You are in: eMedicine Specialties > Trauma > Trauma Management Organ Procurement Considerations in TraumaArticle Last Updated: Aug 7, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Erik B Finger, MD, PhD, Clinical Instructor in Surgery, Division of Transplantation Surgery, University of California San Francisco Medical Center Erik B Finger is a member of the following medical societies: American Medical Association and Massachusetts Medical Society Editors: Ernest Dunn, MD, Program Director of General Surgery, Director of Trauma and Critical Care, Clinical Associate Professor, Department of Surgery, Methodist Hospitals of Dallas, University of Texas Southwestern; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Robert L Sheridan, MD, Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School; Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: organ transplant, organ donor, organ donation, United Network for Organ Sharing, UNOS, organ procurement organizations, OPO, Uniform Anatomical Gift Act of 1968, vascularized organ transplantation, brain death, cadaveric organs, cardiac death INTRODUCTIONSection 2 of 11
  Following the advent of vascularized organ transplantation in the 1950s, improvements in the techniques of transplant surgery and in the management of patient immunosuppression have significantly increased the success of organ transplantation and the practicality of using transplantation to treat end-stage organ dysfunction. These successes have brought about an increased demand for donor organs. The number of patients listed on transplant waiting lists has increased steadily; at present, in excess of 92,000 people are awaiting transplantation in the United States. Attempts to increase the donor supply have been insufficient to cope with this increased need. With this discrepancy, the number of patients who have died while awaiting transplantation has also increased correspondingly (see Media file 1). Significant attention has been devoted to the identification of other sources of organs for transplantation, but the mainstay of organ supply comes from deceased donor (cadaveric) donation. Nationwide, approximately 30% of all deceased organ donors come from trauma patients. The distribution of traumatic causes of brain death is presented in Media file 2. Evaluation of the trauma patient as a potential organ donor is critical to maximizing the availability of deceased donor organs for transplantation. ORGAN DISTRIBUTIONSection 3 of 11
To maintain listings of potential organ recipients, the Department of Health and Human Services contracts the United Network for Organ Sharing (UNOS). Local organ procurement organizations (OPOs) are authorized by the Health Care Financing Administration and UNOS to manage the procurement of organs in their region. OPOs are responsible for organizing and overseeing the following:
Organ allocation is decided by a complex set of guidelines that continuously evolve. UNOS maintains the lists of potential recipients divided by organ and ABO blood type. Potential recipients can be listed under multiple blood group lists as well as in multiple regions. Priority on each organ list is based upon several factors, including proximity to the donor, severity of illness, length of time on the waiting list, and special circumstances related to particular medical conditions. Objective scoring systems have been set up for the liver (MELD/PELD) and the lung (LAS). These objective scoring systems are based upon defined physiologic and laboratory parameters. A point scale system determines the recipient's rank on each list. Organ allocation is then decided by the recipient's points and the following additional factors:
CRITERIA FOR ORGAN DONORSSection 4 of 11
Regional transplant centers have different sets of absolute and relative criteria for excluding potential organ donors. Early criteria were fairly strict, limiting evaluation to ideal donors aged 10-50 years with no comorbid conditions. With the increasing demand for organs, donation from an expanded donor pool has loosened restrictions considerably. Organs are harvested routinely from patients younger than 10 years and older than 50 years. Previously, such factors, as hepatitis C or active bacterial infection, were absolute contraindications. Now, such donors are often used for specific recipients. Relatively few absolute contraindications exist, and most potential donors are reviewed on a case-by-case basis. Additional absolute and relative contraindications are assessed for donation of specific organs. Adaptations of the New England Organ Bank (NEOB) and the California Transplant Donor Network (CTDN) criteria are as follows:
BRAIN AND CARDIAC DEATHSection 5 of 11
Determination of brain death No defined consensus exists on the most appropriate manner in which to determine brain death. The diagnosis is based principally on the clinical examination, but diagnostic tests often are used for confirmation. The success of organ procurement increases with a shorter interval from brain death to organ harvest; therefore, speed in diagnosis in the critically injured trauma patient is of some concern. To assist in raising the suspicion of clinical brain death for patients at risk for such, several clinical indicators augment a periodic neurologic examination, as follows:
To complete the documentation of clinical brain death, the physician must demonstrate the following:
