A 35-year-old man is brought to the emergency room after sustaining gunshots to the head. After initial hemodynamic stabilization, the patient is transferred to the intensive care unit. The following day, after consultations with the neurosurgeons, it is concluded that the patient is brain dead and there is no chance of meaningful recovery. While searching for a contact address, the nurse finds an organ donation card in the patient's clothing. Family members are contacted and they confirm that the patient had always wanted to donate his organs. Which of the following is the most appropriate next step in management of this patient?

Question

A 35-year-old man is brought to the emergency room after sustaining gunshots to the head.  After initial hemodynamic stabilization, the patient is transferred to the intensive care unit.  The following day, after consultations with the neurosurgeons, it is concluded that the patient is brain dead and there is no chance of meaningful recovery.  While searching for a contact address, the nurse finds an organ donation card in the patient's clothing.  Family members are contacted and they confirm that the patient had always wanted to donate his organs.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Most organs for transplantation are obtained from brain dead donors. The successful recovery of viable organs depends on appropriate identification and medical care of brain dead patients. These donors should ideally be managed in an intensive care unit (ICU) with continued hemodynamic support. Brain death leads to hypotension (loss of sympathetic tone), volume depletion (eg, secondary to central diabetes insipidus) and systemic infections. Adequate intravenous volume resuscitation (Choice C) and pressor support (if necessary) (Choice B) maintain a normotensive, euvolemic state with adequate urine output, helps improve the viability of the organs. Endocrinologic abnormalities after brain death are being increasingly recognized. Diabetes insipidus can cause severe volume depletion and adrenal insufficiency contributes to hypotension. Combined administration of corticosteroids (methylprednisolone), thyroxine (triiodothyronine or levothyroxine) and vasopressin (or desmopressin) is routinely used in most centers but the absolute efficacy of this therapy is yet unknown. (Choice A) One of the goals of care in the intensive care unit is to provide optimal ventilator support to prevent hypoxia and hypercapnia. Hypercapnia causes acidosis, which has deleterious effects on multiple organ systems and should be avoided. (Choice E) Cardiac arrest in brain death signifies complete loss of sympathetic tone, making it more difficult to maintain organ perfusion with supportive measures. Also, a shorter time interval between brain death and organ recovery improves the chances of viable organ recovery. Therefore, organs should be procured by the transplant surgery team immediately. Educational objective: Brain dead organ donors should be managed in the intensive care unit to maintain hemodynamic support with intravenous fluids and pressors if needed. Mechanical ventilation should be continued to prevent hypoxia and hypercapnia. Hormone replacement therapy (methylprednisolone, thyroid hormone, and vasopressin) should be administered. References: Organ protective management of the brain-dead donor. (http://www.ncbi.nlm.nih.gov/pubmed/15546816) Brain death and management of a potential organ donor in the intensive care unit. (http://www.ncbi.nlm.nih.gov/pubmed/25257743)

A 35-Year-Old Man Is Brought to the Emergency Room After