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ICU and trauma · Core13 / 13

Brain-dead donor for multi-organ retrieval34-year-old man, 80 kg, after a massive intracerebral haemorrhage

Organ donation: brain-death physiology, diabetes insipidus and donor optimisation

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Know this first

  • Testing needs core temperature 36 °C or more and SBP 100 or more.
  • Apnoea test: pH under 7.30 and PaCO2 60 or more, 20 above baseline.
  • Diabetes insipidus affects as many as 90% of donors after brain death.
  • Donor lungs: 6–8 mL/kg, PEEP 8–10, peak under 35 cmH2O.
  • Glucose 120–180 mg/dL; sodium under 155 mmol/L.

The patient

34-year-old man, 80 kg, after a massive intracerebral haemorrhage; brain death confirmed on clinical tests and EEG; family consented through SCOT. Urine 450 mL/h, sodium 156 mmol/L, glucose 14 mmol/L; temperature 35.4 °C. Drugs: noradrenaline 0.3 mcg/kg/min. Multi-organ retrieval tonight. Vitals: BP 82/48 (MAP 59), HR 118, SpO2 95% on FiO2 0.5, PEEP 8.

The examiner asks

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  1. Consider

    What are your considerations?

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    • A 34-year-old brain-dead donor for multi-organ retrieval; I'm now protecting his organs. Patient
    • Testing needed core temperature of 36 or more and systolic of 100 or more. Disease
    • Apnoea test: no breaths, pH under 7.30, PaCO2 60 or more and 20 above baseline.
    • In Saudi Arabia an EEG is required to confirm the diagnosis.
    • SCOT coordinators approach the family for consent, not the treating team alone.
    • Spinal reflexes may persist; they don't mean he's aware.

  2. Plan

    How do you manage him for retrieval?

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    • MAP 60–100 with fluids first and the least vasopressor possible. Disease
    • High-dose catecholamines harm grafts; vasopressin spares them.
    • Donor lungs: 6–8 mL/kg, PEEP 8–10, peak pressure under 35.
    • Glucose 120–180 mg/dL with insulin; his 14 mmol/L is above that.
    • Thyroid hormone and methylprednisolone improve organ yield.
    • Relaxant during retrieval, since spinal reflexes can move him. Surgery
    • Heparin ready when the surgeons ask for it.

  3. Crisis

    Over the next 2 hours, urine output is 600 mL/h and sodium rises to 162 mmol/L. What do you do?

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    • Central diabetes insipidus; as many as nine in ten such donors develop it. (Crisis)
    • Desmopressin 2–4 mcg SC, or vasopressin, which treats it as well.
    • Once he's filled, replace losses with 0.45% saline or dextrose.
    • Sodium above 155 harms the liver graft, so I bring it down.
    • Potassium, magnesium and phosphate checked and replaced.

  4. Crisis

    BP falls to 70/40 despite noradrenaline at 0.5 mcg/kg/min; echo shows a well-filled, well-contracting heart. What now?

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    • Vasoplegia: add vasopressin instead of pushing noradrenaline higher. Crisis
    • Vasopressin infusion at 0.03 units/min.
    • Hormone rescue: thyroid hormone and methylprednisolone if not yet given.
    • Warm him; he has lost temperature control and is cooling.
    • Tell the retrieval teams; retrieval brought forward if he keeps sliding. After surgery

Fatal mistakes

  • Leaving diabetes insipidus untreated.
  • High-dose catecholamines with no vasopressin.
  • Injurious ventilation of donor lungs.

Checked against: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM (2023) · Do not resuscitate, brain death, and organ transplantation: Islamic perspective (2017) · Miller 10e · Barash 9e

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