Anesthesia Management for Brain-Dead Organ Donors

Introduction to Brain-Dead Organ Donor Management

Brain-dead organ donors require intensive hemodynamic, metabolic, and hormonal management to optimize organ viability and prevent cardiovascular collapse during procurement, as recommended by the American College of Cardiology 1, 2

Brain-dead donors are legally deceased and do not experience pain or awareness, according to the American Journal of Transplantation 3, 4

The primary management goals can be remembered as the "Rule of 100": systolic blood pressure >100 mmHg, urine output >100 mL/hr, PaO₂ >100 mmHg with O₂ saturation >95%, and hemoglobin >100 g/L, as recommended by the American College of Cardiology 1
Administer 1000 mL balanced salt solution bolus immediately, and maintain with hourly infusions of 100-150 mL plus previous hour's urinary output replacement, as recommended by the American College of Cardiology 1, 2, 5
Target central venous pressure 6-10 mm Hg, as recommended by the American College of Cardiology 1, 5
Rapidly taper norepinephrine and epinephrine, as they are detrimental to organ viability, and use arginine vasopressin, dopamine, and dobutamine instead, as recommended by the American College of Cardiology 1, 5

For donors with LVEF <45% or hemodynamic instability, implement three-component hormonal therapy: triiodothyronine, arginine vasopressin, and methylprednisolone, as recommended by the American College of Cardiology 1

Maintain pH 7.40-7.45, PaO₂ >80 mmHg with goal PaO₂/FiO₂ ≥300, and PCO₂ 30-35 mmHg, as recommended by the American College of Cardiology 1
Perform frequent arterial blood gas analysis to guide ventilator adjustments, as recommended by the American College of Cardiology 5

Brain death causes neurogenic pulmonary edema requiring frequent endotracheal suction, positive end-expiratory pressure (PEEP), and lung-protective ventilation strategies, as recommended by the American College of Cardiology 5

Use continuous intraarterial pressure monitoring, central venous pressure monitoring, and urinary catheter with hourly output measurement, as recommended by the American College of Cardiology 2
Consider pulmonary artery catheter placement when LVEF <45% for precise hemodynamic assessment, as recommended by the American College of Cardiology 1

Never decline organs based on single echocardiographic assessment without attempting full optimization, as recommended by the American College of Cardiology 1
Avoid norepinephrine/epinephrine as first-line agents, as they damage organs, and do not allow dopamine infusions >10 µg/kg/min, as recommended by the American College of Cardiology 1, 5
Never allow transplant team involvement in brain death determination or withdrawal decisions, as this represents a conflict of interest, according to the American Journal of Transplantation 6, 7