Management of the brain-dead donor in the ICU: general and specific therapy to improve transplantable organ quality

  • Geert MeyfroidtEmail author
  • Jan Gunst
  • Ignacio Martin-Loeches
  • Martin Smith
  • Chiara Robba
  • Fabio Silvio Taccone
  • Giuseppe Citerio



To provide a practical overview of the management of the potential organ donor in the intensive care unit.


Seven areas of donor management were considered for this review: hemodynamic management; fluids and electrolytes; respiratory management; endocrine management; temperature management; anaemia and coagulation; infection management. For each subchapter, a narrative review was conducted.

Results and conclusions

Most elements in the current recommendations and guidelines are based on pathophysiological reasoning, epidemiological observations, or extrapolations from general ICU management strategies, and not on evidence from randomized controlled trials. The cardiorespiratory management of brain-dead donors is very similar to the management of critically ill patients, and the same applies to the management of anaemia and coagulation. Central diabetes insipidus is of particular concern, and should be diagnosed based on clinical criteria. Depending on the degree of vasopressor dependency, it can be treated with intermittent desmopressin or continuous vasopressin, intravenously. Temperature management of the donor is an area of uncertainty, but it appears reasonable to strive for a core temperature of > 35 °C. The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. Although the rate of infection transmission from donor to receptor is low, certain infections are still a formal contraindication to organ donation. However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely.


Organ transplantation Brain death Organ donor Tissue and Organ procurement 



Geert Meyfroidt is funded by the Fonds Wetenschappelijk Onderzoek as senior clinical investigator (grant no. 1846118N).

Compliance with ethical standards

Conflicts of interest

MS is Editor in Chief of the Journal of Neurosurgical Anesthesiology. GC is Editor in Chief of Intensive Care Medicine. GM and IML are Associate Editors of Intensive Care Medicine. CR is Junior Editor of Intensive Care Medicine.

Ethical approval

An approval by an ethics committee was not applicable.


