The optimal hormonal replacement modality selection for multiple organ procurement from brain-dead organ donors

Abstract Background Brain death frequently induces hemodynamic instability and cardiac stunning. Impairments in cardiac performance are major contributors to hearts from otherwise eligible organ donors not being transplanted. Deficiencies in pituitary hormones (including thyroid-stimulating hormone) may contribute to hemodynamic instability, and replacement of thyroid hormone has been proposed as a means of improving stability and increasing hearts available for transplantation. Intravenous thyroxine is commonly used in donor management. However, small controlled trials have not been able to demonstrate efficacy. Methods This multicenter study will involve organ procurement organizations (OPOs) across the country. A total of 800 heart-eligible brain-dead organ donors who require vasopressor support will be randomly assigned to intravenous thyroxine for at least 12 h or saline placebo. The primary study hypotheses are that thyroxine treatment will result in a higher proportion of hearts transplanted and that these hearts will have non-inferior function to hearts not treated with thyroxine. Additional outcome measures are the time to achieve hemodynamic stability (weaning off vasopressors) and improvement in cardiac ejection fraction on echocardiography. Discussion This will be the largest randomized controlled study to evaluate the efficacy of thyroid hormone treatment in organ donor management. By collaborating across multiple OPOs, it will be able to enroll an adequate number of donors and be powered to definitively answer the critical question of whether intravenous thyroxine treatment increases hearts transplanted and/or provides hemodynamic benefits for donor management. Trial registration ClinicalTrials.govNCT04415658. Registered on June 4, 2020

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How nurses shift from care of a brain-injured patient to maintenance of a brain-dead organ donor

American Journal of Critical Care ◽

10.4037/ajcc2001.10.5.306 ◽

2001 ◽

Vol 10 (5) ◽

pp. 306-312 ◽

Cited By ~ 21

Author(s):

L Day

Keyword(s):

Critical Care ◽

Organ Procurement ◽

Injured Patient ◽

Organ Donor ◽

Critical Care Nurses ◽

Organ Donors ◽

Early Referral ◽

Brain Injured Patient ◽

Brain Injured ◽

Brain Dead

BACKGROUND: The responsibility of obtaining organs for transplantation rests partly on critical care nurses. How nurses balance care of critically ill, brain-injured patients with the professional responsibility to procure organs is a question of ethical and clinical importance. OBJECTIVES: To describe the experiences of critical care nurses in making the shift from caring for a brain-injured patient identified as a potential organ donor to maintaining a brain-dead body. METHODS: An interpretive, phenomenological design was used. In 2 trauma centers, 9 critical care nurses were interviewed, and 2 of the 9 nurses were observed. RESULTS: Identification of potential organ donors is made under conditions of prognostic ambiguity. The transition from brain injury to brain death is a period of instability in which the critical care team must decide quickly whether to resuscitate a patient in order to procure organs. After a patient is brain dead, critical care nurses' relationship with and responsibility toward the patient change. CONCLUSIONS: The process of identifying potential organ donors and holding open the tentative possibility of organ procurement illustrates the practical difficulties of early referral of potential donors to organ procurement organizations. Early referral to an organ procurement organization implies a commitment to organ procurement that some nurses may hesitate to make because such a commitment changes their relationship with a brain-injured patient.

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Never Declared Brain Dead Potential Organ Donors—An Additional Source of Donor Organs?

Progress in Transplantation ◽

10.1177/1526924817746683 ◽

2017 ◽

Vol 28 (1) ◽

pp. 43-48 ◽

Cited By ~ 2

Author(s):

Patricia A. Webster ◽

Lori E. Markham

Keyword(s):

Outcome Measures ◽

Organ Procurement ◽

Retrospective Chart Review ◽

Donation After Cardiac Death ◽

Organ Donors ◽

Additional Source ◽

Imminent Death ◽

Brain Dead ◽

Injured Patients ◽

Donor Organs

Context: Patients never declared brain dead may represent an additional source of donor organs. Objective: To determine the number of likely brain dead potential donors who are never declared brain dead and to compare them with brain dead and donation after cardiac death potential organ donors. Design, Setting, and Participants: This study was a retrospective chart review of all catastrophically brain-injured patients referred to a single-organ procurement organization (OPO) over a 4-year period. This study identified 159 likely brain dead potential organ donors, 902 brain dead potential organ donors, and 357 potential donation after circulatory death donors over a 4-year period. Interventions: None. Main Outcome Measures: This study did not predetermine outcome measures before data collection because the study group, likely brain dead potential organ donors, had not previously been described. Results: Likely brain dead potential donors were significantly older than brain dead potential donors ( P < .0001) but were otherwise not different demographically. They were more likely to be a late referral to the OPO ( P < .0001) and less likely to be in the donor registry ( P < .0001). The most commonly identified factors associated with a failure to declare brain death were an unwillingness to continue supportive care by the family, premention of donation, a nontimely imminent death referral, known prior objection to donation, terminal instability, and a lack of cooperation with the OPO.

