Optimal Management of Brain Death Donor

Eunmi Gil; Berm Park Jae

doi:10.4285/jkstn.2015.29.3.89

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Gil and Jae: Optimal Management of Brain Death Donor

Review Article

J Korean Soc Transplant 2015;29(3):89-100.

Published online: 10 September 2015

DOI: https://doi.org/10.4285/jkstn.2015.29.3.89

Optimal Management of Brain Death Donor

Eunmi Gil, M.D.¹, Berm Park Jae, M.D.²

¹Departments of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

²Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Corresponding author: Jae Berm Park, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: 82-2-3410-3647, Fax: 82-2-3410-0040 E-mail: jbparkmd@gmail.com

Received 1 September 2015 Revised 2 September 2015 Accepted 2 September 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Since the Harvard criteria for brain death was proposed in 1968, deceased donor, mainly brain death donor (BD), organ transplantation has been performed worldwide and given the chance for a new life to patients suffering from end-stage organ disease. In Korea by the eager efforts promoting brain-dead organ donation, fortunately, the number of organ donations from the brain-dead has increased successfully in the last decade. However, the disparity between the number of patients awaiting organ transplantation on the list and the number of actual organ donations has become wider and the organ shortage remains a limitation for new lives by transplantation. Because of donor organ restriction, optimal management of brain-dead donors is increasingly important. In addition, the favorable clinical outcomes of recipients is directly associated with the well-preserved organ function of brain-dead donors, which can be accomplished by the maintenance of optimal perfusion. However the brain-dead condition leads to various and profound pathophysiological changes in the neuroendocrine and cardiovascular systems, and management of brain-dead organ donors usually includes active intensive care for maintaining organ function. Therefore, to enhance the potential organ graft function and increase the organ supply, physicians must have knowledge of the pathophysiology of brain death and must deal with rapid hemodynamic changes, endocrine and metabolic abnormalities, and respiratory complications. This article reviews the pathophysiologic changes resulting from brain death and the adequate management for maximizing use of organs recovered from brain death donors.

Keywords: Brain death, Organ donor, Hemodynamics, Hormone replacement therapy

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Fig. 1.

Factors causing hemodynamic instability in the potential organ donor.

Table 1.

Checklist for determination of brain death

다음의 선행조건 및 판정기준에 모두 적합하여야 한다.
1. 선행조건
1) 원인질환이 확실하고 치료될 가능성이 없는 기질적인 뇌병변이 있다.
2) 깊은 혼수상태로서 자발호흡이 없고 인공호흡기로 호흡이 유지된다.
3) 치료 가능한 약물중독(마취제, 수면제, 진정제, 근육이완제 또는 독극물 등에 의한 중독)이나 대사성 또는 내분비성 장애 (간성혼수, 요독성 혼수, 또는 저혈당성 뇌증)의 가능성이 없어야 할 것
4) 저체온상태(직장온도가 섭씨 32 ^o C 이하)가 아니어야 할 것
5) 쇼크상태가 아니어야 할 것
2. 판정기준
1) 외부자극에 전혀 반응이 없는 깊은 혼수 상태
2) 자발호흡이 되살아 날 수 없는 상태로의 소실
3) 두 눈의 동공이 확대 고정되어 있을 것
4) 뇌간반사가 완전히 소실되어 있을 것
다음에 해당하는 반사가 모두 소실된 것을 말한다.
(1) 광반사(light reflex)
(2) 각막반사(corneal reflex)
(3) 안구두부반사(oculo-cephalic reflex)
(4) 전정안구반사(vestibulo-occular reflex)
(5) 모양체척수반사(cilo-spinal reflex)
(6) 구역반사(gag reflex)
(7) 기침반사(cough reflex)
5) 자발운동, 제뇌강직, 제피질강직 및 경련 등이 나타나지 아니할 것
6) 무호흡 검사 결과 자발호흡이 유발되지 아니하여 자발호흡이 되살아날 수 없다고 판정될 것. 무호흡 검사가 불충분하거나 중단된 경우에는 뇌혈류검사로 추가 확인하여야 한다.
7) 다음의 구분에 따른 방법에 따라 1)부터 6)까지의 규정에 따른 판정 결과를 재확인하였을 때에도 그 결과가 같을 것
(1) 뇌사판정대상자가 6세 이상인 경우: 1차 판정부터 6시간이 지난 후에 실시
(2) 뇌사판정대상자가 1세 이상, 6세 미만인 경우: 1차 판정부터 24시간이 지난 후에 실시
(3) 뇌사판정대상자가 생후 2개월 이상, 1세 미만인 경우: 1차 판정부터 48시간이 지난 후에 실시
8) 다음의 구분에 따른 방법에 따라 뇌파검사를 시행하였을 때에 평탄뇌파가 30분 이상 지속될 것
(1) 뇌사판정대상자가 1세 이상인 경우: 7)에 따른 재확인 이후에 실시
(2) 뇌사판정대상자가 생후 2개월 이상, 1세 미만인 경우: 7)에 따른 재확인 이전과 이후에 실시

Table 2.

United Network for Organ Sharing region 5 donor management goals

Donor Management Goals	Parameters
Mean arterial pressure	60∼100 mmHg
Central venous pressure	4∼10 mmHg
Ejection fraction	＞50%
Vasopressors	≤1 and low dose ^a
Arterial blood gas pH	7.3∼7.45
Pao2/Fio2	＞300
Serum sodium	135∼155 mEq/L
Blood glucose	＜150 mg/dL
Urine output	0.5∼3 mL/kg/hr over 4 hrs

^a Low dose of vasopressors was defined as dopamine ≤10  g/kg/min, neosynephrine ≤60  g/kg/min, norepinephrine ≤10  g/kg/min and vasopressin ≤2.4 U/hr (0.04 U/min).

Table 3.

Maastricht donation after cardiac death classification

Class	Description
Maastricht I	Dead on arrival	Uncontrolled
Maastricht II	Unsuccessful resuscitation	Uncontrolled
Maastricht III	Awaiting cardiac death	Controlled
Maastricht IV	Cardiac arrest after brain stem death	Controlled
Maastricht V ^a	Cardiac arrest in a hospital inpatient	Uncontrolled

^a Added in 2000.

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