Brain Death and Management of the Potential Organ Donor

A structured and standardized approach to the diagnosis of brain death is essential to ensure that patients are appropriately classified. This involves a physical exam to establish coma and exclude reversible causes of coma, a comprehensive evaluation of the cranial nerves, and an apnea test. The inability to perform any of the physical exam elements necessitates the use of confirmatory studies. Management of the potential organ donor commences after the diagnosis of brain death is established. Donation after cardiac death should be considered in patients whose prognosis is futile and in whom care is to be withdrawn. Specific donor management goals have been established and have been associated with greater organ procurement. Hemodynamic management forms the cornerstone of brain-dead donor management. Echocardiography should be performed in all potential donors to evaluate cardiac function. Fluid resuscitation is frequently necessary as potential donors tend to be intravascularly volume depleted. Vasopressors should be used to support acceptable blood pressure and hemodynamic profiles. Donor lung management should utilize a lung protective strategy with ventilatory manipulations undertaken to ensure adequate systemic oxygenation and lung expansion. A coordinated, active donor management approach utilizing intensivists and OPO coordinators has been shown to more effectively manage the donation process, resulting in more organs procured and transplanted.