1. Donor Management Somchai Limsrichamrern, M.D. Department of Surgery Faculty of Medicine, Siriraj Hospital

2. Pathophysiology of brain death X Cushing’s response X Autonomic storm X Decreased hepatic perfusion due to intrahepatic shunt X Neurogenic pulmonary edema X Catecholamine decreased to below baseline in 15 minute

3. Pathophysiology of brain death X Abolished vagal tone X Decreased carbon dioxide production X Arterial and venous vasomotor collapse X Activation of proinflammaory and immunoregulatory pathway

4. Routine care and monitoring X Arterial line X CVP X Temperature X Hourly urine output X Frequent laboratory tests X Swan-Ganz catheter

5. Goal of management X Organ viability and function after transplantation correlates with donor care X To increase usability of organs X To optimize organ perfusion and tissue oxygen delivery

6. Goal of management X Systolic blood pressure: 100-120 mmHg X Central venous pressure: 8-10 mmHg X Urine output: 100-300 ml/hr X Core temperature: > 35º c X Arterial oxygen pressure: 80-100 mmHg X Oxygen saturation: > 95% X pH: 7.35-7.45 X Hematocrit: 30-35%

7. Cardiovascular support X Hypertension X Hypotension X Hypovolemia X Decreased vascular resistance

8. Cause of hypotension X Hypovolemia X Hypothermia X Cardiac dysfunction X Arrhythmia X Acidosis X Hypoxemia X Excessive PEEP X Congestive heart failure X Myocardial sequelae of autonomic storm

9. Cause of hypotension X Cardiac dysfunction X Cardiac injury X Preexisting cardiac disease X Hypophosphatemia X Hypocalcemia X Drug side effect or overdose (beta blocker, calcium channel blocker)

10. Hypovolemia X Arterial and venous vasomotor collapse X Dehydration (fluid restriction) X Insufficient resuscitation X Polyuria (Osmotic diuresis, diabetes insipidus, hypothermia) X Third space loss X Decreased intravascular oncotic pressure

11. Cardiovascular support X Optimize volume status X Dopamine is the drug of choice X Try to avoid α-adrenergic agonist X Urine output not reliable

12. Respiratory support X Frequent endotrachial suctioning X Use low level of PEEP X Tidal volume 10-15 ml/kg X Maintain PaO 2 greater than 100 mmHg X Avoid using high PEEP X Increase FiO 2 non-lung donor

13. Renal function X Maintain adequate perfusion X Maintain adequate urine output X Minimize use of vasopressor X Polyuria (DI, osmotic diuresis) X Diabetes insipidus found in 80%

14. Central diabetes insipidus X Urine output > 500 ml/hr X Serum sodium > 155 mEq/L X Urine specific gravity < 1.005 X Serum osmolarity > 305 mOsm/L

15. Effect of hypernatremia X Hypernatremia was associated postoperative graft dysfunction X Graft loss in up to 33% X Correction of hypernatremia X Keep final serum sodium level < 155 mEq/L Liver Transpl Surg - 1999 Sep; 5(5): 421-8

16. Treatment of DI X Hypotonic solution (D5W,.45NaCl) X Desmopressin 1-2 µg IV every 8-12 hr X Vasopressin infusion 1.2 unit/hr

17. Endocrine therapy X Low T3 level: routine use not recommended X Steroid: may decrease proinflammatory reaction, routine use not recommended X Insulin: use to treat hyperglycemia, increase hepatic glycogen storage

18. Prevention of hypothermia X Brain dead donors are poikilothermic X Maintain temperature > 35ºc X Prevent heat loss X Rewarm

19. Organ preservation X To preserve the viability of organ for as long as possible X Hypothermia slows metabolism X Cooling organs from 37 to 0 degree Celsius slows metabolism by a factor of 12-13 X Ischemia causes cell swelling

20. Organ preservation X Collin’s solution X University of Wisconsin solution X Both are high in potassium X UW solution contain impermeants which help reduce cell swelling

21. Ideal cadaver donor X Young adult with no significant medical problem X Brain death due to closed head injury X No extracerebral trauma X Brief hospitalization X Normal blood pressure and heart rate without vasopressor X Excellent organ function

22. Contraindication X Unknown cause of death X Extracranial malignancy X HIV + X Uncontrolled sepsis especially fungal

23. Relative contraindication X Extreme age X Intracranial malignancy X HCV + or HB core antibody + X Bacteremia X Procurement injury X Preexisting medical problem

24. ขั้นตอนการ ขอรับ บริจาค X พบผู้ป่วยที่อาจเป็นผู้บริจาคอวัยวะ X ยืนยันภาวะสมองตาย X แพทย์แจ้งข่าวสมองตายแก่ญาติ X ผู้ประสานงานขอบริจาคจากญาติ X แจ้งศูนย์รับบริจาคอวัยวะ สภากาชาดไทย X ตรวจยืนยันภาวะสมองตายและ ความเหมาะสมในการเป็นผู้บริจาค

25. Pitfall X Care of potential donor X Diagnosis of brain death X Documentation of brain death X Consent form X Preparation for organ retrieval X Operative injury X Packaging

26. Diagnosis of brain dead X Drug X Hypothermia X Decorticate X Decerebrate X Spinal cord injury

27. Documentation of brain death

28. Thank you.