Organ Dysfunction and Failure Following Brain Death Do Not Preclude Successful Donation.

BACKGROUND: Organ dysfunction is common after neurologic determination of death (NDD) but before organ collection. Reliable markers for graft success following transplant of these organs would be useful. We sought to determine the relationship between the donor after neurologic determination of death (DNDD) pathophysiology and successful organ donation. METHODS: Donor information was obtained through the local organ procurement organization. Donor demographics and clinical data points for cardiovascular, renal, respiratory, hepatic, hematological and neuroendocrine systems were reviewed 12 h before and 12 h after neurologic determination of death was declared. The worst values were utilized for analysis and generation of the organ-specific Sequential Organ Failure Assessment (SOFA) scores. SOFA scores were calculated and used to quantify the degree of organ dysfunction. The NDD non-donors for a specific organ were used as a comparison control group. The control group refers to DNDD patients whose specific organs were not transplanted. Lack of use was mostly due to discard by the transplant team as a result of unsuitability of the organ caused by deterioration or possible donor-specific pathology. RESULTS: One hundred and five organ donors were analyzed. Mean age was 35.0 (± 13.6), 78.1% male, median GCS 3, interquartile range (IQR) 3-4 and median injury severity score 32 (IQR 25-43). Of the successful donors, organ-specific severe dysfunction (SOFA 3 or 4) occurred in 96, 27.5 and 3.3% of cardiac, lung and liver donors, respectively. There was no significant difference between the levels of organ dysfunction in donors versus non-donors except lung donors, in which the median lowest partial pressure of arterial oxygen-to-fraction of inspired oxygen (P/F) ratio in the non-donor was 194 (IQR 121.8-308.3) compared to the median lowest P/F ratio in the donor which was 287 (IQR 180-383.5), p = 0.02. In the recipients, graft failure 6 months after transplantation was reported in one kidney recipient (0.74%) (peak donor creatinine = 1 mg/dL) and in five pancreas recipients (11.4%). The median peak glucose of the pancreas donors in failed recipients was 178 mg/dL (IQR 157-213), whereas in the functioning recipients, the median glucose of their donors was not different (185 mg/dL, IQR 157-216), p = 0.394. CONCLUSION: Current measures of organ failure and dysfunction do not predict the success of organ donation. Successful donor management in the face of severe organ dysfunction and failure can result in lives saved.

Autoresuscitation after asystole in patients being considered for organ donation.

OBJECTIVES: A fundamental issue in organ donation after circulatory death is the determination of death. There are limited data regarding the incidence and timing of autoresuscitation after asystole. Prevailing guidelines suggest a 2- to 5-min observation after mechanical asystole before the declaration of death. This study tested the hypothesis that a 2-min observation period after asystole is sufficient for the declaration of death in patients being considered for organ donation after circulatory death. DESIGN: Single-center observational study using prospectively collected data. SETTING: University hospital, Level I trauma center. PATIENTS: Those patients identified by the organ donation registry that underwent organ donation after circulatory death from 2000 to 2008, during which time the institutional protocol required a 5-min observation period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Documentation of medical history, serial Glasgow Coma Scale scores, time of extubation, and time to asystole, hypotension, pulseless electrical activity, and declaration of death were ascertained. Seventy-three patients were identified. The most common mechanism of injury was traumatic brain injury, and eight patients were aged <18 yrs. Patients had a mean Glasgow Coma Scale score of 5 on admission and were taken to organ donation after circulatory death an average of 6.6 days after admission. The average time from extubation to death was 22 mins. No patients exhibited autoresuscitation during the 5-min waiting observation period, including the first 2 mins after asystole. CONCLUSIONS: The absence of autoresuscitation in our series suggests that a 2-min observation period is sufficient for the determination of death after cardiac arrest, including patients younger than 18 yrs. These data may inform practice guidelines.