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Whole Blood Thiamine in Organ Donors After the Neurologic Determination of Death

Progress in Transplantation ◽

10.1177/15269248211024607 ◽

2021 ◽

pp. 152692482110246

Author(s):

Robert S. Ream ◽

Michelle Piole ◽

Eric S. Armbrecht ◽

Gary F. Marklin ◽

Jeremy S. Garrett

Keyword(s):

Lactic Acidosis ◽

Whole Blood ◽

Thiamine Deficiency ◽

Organ Procurement ◽

Vitamin B1 ◽

Organ Donors ◽

Donor Population ◽

Hospital Stays ◽

Brain Dead

Introduction: Metabolic resuscitation of organ donors and the attenuation of oxidative stress incurred by organs following brain death and transplantation have the potential to improve organ yield and allograft function. Thiamine (vitamin B1) is a vital coenzyme in both energy metabolism and the production of antioxidants that has not been studied in the donor population. Research Aim: To determine the frequency of subclinical thiamine deficiency in brain-dead organ donors and its correlation with demographics, length of hospitalization, donor management, lactic acidosis, and the requirement for vasoactive support. Design: Prospective cohort study of brain-dead donors managed at a single organ procurement organization’s organ recovery facility. Results: A total 64 donors were enrolled; 24 donors had thiamine levels drawn upon arrival and 40 donors had levels drawn at the time of organ procurement. Whole blood thiamine levels were inversely correlated with the time from death (P = .007) and 20% (8/40) of donors had levels below the normal range at the time of organ procurement. Demographic features of the donor were not associated with thiamine levels although longer hospital stays prior to death were associated with lower levels ( P < .05). The presence and resolution of lactic acidosis was not associated with whole blood thiamine level. Higher thiamine levels were associated with earlier discontinuation of vasoactive support ( P = .04). Discussion: Whole blood thiamine deficiency was not uncommon at the time of organ procurement. Thiamine may be associated with the requirement for hemodynamic support.

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Effects of Terlipressin on Management of Hypotensive Brain-Dead Patients Who are Potential Organ Donors: A Retrospective Study

Frontiers in Pharmacology ◽

10.3389/fphar.2021.716759 ◽

2021 ◽

Vol 12 ◽

Author(s):

Donghua Zheng ◽

Genglong Liu ◽

Li Chen ◽

Wenfeng Xie ◽

Jiaqi Sun ◽

...

Keyword(s):

Renal Function ◽

Retrospective Study ◽

Liver Function ◽

Estimated Glomerular Filtration Rate ◽

Organ Procurement ◽

Venous Pressure ◽

Organ Donors ◽

Hemodynamic Stability ◽

Norepinephrine Dose ◽

Brain Dead

Background: Administration of terlipressin can reverse hypotension in potential organ donors with norepinephrine-resistance. The aim of this study was to determine the effects of terlipressin on the hemodynamics, liver function, and renal function of hypotensive brain-dead patients who were potential organ donors.Methods: A retrospective study was conducted by using the ICU database of one hospital. 18 patients in a total of 294 brain-dead cases were enrolled and administered terlipressin intravenously. All physiological parameters of recruited patients were obtained at baseline, 24 and 72 h after administration, and immediately before organ procurement.Results: Terlipressin induced significant increases in mean arterial pressure (MAP) from 69.56 ± 10.68 mm Hg (baseline) to 101.82 ± 19.27 mm Hg (immediately before organ procurement) and systolic blood pressure (SBP) from 89.78 ± 8.53 mm Hg (baseline) to 133.42 ± 26.11 mm Hg (immediately before organ procurement) in all patients. The increases in MAP were accompanied by significant decreases in heart rate (HR) from 113.56 ± 28.43 bpm (baseline) to 83.89 ± 11.70 bpm (immediately before organ procurement), which resulted in the decrease of norepinephrine dose over time from 0.8 ± 0.2 μg/kg/min (baseline) to 0.09 ± 0.02 μg/kg/min (immediately before organ procurement). There were no changes in central venous pressure, liver function including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin. Renal function, assessed by serum creatinine (SCr), urine output (UOP), creatinine clearance rate (CCr), and estimated glomerular filtration rate (eGFR), improved significantly.Conclusion: Our analysis of brain-dead patients with hypotension indicates that administration of terlipressin can significantly increases MAP, SBP, UOP, CCr, and eGFR, while decreases HR and Scr. Terlipressin appears to help maintain hemodynamic stability, reduce vasoactive support, and improve renal function.

