What medications are recommended prior to death in potential organ donors?

Medications Recommended Prior to Death in Potential Organ Donors

Heparin should be administered prior to withdrawal of life-sustaining therapy (WLST) in potential organ donors to prevent thrombosis and improve transplant outcomes. 1

Key Antemortem Medications

Heparin

• Dosing: 100-300 units/kg or fixed dose of 30,000 units 1
• Timing: Administer immediately prior to WLST rather than during the agonal phase to ensure adequate circulation 1
• Evidence: Reduces odds of primary non-function following donation after circulatory death (DCD) liver transplantation 1
• Caution: Specific informed consent should be obtained from the patient's legal decision maker(s) 1
• Exception: May be withheld in rare cases when it might be expected to hasten death or is prohibited by local procurement protocol 1

Vasodilators

• Medication: Phentolamine (alpha-blocker) 1
• Purpose: Combat vasoconstriction during the agonal phase, enhance organ blood flow, and potentially lower incidence of delayed renal graft function 1
• Administration: Prior to withdrawal of life support 1
• Requirement: Specific informed consent should be obtained 1

Analgesics

• Medications: Morphine and/or other analgesics 1
• Purpose: Minimize discomfort in the dying patient according to accepted end-of-life protocols 1
• Administration: At the discretion of the patient's treating care team 1
• Note: Procurement team members should not participate in decisions regarding the use of such agents 1

Monitoring and Procedural Considerations

Arterial Line Placement

• An arterial line should be routinely placed prior to WLST to:
  • Accurately determine loss of circulation
  • Monitor duration of functional donor warm ischemia time (f-DWIT)
  • Ensure lack of brain perfusion when normothermic regional perfusion (NRP) is utilized 1

Location for WLST

• Optimally, withdrawal should occur in the operating room to reduce recovery time for organs after death 1
• Family should be offered similar support during withdrawal as they would experience in the ICU 1

Ethical Considerations

Informed Consent

• Specific, informed consent must be obtained for all antemortem medications administered to facilitate organ donation 1
• The possibility that the patient may not die or may not provide transplantable organs should be communicated to the decision maker(s) 1

Separation of Roles

• Members of the procurement team should not be present at the time of withdrawal of support and until the declaration of death 1
• The patient's treating care team should monitor the patient and note the time of cessation of cardiorespiratory function 1

Common Pitfalls and Caveats

1. Timing of heparin administration: Administering heparin during the agonal phase rather than before WLST may result in inadequate circulation of the anticoagulant 1

2. Failure to obtain specific consent: Antemortem interventions require specific informed consent from the patient's legal decision maker(s) 1

3. Blurring of roles: Procurement team members should never participate in decisions regarding the use of analgesics or other end-of-life medications 1

4. Inconsistent practices: Variability exists in heparin dosing and timing based on hospital and organ procurement organization (OPO) policies 1

5. Overlooking arterial line placement: Failure to place an arterial line may result in inaccurate determination of functional donor warm ischemia time 1

The American Society of Transplant Surgeons strongly recommends these medication protocols to optimize organ viability while maintaining ethical standards in the organ donation process 1.