Intensive Care Management of Potential Organ Donors

Dear Colleagues,

The phrase “intensive care management of organ transplantation” refers to the challenging management strategy for potential organ donors, both donors after brain death and those after circulatory death (controlled cDCD). The goal of DBD management is to counteract all of the pathophysiologic alterations following brain death, therefore preserving organ function. The main cornerstones are hemodynamic support, respiratory and temperature management, endocrine therapy, and the prevention of complications. Though solid evidence is often lacking in optimizing management in single DBDs, it is imperative that everyday clinical practice not only guarantees systemic perfusion but also improves transplantable organ quality.

Increasing DBD age (and comorbidities) as well as the growing incidence of donors on extracorporeal membrane oxygenation support make DBD management more and more challenging. In this context, the personalization of the donor management strategy is needed. The timeframe between the time of brain death diagnosis (in Italy, the 6 h observation period) and referral to the operating room for procurement should be viewed as an opportunity to optimize DBD management and improve organ quality.

According to emerging evidence, DBD management should be tailored for single BD donors by considering three main factors: age, the etiology of brain death, and potential transplantable organs.

Age is known to affect the cardiovascular response to brain death development, most likely related to arterial changes owing to aging. Older donors exhibit lower diastolic blood pressure due to age-related large-artery stiffening. The latter may contribute to a wider pulse pressure, which in turn may affect perfusion pressure, which in turn may be worsened by the age-related reduction in β-receptor function. Vasopressin may even be considered in older DBDs associated with low-dose norepinephrine (less than 0.2 ug/kg/min) to guarantee organ perfusion. 

The etiology of brain death influences the hemodynamic profile in DBDs. Patients that are brain dead after successful resuscitation after cardiac arrest [5] show features of so-called post-resuscitated cardiac syndrome (frequently in its early and intermediate phases), mainly characterized by myocardial dysfunction and a systemic ischemia/reperfusion response. The latter causes the activation of immunologic and coagulation pathways, which increase the risk of organ failure and infection. In these donors, strict hemodynamic monitoring is mandatory, and a careful assessment of organ function is required, often via ex vivo machine perfusion. The management of single donors cannot ignore the organ(s) potentially suitable for transplantation. For instance, in a potential heart donor, the dosage of norepinephrine should be strictly monitored, since high doses of norepinephrine are known to be harmful for a transplanted heart. Allocation policies and the time to operating room referral cannot ignore the hemodynamic profile of single DBDs.

Controlled DCDs present different clinical challenges for intensivists, since days elapse until the operating room is utilized for organ retrieval from donor referral to the transplantation coordinator.

Transplantation medicine is an evolving discipline, which has translated pathophysiologic concepts of critical care into new clinical, technological, and organizational pathways.

Dr. Chiara Lazzeri
Dr. Adriano Peris
Guest Editors

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• intensive care
• organ donation
• organ transplant
• vasoactive drugs
• infection control
• glucose control
• hemodynamic profiles
• ECMO