A 32-year-old man is brought to the emergency department after a motor vehicle accident that resulted in severe head injuries. The patient was unresponsive and hypotensive when paramedics arrived at the scene. He was intubated on-site and given aggressive intravenous fluids. Neurologic imaging reveals multiple cortical contusions, brain hemorrhage, and diffuse axonal injury. The patient is admitted to the intensive care unit. Three days later, he continues to require mechanical ventilation. Temperature is 36.7 C (98 F), blood pressure is 100/45 mm Hg, and pulse is 62/min. Sedation is held, and the patient is examined. There is no response to stimuli of any type. Brainstem reflexes are absent. The ventilator is temporally disconnected to assess for spontaneous respiration. No spontaneous breathing movements are visualized, and arterial blood gas results after 10 minutes are consistent with a positive apnea test, confirming brainstem failure. The patient is declared brain-dead. His wife informs the medical team that the patient always wanted to donate his organs in the event of unexpected death. Which of the following is an important component of care to maximize the viability of this patient's organs for donation?

Question

A 32-year-old man is brought to the emergency department after a motor vehicle accident that resulted in severe head injuries.  The patient was unresponsive and hypotensive when paramedics arrived at the scene.  He was intubated on-site and given aggressive intravenous fluids.  Neurologic imaging reveals multiple cortical contusions, brain hemorrhage, and diffuse axonal injury.  The patient is admitted to the intensive care unit.  Three days later, he continues to require mechanical ventilation.  Temperature is 36.7 C (98 F), blood pressure is 100/45 mm Hg, and pulse is 62/min.  Sedation is held, and the patient is examined.  There is no response to stimuli of any type.  Brainstem reflexes are absent.  The ventilator is temporally disconnected to assess for spontaneous respiration.  No spontaneous breathing movements are visualized, and arterial blood gas results after 10 minutes are consistent with a positive apnea test, confirming brainstem failure.  The patient is declared brain-dead.  His wife informs the medical team that the patient always wanted to donate his organs in the event of unexpected death.  Which of the following is an important component of care to maximize the viability of this patient's organs for donation?

Quizplus · Accepted Answer

Explanation: Most transplanted organs come from donors who meet criteria for brain death. Brain death is associated with several physiologic changes that upset homeostasis and threaten the viability of potential donated organs, including: Central diabetes insipidus, which can increase urine output to >1000 mL/hr and cause volume depletion Systemic hypotension due to loss of sympathetic tone (and volume depletion) Hypothermia To prevent damage to organs, potential donors require aggressive intensive care unit treatment to maintain a euvolemic, normotensive, and normothermic (or mildly hypothermic) state. This is typically achieved by administering intravenous fluids and desmopressin to reduce the diuretic impact of central diabetes insipidus, ionotropic or pressor support to maintain blood pressure, and warm air blankets to maintain temperature. (Choice A) Administering anticoagulation is not indicated as most patients who meet criteria for brain death proceed to organ procurement rapidly to avoid organ damage. (Choice B) Hypercapnia has not been shown to improve organ viability and can damage organs by causing acidosis. (Choices C and D) Keeping the heart rate <60/min and the systolic blood pressure <100 mm Hg by administering medications has not been shown to improve organ viability. It is important to keep the patient normotensive to ensure adequate organ perfusion until procurement occurs. Educational objective: The primary goal of managing a brain-dead organ donor is to maintain a euvolemic, normotensive, and normothermic (or mildly hypothermic) state. Patients often receive intravenous fluids, desmopressin, and pressor support. References: ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/19624569) Physiologic changes during brain stem death-lessons for management of the organ donor. (http://www.ncbi.nlm.nih.gov/pubmed/15381167)

A 32-Year-Old Man Is Brought to the Emergency Department After