[MUSIC] Managing a donor well is essential to maximize the amount of good that can come out of organ donation. In South Africa, there is sometimes resistance to devoting resources to someone who is already dead. And yet the investment of a limited amount of time and resources has the potential to benefit many people for many years. If one were to perform seven solid organ transplants from a single donor, the average number of life-years gained by the recipients would be 53 years. The average amount of time taken to sort out the logistics of that many transplants is just under 24 hours. In our setting a multi-organ donor is typically managed overnight with a procurement operation scheduled to occur first thing in the morning. The tissue typing laboratory works through the night as does the donor transplant coordinator, arranging flights, theater times and surgical teams. The recipient coordinator is doing the same for recipients to have them in hospital and ready for surgery in time. Brain death is often associated with marked physiological instability. This needs to be actively managed to prevent deterioration in organ function prior to organ procurement. In some cases, the deterioration can be so severe as to prevent successful donation. We do not routinely transfer donors from referring hospitals, preferring to take the transplant team to the donor because of the risks inherent in moving such unstable patients. The management of a potential donor must start early, and the referring clinical team needs to actively manage the patient until the transplant team can takeover after death is declared. There is not much difference between the management of a severely ill patient with multiple organ failure and the potential donor. Only treatments provided for neurological reasons, osmotherapy or management of cerebral profusion pressure, can be stopped in a donor. All other treatments and care, especially vasopressors and mechanical ventilation must be continued. ICU monitoring in the form of continuous ECG tracing, intra-arterial blood pressure monitoring, pulse oximetry and urine output monitoring are essential. A CVP may be required for inotropes. Suggested targets for active management of brain dead donors are a heart rate between 60 to 120 beats per minute, an arterial pressure with a systolic pressure above 90 millimeters of mercury, or a mean pressure of greater than 70 millimeters of mercury. Urine output should be more than half a ml/kg/hr. For electrolytes, a serum sodium of 130 to 150 mmol/L is acceptable, while potassium, magnesium, and phosphate should be kept within their normal ranges. The donor's glucose level should be kept between 6 to 10 mmol/L and blood gases should strive for normality, with a normal pH of 7.35 to 7.45, a normal carbon dioxide level of 4.6 to 6 kPa, and a normal oxygen level of more than 8 kPa. Peripheral oxygenation saturation should be more than 90%. Hemoglobin can be maintained between 7 to 9 g/dL and the lactate should be normal. Active management is important, because there are a number of physiological complications that typically occur in the brain-dead patient. Hypertension can be followed by a precipitous drop in the blood pressure, when the catecholamine surge or sympathetic storm that can occur with brain death wears off. Hypotension occurs in 81 to 97% of donors. It is typically multifactorial in nature and occurs on the basis of vasodilatation, myocardial depression, and excessive urinary losses. It should be managed by judicious use of intravenous fluid resuscitation and by vasopressor drugs when there is no longer any response to fluid administration. Different organs prefer different strategies to maintain stable haemodynamics. Lungs are particularly sensitive to excessive fluid administration, and the heart is particularly sensitive to vasopressor and inotropic drugs. Hypothermia is invariable, if not prevented. The core temperature should be maintained above 35 degrees with active warming blankets. This helps to prevent arrhythmias and coagulation disorders. Diabetes Insipidus occurs in 46 to 78% of donors and is secondary to damage of the posterior pituitary in the brain. I have seen donors with a urine output of over a liter per hour. If this loss of fluid is not actively replaced, the donor can become quickly shocked. Giving DDAVP can help control the urine output in such cases. Hypernatraemia occurs in up to 45% of patients with brain death, as the body retains sodium secondary to the polyuria. This can have an adverse effect on transplant outcomes and IV fluids should be checked to be low in sodium. Five% dextrose is commonly used as a replacement fluid. Arrhythmias, or cardiac rhythm disturbances, are also common and occur in 25 to 31% of brain dead patients. Preventing electrolyte disturbances and maintaining normothermia can help to prevent this complication. Necrotic brain tissue is a potent tissue plasminogen activator and disseminated intravascular coagulation occurs in 24- 50% of brain dead patients. Clotting factors can also be diluted by large amounts of clear fluid donors typically receive. Blood products may be required to correct coagulation deficiencies prior to going to theater. Focused donor management, preventing complications, and achieving physiological targets will prevent donors being lost to cardiovascular collapse. Standard ICU care of the donor is also important. This includes elevation of the head to 30 degrees, routine suctioning of the endotracheal tube, artificial tears, regular turning, and continued nasogastric feeds. Pharmacological management includes corticosteroids, which can help with haemodynamic instability, vasopressors, which can maintain blood pressure, once the donor is adequately volume-resuscitated, heparin prophylaxis, which prevents clot formation, and intravenous insulin to prevent episodes of hypoglycemia. Thyroid hormone levels are low in brain-dead donors, and some centers replace this. Infection Prevention Control measures, such as adequate hand hygiene before and after contact with the donor and contact precautions, such as wearing an apron and gloves, should be maintained. Lungs are the organ most frequently assessed as medically unsuitable for transplantation. This is due to damage caused by fluid therapy and mechanical ventilation. Only 10 to 20% of lungs from multi-organ donors are able to be transplanted. Lung protective ventilation strategies with low tidal volumes of 6 to 8 ml/kg and a PEEP of 8 to 10 cm H2O are recommended.� Recruitment maneuvers can be used to prevent atelectasis. The administration of less intravenous fluids and giving more vasopressors to maintain the blood pressure will improve lung mechanics. However, this may conflict with other organs, such as the heart and the kidneys, which prefer fluids. Where available, a cardiac output monitor, or pulmonary artery catheter, and consultation with an intensivist can be used to further refine and guide haemodynamic therapy in difficult to manage patients. To recap, donors are often unstable and need ongoing resuscitation. Donor management is an active process and must take into account the complications associated with brain death. [MUSIC]
