Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement.

Abstract

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement This consensus statement provides important guidelines for deceased donation to the transplant community. The document defines the standard of care for intensive care units regarding: (1) Definitions of death; (2) Timing and request for authorization; (3) Use of donors with malignancies and infections; (4) Testing for human immunodeficiency virus, hepatitis B and C; (5) Hemodynamic management; (6) Fluid resuscitation; (7) Vasoactive drugs; (8) Hemodynamic monitoring; (9) Endocrine dysfunction and hormone replacement; (10) Pediatric donor issues; (11) Specific organ management: heart, kidney, liver, lung and pancreas. The authors confirm the important impact that donation after circulatory determination of death (DCD) can make to increase the availability of organs. They highlight that liver and lungs can be used from selected DCD donors for transplantation. Clinicians must be prepared for potential DCD scenarios in which death does not occur within the established time after withdrawal of life-sustaining therapy: appropriate protocols should be in place to return the patient to a critical care setting for continuing care and to provide appropriate family support. The authors comment that intensive care unit caregivers and OPO representatives should provide all patients with equal opportunities for organ donation. One important recommendation is the early referral of potential donors to procurement agencies to increase the period available to evaluate a patient’s medical suitability for donation and to relay information to families in a manner that minimizes time pressure. The group recommends that OPO or designated coordinators with expertise should request authorization for organ donation in all institutions, using a collaborative approach with the rest of the healthcare team. There are several recommendations regarding malignancies and infections, but in general, risks of donor transmission must be weighed against risks for a potential recipient of not receiving the organ. Determinations about an individual donor’s medical suitability for organ donation should be made in conjunction with the local OPO and involved transplant centers. The authors recommend that patients with bacterial meningitis are suitable organ donors as long as they have received therapy directed against an identified or presumed pathogen while organ recipients get treated with a similar antibiotic regimen for 5 to 10 days. Organs should not be procured from patients with undiagnosed febrile illnesses, encephalitis, meningitis, or flaccid paralysis of unknown etiology. The use of nucleic acid amplification testing to detect the presence of human immunodeficiency virus RNA reduces the likelihood of unrecognized viremia by approximately half in all high-risk behavior categories; therefore, the use of nucleic-acid amplification testing was recommended for high-risk behavior groups. A frequent challenge for kidney and lung procurement is conflicting fluid requirements for the donor. Traditionally, aggressive fluid resuscitation and management were thought to result in improved procurement of kidneys, whereas a conservative fluid replacement strategy is thought to benefit the quality of lungs. The authors recommend a central venous catheter and/or pulmonary artery catheter to manage fluids: a combination of hormone replacement therapy and CVP-targeted fluid resuscitation should be the gold standard. Specific variables include a mean arterial pressure of 60 to 70 mm Hg, urinary output of 1 to 3 mL/kg per hour, a decrease in dose of vasoactive agents (dopamine ≤ 10 μg/kg per minute), and a left ventricular ejection fraction of at least 45%. Isotonic crystalloids and lactated Ringer are recommended as first line fluid management. Dopamine and arginine vasopressin replacement should be considered when hypotension persists despite adequate volume resuscitation. High-dose corticosteroid administration reduces the potential deleterious effects of the inflammatory cascade set in place subsequent to brain death. Ideally, steroids should be administered after blood has been collected for tissue typing as the expression of human leukocyte antigen may be suppressed. Thyroid replacement therapy—either alone or as part of a combination hormone therapy with intravenous arginine vasopressin, corticosteroids, and insulin—should be considered for hemodynamically unstable donors or for potential cardiac donors with abnormal (<45%) left ventricular ejection fraction. Specific aspects of death declaration for pediatric donors, including management goals are detailed in this report and differ from adult donors. Furthermore, organ-specific considerations are discussed in great detail—an extremely helpful tool in donor management and procurement.