Management of Brain-Dead Donors for Liver and Lung Recovery
For brain-dead donors when only liver and lungs are being recovered, implement standard comprehensive donor management protocols focusing on hemodynamic stabilization, lung-protective ventilation, correction of metabolic derangements, and neurohormonal support—the same approach used for multi-organ donors. 1, 2
Core Management Principles
The management strategy does not fundamentally change based on which organs are being recovered. Both liver and lung procurement require optimization of the same physiological parameters that preserve all transplantable organs 3, 4.
Hemodynamic Management
- Target mean arterial pressure ≥70 mmHg through volume resuscitation and vasopressor support 5, 4
- Norepinephrine is the preferred vasopressor (used by 64.5% of experienced centers) 4
- Consider advanced hemodynamic monitoring: cardiac ultrasound and invasive monitoring help guide fluid and vasopressor therapy 4
- Pulmonary artery catheter insertion for cardiac output monitoring can be valuable (used in 87% of cases in high-performing centers) 6
Fluid Management
- Use balanced crystalloids as first-line fluid therapy (preferred by 58% of practitioners) 4
- Maintain adequate volume replacement while avoiding hypernatremia, which specifically compromises liver transplant outcomes 3
- Monitor serum sodium closely—elevated levels are linked to poorer liver graft function 3
Respiratory Management
Implement lung-protective ventilation strategies 1, 2, 5:
- Tidal volume ≤6 mL/kg predicted body weight
- PEEP ≤10 cmH₂O
- Maintain adequate oxygenation and ventilation
- Continue ventilation throughout the entire donor management period
This approach achieved 58% compliance in multi-center data but should be standard practice 5.
Metabolic and Endocrine Support
- Treat diabetes insipidus aggressively with desmopressin or vasopressin 1
- Implement neurohormonal support including thyroid hormone replacement and corticosteroids 1, 4
- 41% of centers use hormonal replacement therapy routinely, while 38% reserve it for hemodynamic instability—the evidence supports more liberal use 4
- Maintain normoglycemia (target achieved in 84% of cases) 5
- Maintain normothermia (target achieved in 96% of cases) 5
Organ-Specific Considerations
- Prioritize serum sodium control
- Ensure adequate tissue perfusion to prevent ischemic injury
- Monitor liver function parameters
- Correct coagulopathy if present
For lung preservation 2:
- Meticulous bronchial clearance management
- Maintain protective ventilation throughout
- Monitor arterial blood gases
- Prevent ventilator-associated lung injury
Intraoperative Anesthetic Management
During organ recovery, standard practice includes 5, 4:
- Neuromuscular blocking agents (administered in 90% of cases)
- Inhaled anesthetics (used in 63.3% of cases)
- Opioids (used in 33.9% of cases)
These medications prevent spinal reflexes and facilitate surgical exposure, though their use remains somewhat variable across centers.
Critical Pitfalls to Avoid
- Do not reduce management intensity because fewer organs are being recovered—liver and lungs require the same physiological optimization as multi-organ donors
- Avoid hypernatremia—this specifically damages liver grafts 3
- Do not abandon lung-protective ventilation—high tidal volumes will compromise lung transplant outcomes 2, 5
- Do not delay treatment of diabetes insipidus—this leads to hypovolemia and hypernatremia 1
Duration and Monitoring
Average donor management time is 2.81±1.21 days 6, with anesthetic time during recovery averaging 127±53.5 minutes 5. Continuous monitoring and adjustment of all parameters throughout this period maximizes organ quality and transplant success rates.
The 2025 European liver guidelines 1 and American thoracic surgery lung procurement guidelines 2 both emphasize that proper donor management—regardless of which organs are recovered—follows the same fundamental principles of maintaining physiological homeostasis and preventing ischemic injury.