Management of Brain-Dead Potential Organ Donors

Initial Hemodynamic Stabilization

The American College of Cardiology recommends target central venous pressure 6-10 mm Hg through volume resuscitation with 1000 mL balanced salt solution bolus, followed by hourly maintenance fluids of 100-150 mL plus urinary output replacement 1, 3
Maintain mean arterial pressure ≥60-65 mm Hg initially, with goal-directed protocols showing better outcomes when MAP is maintained ≥65 mm Hg 1
Rapidly taper norepinephrine and epinephrine in favor of dopamine (<10 µg/kg/min) or dobutamine (<10 µg/kg/min) to avoid myocardial oxygen demand and high-energy phosphate depletion 1, 2

Maintain pH 7.40-7.45 (acceptable range 7.3-7.5 per goal-directed protocols) 1
Maintain PaO₂ >80 mm Hg with O₂ saturation >95% (goal-directed protocols target PaO₂/FiO₂ ≥300) 1
Maintain PCO₂ 30-35 mm Hg 1
Maintain hematocrit 30%, hemoglobin 10 g/dL 1
Meticulous potassium supplementation and electrolyte management 3

The American College of Cardiology recommends a three-component hormonal therapy including triiodothyronine (T₃), arginine vasopressin, and methylprednisolone for brain-dead donors with left ventricular ejection fraction <45% or hemodynamic instability 1, 2
Triiodothyronine (T₃): 4-µg bolus, then continuous infusion at 3 µg/h 1, 2
Arginine vasopressin: 1-U bolus, then continuous infusion at 0.5-4 U/h, titrated to systemic vascular resistance of 800-1200 dyne·s⁻¹·cm⁻⁵ 1, 2
Methylprednisolone: 15-mg/kg bolus 1, 2

Strongly consider PA catheter placement for physiological assessment and management guidance, particularly when echocardiography shows LVEF <45% 1, 2

Never decline organs based on single echocardiographic assessment alone without attempting hemodynamic and metabolic optimization 1, 2
Avoid high-dose β-agonists (dopamine >10 µg/kg/min) which increase myocardial oxygen demand and deplete high-energy phosphates 1
Do not use norepinephrine or epinephrine as first-line vasopressors; taper rapidly if already in use 1