Vasopressin in Organ Donor Management: Effect on Pulmonary Permeability

Mechanism of Action and Pulmonary Benefit

• The American College of Cardiology suggests that brain death is associated with neurogenic pulmonary edema of low pressure that requires frequent endotracheal suction and positive end-expiratory pressure (PEEP) 1, 2, 3, 4.

Specific Indications in Organ Donors

• The American College of Cardiology recommends maintaining urinary output <150 ml/h with titrated parenteral vasopressin infusion for diabetes insipidus 1, 2, 3, 4.

Recommended Management Protocol

Hemodynamic Objectives

• The American College of Cardiology suggests maintaining systolic blood pressure >100 mm Hg with central venous pressure of 10-12 mm Hg 1, 2, 3, 4.
• The American College of Cardiology recommends titrating dopamine to maintain systolic performance, but avoiding infusions >7.5-10 µg/kg/min 1, 2, 3, 4.
• The American Heart Association suggests rapidly reducing norepinephrine and epinephrine in favor of dopamine or dobutamine 5.

Fluid and Electrolyte Management

• The American College of Cardiology recommends initiating fluid resuscitation with a 1,000 ml bolus of balanced saline solution and maintaining adequate hydration with hourly infusion of 100-150 ml plus the previous hour's urinary output 1, 2, 3, 4.
• Meticulous attention to electrolyte levels, acid-base balance, and oxygenation is critical for successful organ donation 6.

Respiratory Management

• The American College of Cardiology suggests that all donors are ventilator-dependent and frequent analysis of arterial blood gases allows for correction of inadequate oxygenation and alterations in pulmonary function 1, 2, 3, 4.
• Frequent endotracheal suction and positive end-expiratory pressure (PEEP) are required for neurogenic pulmonary edema 1, 2, 3, 4.

Important Warnings

Hypertensive Effect

• The American College of Cardiology notes that the hemodynamic instability of the donor may be evidenced by hypertension as well as hypotension, and an increase in systolic pressure results when vasopressin is used 1, 2, 3, 4.
• Sodium nitroprusside is the preferred drug for rapid and effective reduction of afterload when hypertension occurs 1, 2, 3, 4.