  1. 1.
    Citerio G, Cypel M, Dobb GJ et al (2016) Organ donation in adults: a critical care perspective. Intensive Care Med 42:305–315Google Scholar
  2. 2.
    Tullius SG, Rabb H (2018) Improving the supply and quality of deceased-donor organs for transplantation. N Engl J Med 378:1920–1929Google Scholar
  3. 3.
    Van Loon J, Shivalkar B, Plets C et al (1993) Catecholamine response to a gradual increase of intracranial pressure. J Neurosurg 79:705–709Google Scholar
  4. 4.
    Smith M (2004) Physiologic changes during brain stem death—lessons for management of the organ donor. J Heart Lung Transplant 23:S217–S222Google Scholar
  5. 5.
    Novitzky D, Rhodin J, Cooper DKC et al (1997) Ultrastructure changes associated with brain death in the human donor heart. Transpl Int 10:24–32Google Scholar
  6. 6.
    Audibert G, Charpentier C, Seguin-Devaux C et al (2006) Improvement of donor myocardial function after treatment of autonomic storm during brain death. Transplantation 82:1031–1036Google Scholar
  7. 7.
    Drory Y, Ouaknine G, Kosary IZ, Kellermann JJ (1975) Electrocardiographic findings in brain death; description and presumed mechanism. Chest 67:425–432Google Scholar
  8. 8.
    Kotloff RM, Blosser S, Fulda GJ et al (2015) 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. Crit Care Med 43:1291–1325Google Scholar
  9. 9.
    Lazzeri C, Guetti C, Migliaccio ML et al (2017) The utility of serial echocardiograms for organ procurement in brain death. Clin Transplant 31:e13094Google Scholar
  10. 10.
    Dictus C, Vienenkoetter B, Esmaeilzadeh M et al (2009) Critical care management of potential organ donors: our current standard. Clin Transplant 23:2–9Google Scholar
  11. 11.
    Al-Khafaji A, Elder M, Lebovitz DJ et al (2015) Protocolized fluid therapy in brain-dead donors: the multicenter randomized MOnIToR trial. Intensive Care Med 41:418–426PubMedCentralGoogle Scholar
  12. 12.
    Stoica SC, Satchithananda DK, White PA et al (2004) Noradrenaline use in the human donor and relationship with load-independent right ventricular contractility. Transplantation 78:1193–1197Google Scholar
  13. 13.
    Schnuelle P, Gottmann U, Hoeger S et al (2009) Effects of donor pretreatment with dopamine on graft function after kidney transplantation. JAMA 302:1067–1075Google Scholar
  14. 14.
    Birtan D, Arslantas MK, Altun GT et al (2018) Effect of vasoactive therapy used for brain-dead donors on graft survival after kidney transplantation. Transplant Proc 50:1289–1291Google Scholar
  15. 15.
    McKeown DW, Bonser RS, Kellum JA (2012) Management of the heartbeating brain-dead organ donor. Br J Anaesth 108:i96–i107Google Scholar
  16. 16.
    Maciel CB, Greer DM (2016) ICU management of the potential organ donor: state of the art. Curr Neurol Neurosci Rep 16:86Google Scholar
  17. 17.
    Perner A, Haase N, Guttormsen AB et al (2012) Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 367:124–134Google Scholar
  18. 18.
    Myburgh JA, Finfer S, Bellomo R et al (2012) Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 367:1901–1911Google Scholar
  19. 19.
    Patel MS, Niemann CU, Sally MB et al (2015) The impact of hydroxyethyl starch use in deceased organ donors on the development of delayed graft function in kidney transplant recipients: a propensity-adjusted analysis. Am J Transplant 15:2152–2158Google Scholar
  20. 20.
    Miñambres E, Ballesteros MA, Rodrigo E et al (2013) Aggressive lung donor management increases graft procurement without increasing renal graft loss after transplantation. Clin Transplant 27:52–59Google Scholar
  21. 21.
    Youn TS, Greer DM (2014) Brain death and management of a potential organ donor in the intensive care unit. Crit Care Clin 30:813–831Google Scholar
  22. 22.
    Tisdall M, Crocker M, Watkiss J, Smith M (2006) Disturbances of sodium in critically ill adult neurologic patients. J Neurosurg Anesthesiol 18:57–63PubMedCentralGoogle Scholar
  23. 23.
    Plurad DS, Bricker S, Neville A et al (2012) Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors. Am J Surg 204:856–861Google Scholar
  24. 24.
    Busl KM, Bleck TP (2015) Neurogenic pulmonary edema. Crit Care Med 43:1710–1715Google Scholar
  25. 25.
    López-Aguilar J, Villagrá A, Bernabé F et al (2005) Massive brain injury enhances lung damage in an isolated lung model of ventilator-induced lung injury*. Crit Care Med 33:1077–1083Google Scholar
