Management of Hemodynamic and Metabolic Impairments in Heart-Beating Donors

  • Antonino M. GrandeEmail author
  • Paolo Aseni


Transplantation results are significantly better when organs are obtained from live donors compared with organs from brain-dead and from nonheart- beating donors. This outcome is closely related to acute and widespread physiological changes occurring during brain death that, if untreated, cause organic deterioration and cardiac arrest. Furthermore, inflammatory and hormonal changes, if not carefully diagnosed and treated, may adversely affect donor organ function after transplantation and susceptibility to rejection.

In brain death, the impairments eventually developed are initially caused by the physiological response and then aggravated by the lesion/injury and the medications given. Cardiovascular changes in the donor during the observation period and the harvesting procedure may jeopardize the functionality of potential transplantable organs. The increasing intracranial pressure produces a compensatory arterial hypertension that is followed by sympathetic overactivity, which in turn induces a “catecholamine storm” with increased cardiac output, heart rate, and systemic vascular resistance. Treatment algorithms for donor management in some common clinical settings are shown. Management of glycemic homeostatic derangements, acid-base alterations, fluid, electrolyte changes and pulmonary changes are discussed.


Urine Output Central Venous Pressure Disseminate Intravascular Coagulation Brain Death Cerebral Perfusion Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Wilhelm MJ, Pratschke J, Beato F, Taal M, Kusaka M, Hancock WW, Tilney NL (2000) Activation of the heart by donor brain death accelerates acute rejection after transplantation. Circulation 102(19):2426–2433CrossRefPubMedGoogle Scholar
  2. 2.
    Zweers N, Petersen AH, Van Der Hoeven JA, De Haan A, Ploeg RJ, De Leij LF, Prop J (2004) Donor brain death aggravates chronic rejection after lung transplantation in rats. Transplantation 78(9):1251–1258CrossRefPubMedGoogle Scholar
  3. 3.
    Pratschke J, Wilhelm MJ, Laskowski I, Kusaka M, Beato F, Tullius SG, Neuhaus P, Hancock WW, Tilney NL (2001) Influence of donor brain death on chronic rejection of renal transplants in rats. J Am Soc Nephrol 12(11):2474–2481PubMedGoogle Scholar
  4. 4.
    Barklin A (2009) Systemic inflammation in the brain-dead organ donor. Acta Anaesthesiol Scand 53:425–435CrossRefPubMedGoogle Scholar
  5. 5.
    Avlonitis VS, Wigfield CH, Kirby JA, Dark JH (2005) The hemodynamic mechanisms of lung injury and systemic inflammatory response following brain death in the transplant donor. Am J Transplant 5(4 Pt 1):684–693CrossRefPubMedGoogle Scholar
  6. 6.
    Bos E, Leuvenink H, van Goor H, Ploeg RJ (2007) Kidney grafts from brain dead donors: inferior quality or opportunity for improvement? Kidney Int 72:797–805CrossRefPubMedGoogle Scholar
  7. 7.
    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 7:1584–1593CrossRefPubMedGoogle Scholar
  8. 8.
    Kutsogiannis DJ, Pagliarello G, Doig C, Ross H, Shemie SD (2006) Medical management to optimize donor organ potential: review of the literature. Can J Anaesth 53:820–830CrossRefPubMedGoogle Scholar
  9. 9.
    Rangel-Castillo L, Gopinath S, Robertson CS (2008) Management of intracranial hypertension. Neurol Clin 26:521–541CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Docze T (1993) Volume regulation of the brain tissue – a survey. Acta Neurochir (Wien) 121:1–8CrossRefGoogle Scholar
  11. 11.
    Langfit TW, Weinstein JD, Kassell NF (1965) Cerebral vasomotor paralysis produced by intracranial hypertension. Neurology 15:622–641CrossRefGoogle Scholar
  12. 12.
    Miller JD, Sullivan HG (1979) Severe intracranial hypertension. Int Anesthesiol Clin 17:19–75CrossRefPubMedGoogle Scholar
  13. 13.
    Sesso HD, Stampfer MJ, Rosner B, Hennekens CH, Gaziano JM, Manson JE, Glynn RJ (2000) Systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure as predictors of cardiovascular disease risk in men. Hypertension 36:801–807CrossRefPubMedGoogle Scholar
  14. 14.
    Smith M (2004) Physiologic changes during brain stem death – lessons for management of the organ donor. J Heart Lung Transplant 23:217–222CrossRefGoogle Scholar
  15. 15.
    Agrawal A, Timothy J, Cincu R, Agarwal T, Waghmare LB (2008) Bradycardia in neurosurgery. Clin Neurol Neurosurg 110:321–327CrossRefPubMedGoogle Scholar
  16. 16.
    Bugge J (2009) Brain death and its implications for management of the potential organ donor. Acta Anaesthesiol Scand 53:1239–1250CrossRefPubMedGoogle Scholar
  17. 17.
    Smith M (2004) Physiologic changes during brain stem death—lessons for management of the organ donor. J Heart Lung Transplant 23(Suppl 9):S217–S222CrossRefPubMedGoogle Scholar
  18. 18.
    McKeown DW, Bonser RS, Kellum JA (2012) Management of the heartbeating brain-dead organ donor. Br J Anaesth 108(suppl 1):i96–i107CrossRefPubMedGoogle Scholar
  19. 19.
