What is the recommended anesthesia management for an adult or pediatric patient declared brain dead with a varied medical history undergoing organ donation?

Anesthesia Management for Brain-Dead Organ Donors

Brain-dead organ donors do not require general anesthesia or neuromuscular blockade, but they do require intensive hemodynamic, metabolic, and hormonal management to optimize organ viability and prevent cardiovascular collapse during procurement. 1, 2

Critical Distinction: Brain Death vs. Donation After Cardiac Death

Brain-dead donors (DBD) are legally deceased and do not experience pain or awareness. 3 The anesthetic management focuses entirely on physiologic optimization rather than traditional anesthesia. 4, 5 This differs fundamentally from donation after cardiac death (DCD), where the patient is not yet deceased. 3

The "Rule of 100" Framework

The primary management goals can be remembered as the "Rule of 100": 4

• Systolic blood pressure >100 mmHg (preferably MAP ≥65 mmHg) 1, 4
• Urine output >100 mL/hr 4
• PaO₂ >100 mmHg with O₂ saturation >95% 1, 4
• Hemoglobin >100 g/L (10 g/dL, target hematocrit 30%) 1, 4

Hemodynamic Management Protocol

Initial Fluid Resuscitation

• Administer 1000 mL balanced salt solution bolus immediately 1, 2
• Maintain with hourly infusions of 100-150 mL plus previous hour's urinary output replacement 1, 6
• Target central venous pressure 6-10 mm Hg (some protocols use 10-12 mm Hg) 1, 6

Vasopressor Strategy (Critical Pitfall Area)

Rapidly taper norepinephrine and epinephrine—these are detrimental to organ viability. 1, 6 The preferred vasopressor hierarchy is:

1. Arginine vasopressin: 1-U bolus, then 0.5-4 U/h infusion (titrate to SVR 800-1200 dyne·s⁻¹·cm⁻⁵) 1, 6
2. Dopamine <10 µg/kg/min (preferably <7.5 µg/kg/min) 1, 6
3. Dobutamine <10 µg/kg/min 1

High-dose β-agonists increase myocardial oxygen demand and deplete high-energy phosphates, damaging transplantable hearts. 1

Managing Hypertension

If hypertension occurs (common with vasopressin), use sodium nitroprusside for rapid afterload reduction. 6

Hormonal Resuscitation Protocol

For donors with LVEF <45% or hemodynamic instability, implement three-component hormonal therapy: 1

• Triiodothyronine (T₃): 4-µg bolus, then 3 µg/h continuous infusion 1
• Arginine vasopressin: 1-U bolus, then 0.5-4 U/h infusion 1
• Methylprednisolone: 15 mg/kg bolus 1

This protocol is specifically recommended by the American College of Cardiology for unstable donors. 1

Metabolic and Respiratory Targets

Acid-Base and Oxygenation

• Maintain pH 7.40-7.45 (acceptable range 7.3-7.5) 1
• PaO₂ >80 mmHg with goal PaO₂/FiO₂ ≥300 1
• PCO₂ 30-35 mmHg 1
• Frequent arterial blood gas analysis to guide ventilator adjustments 6

Electrolyte Management

• Meticulous potassium supplementation 1
• Sodium <155 mEq/L 7
• Blood glucose ≤180 mg/dL 7

Diabetes Insipidus Management

Brain death commonly causes diabetes insipidus. Maintain urinary output <150 mL/h with titrated vasopressin infusion. 6 This simultaneously addresses both hemodynamic instability and polyuria.

Pulmonary Management

Brain death causes neurogenic pulmonary edema requiring: 6

• Frequent endotracheal suction 6
• Positive end-expiratory pressure (PEEP) 6
• Lung-protective ventilation strategies 5

Vasopressin has the added benefit of reducing pulmonary capillary permeability, improving lung function. 6

Monitoring Requirements

• Continuous intraarterial pressure monitoring 2
• Central venous pressure monitoring 2
• Urinary catheter with hourly output measurement 2
• Strongly consider pulmonary artery catheter placement when LVEF <45% for precise hemodynamic assessment 1

Common Intraoperative Problems

Hypotension

Address sequentially: 4

1. Volume resuscitation first
2. Add vasopressin
3. Add low-dose dopamine if needed
4. Avoid high-dose catecholamines

Arrhythmias

Correct underlying electrolyte abnormalities and hypothermia. 4

Coagulopathy

Maintain hemoglobin ≥10 g/dL and correct coagulation parameters as needed. 1, 4

Critical Pitfalls to Avoid

1. Never decline organs based on single echocardiographic assessment without attempting full optimization 1
2. Do not use traditional general anesthesia or neuromuscular blockade—the donor is legally deceased and cannot perceive pain 4, 5
3. Avoid norepinephrine/epinephrine as first-line agents—they damage organs 1, 6
4. Do not allow dopamine infusions >10 µg/kg/min 1, 6
5. Never allow transplant team involvement in brain death determination or withdrawal decisions—this represents a conflict of interest 3

Evidence Quality Note

The strongest evidence comes from goal-directed protocol studies showing that multifaceted approaches with specific hemodynamic targets (MAP ≥65 mmHg, ≤1 vasopressor, specific metabolic goals) significantly increase organs recovered per donor, organs transplanted per donor, and reduce donor losses from cardiovascular collapse. 7 The American College of Cardiology guidelines provide the most authoritative framework for hormonal resuscitation and hemodynamic management. 1, 2, 6