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Intraoperative management of brain-dead organ donors by anesthesiologists during an organ procurement procedure: results from a French survey

BMC Anesthesiology ◽

10.1186/s12871-019-0766-y ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 1

Author(s):

Benoit Champigneulle ◽

◽

Arthur Neuschwander ◽

Régis Bronchard ◽

Gersende Favé ◽

...

Keyword(s):

Organ Procurement ◽

Organ Donors ◽

Intraoperative Management ◽

Brain Dead ◽

Procurement Procedure

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Organ Donation and Declaration of Death: Combined Neurologic and Cardiopulmonary Standards

The Linacre Quarterly ◽

10.1177/0024363919840129 ◽

2019 ◽

Vol 86 (4) ◽

pp. 285-296

Author(s):

Stephen E. Doran ◽

Joseph M. Vukov

Keyword(s):

Brain Death ◽

Organ Donation ◽

Conflict Of Interest ◽

Life Support ◽

Organ Procurement ◽

Organ Donors ◽

Neurologic Injury ◽

Brain Dead ◽

Moral Certainty ◽

Death By Neurologic Criteria

Prolonged survival after the declaration of death by neurologic criteria creates ambiguity regarding the validity of this methodology. This ambiguity has perpetuated the debate among secular and nondissenting Catholic authors who question whether the neurologic standards are sufficient for the declaration of death of organ donors. Cardiopulmonary criteria are being increasingly used for organ donors who do not meet brain death standards. However, cardiopulmonary criteria are plagued by conflict of interest issues, arbitrary standards for candidacy, and the lack of standardized protocols for organ procurement. Combining the neurological and cardiopulmonary standards into a single protocol would mitigate the weaknesses of both and provide greater biologic and moral certainty that a donor of unpaired vital organs is indeed dead. Summary: Before a person’s organs can be used for transplantation, he or she must be declared “brain-dead.” However, sometimes when someone is declared brain-dead, that person can be maintained on life-support for days or even weeks. This creates some confusion about whether the person has truly died. For patients who have a severe neurologic injury but are not brain-dead, organ donation can also occur after his or her heart stops beating. However, this protocol is more ambiguous and lacks standardized protocols. We propose that before a person can donate organs, he or she must first be declared brain-dead, and then his or her heart must irreversibly stop beating before organs are taken.

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Intraoperative Management of Brain-dead Organ Donors by Anesthesiologists during an Organ Procurement Procedure: Results from a French survey

10.21203/rs.2.151/v1 ◽

2019 ◽

Author(s):

Benoit Champigneulle ◽

Arthur Neuschwander ◽

Régis Bronchard ◽

Gersende Favé ◽

Julien Josserand ◽

...

Keyword(s):

Organ Procurement ◽

Anesthetic Management ◽

Organ Donors ◽

French Society ◽

Anesthetic Drugs ◽

Intraoperative Management ◽

Brain Dead ◽

Icu Management ◽

Procurement Procedure ◽

High Level

Abstract Background: There is no specific guidelines concerning intraoperative management of brain-dead donors (BDD) during organ procurement (OP). This study aimed at describing usual anesthetic practices for BDD during an OP procedure and to assess the knowledge and self-confidence of French anesthesiologists with this practice. Methods: An electronic, national and anonymous survey with closed-questions about anesthetic management of BDD was distributed to French anesthesiologists via the mailing list of the French Society of Anesthesiology and Intensive Care. The questionnaire included questions concerning monitoring, intraoperative resuscitation, anesthetic drugs use and confidence of the respondents. Results: 458 responses were analyzed. Respondents were mainly attending physicians with more than 10 years of professional experience, equally distributed between university and non-university centers. Seventy-eight percent of them declared knowledge about guidelines regarding ICU management of BDD. Advanced hemodynamic monitoring and endocrine substitution were poorly considered by respondents (31% and 35% of respondents, respectively). 98% of the respondents used crystalloids for fluid resuscitation. During the procedure, use of neuromuscular blockers, opioids and sedative agents were considered by respectively 84%, 61% and 27% of the respondents. A very high level of agreement (10 [8-10], on a ten-points Likert-style scale) was reported concerning the expected impact of intraoperative anesthetic management on the primary function of grafts. Conclusions: Declared anesthetic practice appeared in accordance with guidelines concerning ICU management of organ donors. Further studies are needed to evaluate the specific impact of intraoperative management during this procedure and thus the need for specific anesthetic guidelines.

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