What is the best way to care for a brain dead patient who is a potential organ donor?

Management of Brain-Dead Potential Organ Donors

The optimal care of brain-dead organ donors requires aggressive hemodynamic and metabolic management using a standardized protocol that includes euvolemia, vasopressor optimization, hormonal resuscitation, and meticulous correction of metabolic derangements to maximize the number and quality of transplantable organs. 1

Initial Hemodynamic Stabilization

The foundation of donor management begins with conventional hemodynamic optimization before any organ assessment 1:

• Target central venous pressure 6-10 mm Hg through volume resuscitation with 1000 mL balanced salt solution bolus, followed by hourly maintenance fluids of 100-150 mL plus urinary output replacement 1, 2
• Maintain mean arterial pressure ≥60-65 mm Hg initially, with goal-directed protocols showing better outcomes when MAP is maintained ≥65 mm Hg 1, 3
• Rapidly taper norepinephrine and epinephrine in favor of dopamine (<10 µg/kg/min) or dobutamine (<10 µg/kg/min) to avoid myocardial oxygen demand and high-energy phosphate depletion 1

Metabolic Correction

Aggressive correction of metabolic perturbations is essential before declining any organs 1, 4:

• pH 7.40-7.45 (acceptable range 7.3-7.5 per goal-directed protocols) 1, 3
• PaO₂ >80 mm Hg with O₂ saturation >95% (goal-directed protocols target PaO₂/FiO₂ ≥300) 1, 3
• PCO₂ 30-35 mm Hg 1
• Hematocrit 30%, hemoglobin 10 g/dL 1
• Sodium <155 mEq/L 3
• Blood glucose ≤180 mg/dL with insulin therapy 3
• Meticulous potassium supplementation and electrolyte management 2

Hormonal Resuscitation Protocol

When left ventricular ejection fraction is <45% or hemodynamic instability persists despite conventional management, implement aggressive hormonal resuscitation with pulmonary artery catheter placement 1:

The three-component hormonal therapy includes:

1. Triiodothyronine (T₃): 4-µg bolus, then continuous infusion at 3 µg/h 1
2. Arginine vasopressin: 1-U bolus, then continuous infusion at 0.5-4 U/h, titrated to systemic vascular resistance of 800-1200 dyne·s⁻¹·cm⁻⁵ 1
3. Methylprednisolone: 15-mg/kg bolus 1

Important caveat: While the American College of Cardiology historically stated that thyroid hormone supplementation should NOT be routinely used in brain-dead donors noting "the efficacy of such therapy is unproved," the consensus conference recommendations from Circulation advocate for its use as part of aggressive management when ventricular dysfunction is present 2, 1. A 2013 meta-analysis showed triiodothyronine did not add hemodynamic benefits versus standard management, but the Papworth program demonstrated that 92% of organs failing initial criteria could be functionally resuscitated using combined hemodynamic and hormonal management, resulting in 30% donor pool expansion 5, 1.

Diabetes Insipidus Management

Brain death commonly causes diabetes insipidus requiring specific treatment 2, 4:

• Vasopressin infusion for diabetes insipidus as described above 2
• Monitor for hypernatremia and maintain sodium <155 mEq/L 3

Goal-Directed Protocol Targets

Multifaceted goal-directed protocols are associated with more recovered and transplanted organs, fewer donor losses from cardiovascular collapse, and less primary graft dysfunction 3:

• ≤1 vasopressor 3
• Vasopressin use (as opposed to high-dose catecholamines) 3
• Thyroid hormone administration 3
• All metabolic targets as listed above 3

Pulmonary Artery Catheterization

Strongly consider PA catheter placement for physiological assessment and management guidance, particularly when echocardiography shows LVEF <45% 1. The Papworth Hospital program increased donor yield substantially by using PA catheters to guide physiological assessment rather than relying solely on echocardiography, which may be inaccurate or fail to predict long-term ventricular function 1.

Critical Pitfalls to Avoid

• Never decline organs based on single echocardiographic assessment alone without attempting hemodynamic and metabolic optimization 1
• Avoid high-dose β-agonists (dopamine >10 µg/kg/min) which increase myocardial oxygen demand and deplete high-energy phosphates 1
• Do not use norepinephrine or epinephrine as first-line vasopressors; taper rapidly if already in use 1
• Recognize that suboptimal, unstandardized critical care management is one of the main reasons for insufficient organ procurement 4

Multidisciplinary Involvement

Active involvement of cardiologists, pulmonologists, intensive care specialists, and surgeons in brain-dead donor management is highly desirable 1. Organ procurement organizations should use standardized protocols accepted in advance by regional organ-specific recovery teams and implemented independently by OPO staff 1.