/Kg Bolus

11. Overview of specific issues
Diabetes insipidus (DI)
DDAVP or vasopressin should be administered early.
DDAVP usually given as IV bolus 2 to 4 μg (paediatric: 0.25 to 2 μg) every 2 to 6 hours, or as required.
Vasopressin given as an IV infusion at a dose of 0.5 to 2.0 U/h (paediatric: to 0.04 U/kg/h).
Volume replacements

12. Overview of specific issues
Metabolic derangement
Appropriate IV fluid is required to maintain euvolaemia and electrolytes within normal range.
Serum sodium and potassium should be monitored every 2 – 4 hours to guide fluid replacement and electrolyte supplementation.
Insulin infusion may be given to maintain blood glucose in the normal range
Hypothermia is easier to prevent than reverse.

13. Overview of specific issues
Anaemia and coagulopathy
Blood, coagulation factors and platelets transfusion may be required to correct severe anaemia and/or coagulopathy.
Procurement should be expedited if there is a worsening coagulopathy.
Nutrition:
Continuing enteral feeding might have beneficial effects on organ function in transplant recipients.
Gastric stasis
Neuromuscular Blocking Agents, Adequate IV access, Continued monitoring

14. Overview of specific issues
Donor management during organ retrieval:
Anaesthetist should ensure adequate monitoring.
Blood products should be available
Normal ventilatory and circulatory parameters maintained.
Neuromuscular blocking drug.
Sympathetic responses could result in myocardial injury and exacerbate bleeding.
Opioid agents are also used but may not suppress catecholamine-mediated sympathetic activity.

15. Specific problems and solutions
Severe oxygenation failure
What is the diagnosis?
Can lung function be improved? (diuretic, physiotherapy, position, suctioning, bronchoscopy)
Spinal reflexes
These may occur during brain death testing
Warn everyone (especially family members)
Explain what these are when they occur
They may also occur during organ reterivalr
PLEASE EXTUBATE PATIENT IN OPERATION THEATRE

16. Some reassurance Do what you usually do and do it well
Maintain usual vigilance and attention
Approach problems systematically
Most problems are amenable to solution
Serious problems are uncommon
Advice is always available from me at any time of the day or night