  26. 26.
    Mascia L, Sakr Y, Pasero D et al (2008) Extracranial complications in patients with acute brain injury: a post-hoc analysis of the SOAP study. Intensive Care Med 34:720–727Google Scholar
  27. 27.
    MacLean A, Dunning J (1997) The retrieval of thoracic organs: donor assessment and management. Br Med Bull 53:829–843Google Scholar
  28. 28.
    Wheeler AP, Bernard GR (2007) Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet 369:1553–1564Google Scholar
  29. 29.
    Krebs J, Tsagogiorgas C, Pelosi P et al (2014) Open lung approach with low tidal volume mechanical ventilation attenuates lung injury in rats with massive brain damage. Crit Care 18:R59PubMedCentralGoogle Scholar
  30. 30.
    Mascia L, Pasero D, Slutsky AS et al (2010) Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation. JAMA 304:2620Google Scholar
  31. 31.
    ARDSNet (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301Google Scholar
  32. 32.
    Slutsky AS, Ranieri VM (2013) Ventilator-induced lung injury. N Engl J Med 369:2126–2136Google Scholar
  33. 33.
    Botha P (2009) Extended donor criteria in lung transplantation. Curr Opin Organ Transplant 14:206–210Google Scholar
  34. 34.
    Mascia L, Bosma K, Pasero D et al (2006) Ventilatory and hemodynamic management of potential organ donors: an observational survey*. Crit Care Med 34(2):321–327Google Scholar
  35. 35.
    Howlett TA, Keogh AM, Perry L et al (1989) Anterior and posterior pituitary function in brain-stem-dead donors. A possible role for hormonal replacement therapy. Transplantation 47:828–834Google Scholar
  36. 36.
    Gramm HJ, Meinhold H, Bickel U et al (1992) Acute endocrine failure after brain death? Transplantation 54:851–857Google Scholar
  37. 37.
    Novitzky D, Mi Z, Sun Q et al (2014) Thyroid hormone therapy in the management of 63,593 brain-dead organ donors. Transplantation 98:1119–1127Google Scholar
  38. 38.
    MacDonald PS, Aneman A, Bhonagiri D et al (2012) A systematic review and meta-analysis of clinical trials of thyroid hormone administration to brain dead potential organ donors. Crit Care Med 40:1635–1644Google Scholar
  39. 39.
    Dimopoulou I, Tsagarakis S, Anthi A, Milou E, Ilias I, Stavrakaki K, Charalambidis C, Tzanela M, Orfanos S, Mandragos K, Nikolaos Thalassinos CR (2003) High prevalence of decreased cortisol reserve in brain-dead potential organ donors. Crit Care Med 31:1113–1117Google Scholar
  40. 40.
    Dupuis S, Amiel J-A, Desgroseilliers M et al (2014) Corticosteroids in the management of brain-dead potential organ donors: a systematic review. Br J Anaesth 113:346–359Google Scholar
  41. 41.
    Pinsard M, Ragot S, Mertes P et al (2014) Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study. Crit Care 18:R158PubMedCentralGoogle Scholar
  42. 42.
    Marvin MR, Morton V (2009) Glycemic control and organ transplantation. J Diabetes Sci Technol 3:1365–1372PubMedCentralGoogle Scholar
  43. 43.
    Casaer MP, Van den Berghe G (2014) Nutrition in the acute phase of critical illness. N Engl J Med 370:1227–1236Google Scholar
  44. 44.
    Hahnenkamp K, Böhler K, Wolters H et al (2016) Organ-protective intensive care in organ donors. Dtsch Aerzteblatt Online. Dtsch Arztebl Int 113(33–34):552–558PubMedCentralGoogle Scholar
  45. 45.
    Weiss S, Kotsch K, Francuski M et al (2007) Brain death activates donor organs and is associated with a worse I/R injury after liver transplantation. Am J Transplant 7:1584–1593Google Scholar
  46. 46.
    Joseph B, Khalil M, Pandit V et al (2014) Hypothermia in organ donation: a friend or foe? J Trauma Acute Care Surg 77(4):559–563Google Scholar
  47. 47.
    Citerio G, Crippa IA, Bronco A et al (2014) Variability in brain death determination in Europe: looking for a solution. Neurocrit Care 21:376–382Google Scholar
  48. 48.
    Niemann CU, Feiner J, Swain S et al (2015) Therapeutic hypothermia in deceased organ donors and kidney-graft function. N Eng J Med 373:405–414Google Scholar
  49. 49.
    Schnuelle P, Mundt HM, Drüschler F et al (2018) Impact of spontaneous donor hypothermia on graft outcomes after kidney transplantation. Am J Transplant 18:704–714Google Scholar
  50. 50.
    Hébert PC, Carson JL (2014) Transfusion threshold of 7 g per deciliter—the new normal. N Engl J Med 371:1459–1461Google Scholar
  51. 51.
