Organ Donation
Last modified: 19 May 2023, 9:41:48 AM AEST
Gems1 / 9
- Warm ischaemia time
- SBP < 50 mmHg
- SaO2 < 70%
- time from withdrawal of treatment to onset of cold perfusion = cold ischaemia
- Functional warm ischaemia
- Donor SBP < 50
- Donor SpO2 < 70
- Ends with cold perfusion
- Warm ischaemia time
- Kidney
- 2 hours (BJAE)
- 60 mins
- Lung
- 1 hour (BJAE)
- Time to re-inflation of lungs is more critical
- 90 mins
- Liver
- 30 mins
- DCD grafts have higher M+M than with DBD grafts
- Pancreas
- 30 mins
- Kidney
- Maintain patient dignity throughout donation process
Indications2 / 9
- Donation after Cardiac Death = DCD
- irreversible cessation of circulatory function
- Donation after Brain Death = DBD
- irreversible cessation of brain / brainstem function
- DD = Deceased Donor
- Live = related / unrelated
- Autologous = same patient, eg. bone marrow stem cell
Suitable organs3 / 9
- heart, lungs
- kidneys, liver, pancreas
- trachea, bowel, skin, cornea
Contraindications4 / 9
- Absolute
- HIV disease (HIV infection is ok)
- CJD / suspected CJD
- Relative
- Patient / family refusal
- Systemic malignancy (except eye)
- Systemic sepsis
- Donor age
- heart = 40
- liver = 50
- kidneys = 70
DBD = Donation after Brain Death5 / 9
- Pre-op
- confirm brainstem death
- Blood group, EUC, HIV, hepatitis
- discuss with coroner and obtain permission
- Intra-op
- IVF +/- vasopressin, dobutamine
- Consider CO monitor
- protective ventilation strategy
- Treat DI with DDAVP
- Post-op
DCD = Donation after Cardiac Death6 / 9
- consider in all patients for withdrawal of treatment
- life support is withdrawn IN the operating room
- death is confirmed 2 minutes after asystole
- organ harvest can begin 5-10 minutes after asystole
Anaesthetic considerations (DBD)7 / 9
- Pre-op
- Much more organised, enough time for timeout etc once patient arrives in OT
- Slower and more dignified
- Intra-op
- Administration of drugs
- AB = Cefotaxime
- Methylprednisolone 1 g
- Cross-clamp to aorta
- Incision to Aorta
- Exsanguination
- B = Respiratory
- Lung-protective ventilation (continue)
- Minimise FiO2
- C = Cardiovascular
- Myocardial damage may be present from catecholamine storm
- maintain euvolaemia
- MAP 60-70
- UO 1-3 mL/kg/hr
- CI > 2.4 L/min/m2
- Vasopressin for vasodilatory shock
- E = Endocrine
- Beware diabetes insipidus
- ⬇ADH secretion = renal excretion of large volumes of dilute urine
- UO > 4 mL/kg/hr = ⬆risk
- replace fluids = hypotonic IVF
- replace ADH = vasopressin
- 1 iu boluses then 0.01-0.04 iu/hr infusion
- Methylprednisolone 15 mg/kg
- Keep BGL < 8
- Thyroid replacement
- Beware diabetes insipidus
- D = Neurological
- NMBA as required
- F = Renal
- Isotonic fluids
- Na 135-145
- BGL < 10
- H = Haematological
- Blood products where necessary
- Administration of drugs
- Post-op
Anaesthetic considerations (DCD / NBHD)8 / 9
- NBHD = Non-beating heart donation
- Pre-op
- This is much more rushed, and needs careful planning
- Priorities
- minimise warm ischaemia time
- rapid institution of cooling post cardiac arrest
- Method
- Family say goodbye
- Ideally on OT table already (RNSH)
- Extubate in the anaesthetic bay
- Family may still be present
- disconnection from circuit
- administer opioids / benzodiazepines
- Wait 2 minutes
- Certification by ICU
- Next 5 minutes
- Patient transported to transplant OT
- Move quickly into OT
- Intra-op
- Asystole
- If lung donation
- reintubate
- Organs perfused with cold preservation solution
- Note warm ischaemia time
- the time that asystole must occur after withdrawal of care
- heart and bowel are not candidates for DCD
- Ensure no interventions that may restore cerebral blood flow
- eg. CPR / CPB / ECMO / ventilation
- Post-op
References9 / 9
https://www.life-source.org/partners/hospitals/brain-death/
Donation after circulatory death, BJAE 2011
Anesthetic considerations in organ procurement surgery: a narrative review, CJA 2015
https://resources.wfsahq.org/atotw/organ-donation-after-circulatory-death-anaesthesia-tutorial-of-the-week-282/