To confirm the diagnosis of clinical brain death, several additional diagnostic modalities may be employed. The confirmatory test can be repeated after an interval of 2-24 hours so that observer error can be avoided and persistence of the clinical state can be documented. Diagnostic tests include electroencephalogram (EEG), isotopic flow study, and transcranial Doppler. Donation after cardiac death Under some circumstances, the family of a trauma patient may wish to withdraw care from a critically injured patient who is unlikely to make a meaningful recovery. Although these patients may not meet criteria for brain death, the family may wish for donation. In these cases, procuring organs from the non–heart-beating donor is possible. Exact guideline protocols are established regionally or at individual institutions but involve the withdrawal of mechanical support followed by rapid organ procurement after the clinical pronouncement of death. The manner in which this occurs is of great ethical and practical debate. CONSENT FOR ORGAN DONATIONSection 6 of 11
The Uniform Anatomical Gift Act of 1968 requires explicit consent for organ donation. Most often, this consent is expressed in the form of the donor's discussions with family members or the donor's signature on an organ donor card. This act also allows donors or families to revoke any previous decision to donate. To maximize the number of potential donors used, many states require that the regional organ bank be notified of a potential organ donor so that the family can be approached for consent if deemed appropriate. The rate of donor conversion, that is, use of one or more organ(s) from eligible donors, has increased to greater than 57%, according to the Organ Donation Breakthrough Collaborative. EVALUATION OF THE POTENTIAL ORGAN DONORSection 7 of 11
Evaluation of the potential donor continues after the determination of brain death with both general and organ-specific testing. The exact set of laboratory and diagnostic tests used varies from center to center, but an outline is presented, as follows:
MANAGEMENT OF THE POTENTIAL ORGAN DONORSection 8 of 11
Treatment of the trauma patient continues in the manner deemed optimal for the injuries sustained, until the determination of brain death. After this determination, treatment is directed at maintenance of organ function, while familial consent for organ donation is sought or until mechanical support is withdrawn. The donor is managed with intensive care unit (ICU)–level care as the evaluation proceeds. Care is directed at preservation of the donor's hemodynamic state, protection of the donor organs, and avoidance or treatment of complications that are observed in the brain-dead donor. In addition to common problems observed in patients who are critically ill, many pathologic states are observed frequently in the patient who is brain dead. As the time from brain death to organ procurement increases, so does the number and severity of complications. Common complications present in these patients are noted in Media file 3. In particular, donors who are brain dead are vulnerable to the effects of diabetes insipidus, cardiac arrhythmia, and endocrine dysfunction. Diabetes insipidus and its resultant sequelae (ie, hypovolemia, hypernatremia, hypokalemia, hyposmolarity) are managed with pitressin or desmopressin acetate (DDAVP). This treatment has been shown to delay asystole following brain death from 2 days to 3 weeks. Brain death is associated with disruption of the hypothalamic-pituitary axis. Donors can display adrenal insufficiency, lack of glycemic control, and hypothyroidism. Empiric steroids often are used, and management of other conditions follows clinical presentation. Previously, ultrarapid progression from declaration of brain death to procurement was advised. Currently, there is a shift toward greater optimization of donor physiology prior to procurement. This also enables more precise coordination with recipient institutions and lessens cold-ischemia time. Guidelines for donor management are prepared by each OPO. Specific areas of management concern, as adapted from NEOB and CTDN, are as follows:
ORGAN PROCUREMENTSection 9 of 11
The organ procurement procedure requires careful coordination of several surgical teams. Commonly, teams are sent from each of the institutions of the designated recipients to the location of the donor. Separate teams for heart, lung, and abdominal organs participate. The harvest operation is conducted in defined steps to minimize the warm ischemic time of removed organs, and the organs are removed in the order of their susceptibility to warm ischemic damage. Because of the short time available for transplanting the preserved organs, particularly for heart and lungs, the preparation of the potential recipients and transplant teams also must be coordinated. The recipient operation often commences prior to the actual arrival of the organ at the recipient institution. Prior to the operation, the donor must be adequately volume resuscitated and prepared for surgery. The management of intracerebral edema prior to brain death and resulting diabetes insipidus often results in a hypovolemic state that must be corrected prior to harvesting organs. The donor is volume resuscitated and brought to the operating room where appropriate positioning, monitoring, and ventilation are ensured prior to incision. Following this preparation, and when each team is in attendance, the procedure can begin. The outline of the surgical procedure is summarized below. Steps in organ procurement
MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Organ Procurement Considerations in Trauma excerpt Article Last Updated: Aug 7, 2006 | |||||||||||||||||||||