    Docherty AB, Turgeon AF, Walsh TS (2018) Best practice in critical care: anaemia in acute and critical illness. Transfus Med 28:181–189Google Scholar
  52. 52.
    Coberly EA, Booth GS (2016) Ten-year retrospective review of transfusion practices in beating-heart organ donors. Transfusion 56:339–343Google Scholar
  53. 53.
    De La Cruz JS, Sally MB, Zatarain JR et al (2015) The impact of blood transfusions in deceased organ donors on the outcomes of 1,884 renal grafts from United Network for Organ Sharing Region. J Trauma Acute Care Surg 79(4 Suppl 2):S164–S170Google Scholar
  54. 54.
    Connor JP, Raife T, Medow JE (2018) Outcomes of red blood cell transfusions prescribed in organ donors by the Digital Intern, an electronic decision support algorithm. Transfusion 58:366–371Google Scholar
  55. 55.
    Lisman T, Leuvenink HGD, Porte RJ, Ploeg RJ (2011) Activation of hemostasis in brain dead organ donors: an observational study. J Thromb Haemost 9:1959–1965Google Scholar
  56. 56.
    Valdivia M, Chamorro C, Romera MA et al (2007) Effect of posttraumatic donor’s disseminated intravascular coagulation in intrathoracic organ donation and transplantation. Transplant Proc 39:2427–2428Google Scholar
  57. 57.
    Garrouste C, Baudenon J, Gatault P et al (2018) No impact of disseminated intravascular coagulation in kidney donors on long-term kidney transplantation outcome: A multicenter propensity-matched study. Am J Transplant 19(2):448–456Google Scholar
  58. 58.
    Trotter PB, Robb M, Summers D et al (2017) Donors with immune thrombocytopenia: do they pose a risk to transplant recipients? Am J Transplant 17:796–802Google Scholar
  59. 59.
    Fishman JA, Greenwald MA, Grossi PA (2012) Transmission of infection with human allografts: essential considerations in donor screening. Clin Infect Dis 55:720–727Google Scholar
  60. 60.
    Aguilar C, Husain S, Lortholary O (2018) Recent advances in understanding and managing infectious diseases in solid organ transplant recipients. F1000Research 7:661Google Scholar
  61. 61.
    Fischer SA (2019) Is this organ donor safe?: Donor-derived infections in solid organ transplantation. Surg Clin N Am 99:117–128Google Scholar
  62. 62.
    Len O, Garzoni C, Lumbreras C et al (2014) Recommendations for screening of donor and recipient prior to solid organ transplantation and to minimize transmission of donor–derived infections. Clin Microbiol Infect 20:10–18Google Scholar
  63. 63.
    Vincent J-L, Marshall JC, Namendys-Silva SA et al (2014) Assessment of the worldwide burden of critical illness: the intensive care over nations (ICON) audit. Lancet Respir Med 2:380–386Google Scholar
  64. 64.
    Organ Procurement and Transplantation Network Guidance for Recognizing Central Nervous System Infections in Potential Deceased Organ Donors. Accessed 10 Dec 2018
  65. 65.
    Nogueira ML, Estofolete CF, Terzian ACB et al (2017) Zika virus infection and solid organ transplantation: a new challenge. Am J Transplant 17:791–795Google Scholar
  66. 66.
    Muller E, Barday Z, Mendelson M, Kahn D (2015) HIV-positive–to–HIV-positive kidney transplantation—results at 3 to 5 years. N Engl J Med 372:613–620PubMedCentralGoogle Scholar
  67. 67.
    Schlendorf KH, Zalawadiya S, Shah AS et al (2018) Early outcomes using hepatitis C-positive donors for cardiac transplantation in the era of effective direct-acting anti-viral therapies. J Hear Lung Transplant 37:763–769Google Scholar
  68. 68.
    Durand CM, Bowring MG, Brown DM et al (2018) Direct-acting antiviral prophylaxis in kidney transplantation from hepatitis C virus-infected donors to noninfected recipients. Ann Intern Med 168:533PubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department and Laboratory of Intensive Care MedicineUniversity Hospitals and KU LeuvenLeuvenBelgium
  2. 2.Multidisciplinary Intensive Care Research Organization (MICRO)St. James’s HospitalDublinIreland
  3. 3.Neuro-Critical Care Unit, The National Hospital for Neurology and NeurosurgeryUniversity College London HospitalsLondonUK
  4. 4.Department of Anaesthesia and Intensive Care, San Martino Policlinico HospitalIRCCS for OncologyGenoaItaly
  5. 5.Department of Intensive Care, Erasme HospitalUniversité libre de Bruxelles (ULB)BrusselsBelgium
  6. 6.Neuro-Intensive Care, Department of Emergency and Intensive Care, San Gerardo HospitalASSTMonzaItaly
  7. 7.School of Medicine and SurgeryUniversity of Milan-BicoccaMilanItaly

Personalised recommendations