    Dujardin KS, McCully RB, Wijdicks EF et al (2001) Myocardial dysfunction associated with brain death: clinical, echocardiographic, and pathologic features. J Heart Lung Transplant 20:350–357CrossRefPubMedGoogle Scholar
  20. 20.
    Venkateswaran RV, Townend JN, Wilson IC, Mascaro JG, Bonser RS, Steeds RP (2010) Echocardiography in the potential heart donor. Transplantation 89:894–901CrossRefPubMedGoogle Scholar
  21. 21.
    Potapov EV, Ivanitskaja EA, Loebe M, Mockel M, Muller C, Sodian R, Meyer R, Hetzer R (2001) Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure. Transplantation 71:1394–1400CrossRefPubMedGoogle Scholar
  22. 22.
    Gelb AW, Robertson KM (1990) Anaesthetic management of brain dead for organ donation. Can J Anaesth 37:806–818Google Scholar
  23. 23.
    Powner DJ, Crommett JW (2003) Advanced assessment of hemodynamic parameters during donor care. Prog Transplant 13:249–257Google Scholar
  24. 24.
    Unverferth DR, Magorien RD, Moeschberger ML, Baker PB, Fetters JK, Leier CV (1984) Factors influencing the one-year mortality of dilated cardiomyopathy. Am J Cardiol 54:147–152CrossRefPubMedGoogle Scholar
  25. 25.
    Rosner MJ (1993) Pathophysiology and management of increased intracranial pressure. In: Andrews BT (ed) Neurosurgical intensive care, International Edition. New York :McGraw HillGoogle Scholar
  26. 26.
    Harukuni I, Kirsch JR, Bhardwaj A (2002) Cerebral resuscitation: role of osmotherapy. J Anesth 16:229–237CrossRefPubMedGoogle Scholar
  27. 27.
    Schunelle P, Berger S, De Boer J, Persijn G, Der Wonde FJ (2001) Effects of catecholamine application to brain-dead donors on graft survival in solid organ transplantation. Transplantation 72:455–463CrossRefGoogle Scholar
  28. 28.
    Rosendale JD, Kauffman HM, McBride MA, Chabalewski FL, Zaroff JG, Garrity ER, Delmonico FL, Rosengard BR (2003) Aggressive pharmacological donor management results in more transplanted organs. Transplantation 75:482–487CrossRefPubMedGoogle Scholar
  29. 29.
    Novitzky D, Cooper DK (2014) Thyroid hormone and the stunned myocardium. J Endocrinol 223(1):R1–R8CrossRefPubMedGoogle Scholar
  30. 30.
    Mi Z, Novitzky D, Collins JF, Cooper DKC (2015) The optimal hormonal replacement modality selection for multiple organ procurement from brain-dead organ donors. Clin Epidemiol 7:17–27PubMedPubMedCentralGoogle Scholar
  31. 31.
    Powner DJ, Kellum JA, Darby JM (2000) Abnormalities in fluids, electrolytes, and metabolism of organ donors. Prog Transplant 10:88–96CrossRefPubMedGoogle Scholar
  32. 32.
    Powner DJ, Kellum JA (2000) Maintaining acid–base in organ donors. Prog Transplant 10:98–105CrossRefPubMedGoogle Scholar
  33. 33.
    Mizock BA, Falk JL (1992) Lactic acidosis in critical illness. Crit Care Med 20:80–93CrossRefPubMedGoogle Scholar
  34. 34.
    Oh MS, Carroll HJ (2000) External balance of electrolytes and acids and alkali. In: Seldin DW, Giebisch G (eds) The kidney: physiology & pathophysiology. Lippincott Williams & Wilkins, Philadelphia, pp 33–60Google Scholar
  35. 35.
    Kazemeyni SM, Esfahani F (2008) Influence of hypernatremia and polyuria of brain-dead donors before organ procurement on kidney allograft function. Urol J 5:173–177PubMedGoogle Scholar
  36. 36.
    Katz MA (1973) Hyperglycemia-induced hyponatremia–calculation of expected serum sodium depression. N Engl J Med 289:843–844CrossRefPubMedGoogle Scholar
  37. 37.
    Mandal AK (1997) Hypokalemia and hyperkalemia. Med Clin North Am 81:611–639, - Wrenn KD, Slovis CM, Slovis BS. The ability of the physician to predict hyperkalemia from the ECG. Ann Emerg Med. 1991;20:1229–1232CrossRefPubMedGoogle Scholar
  38. 38.
    Allon M (1993) Treatment and prevention of hyperkalemia in end-stage renal disease. Kidney Int 43:1197–1209CrossRefPubMedGoogle Scholar
  39. 39.
    Ahee P, Crowe AV (2000) The management of hyperkalaemia in the emergency department. J Accid Emerg Med 17:188–191CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Martin KJ, Gonzalez EA, Slatopolsky E (2009) Clinical consequences and management of hypomagnesemia. J Am Soc Nephrol 20:2291–2295CrossRefPubMedGoogle Scholar
  41. 41.
    Bushinsky DA, Monk RD (1998) Calcium. Lancet 352:306–311CrossRefPubMedGoogle Scholar
  42. 42.
    Hirschl MM, Matzner MP, Huber WO et al (1996) Effect of desmopressin substitution during organ procurement on early renal allograft function. Nephrol Dial Transplant 11:173–176CrossRefPubMedGoogle Scholar
  43. 43.
    Shah V, Bhosale G (2006) Organ donor problems and their management. Indian J Crit Care Med 10:29–34CrossRefGoogle Scholar
  44. 44.
    Ramos HC, Lopez R (2002) Critical care management of the brain-dead organ donor. Curr Opin Organ Transplant 7:70–75CrossRefGoogle Scholar
  45. 45.
    Distress Syndrome Network. 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. 2000; 342(18):1301–1308Google Scholar
  46. 46.
    Mascia L, Pasero D, Slutsky A et al (2010) Effect of a lung protective strategy for organ donors an eligibility and availability of lungs for transplantation. JAMA 304:2620–2627CrossRefPubMedGoogle Scholar
  47. 47.
    Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903CrossRefPubMedGoogle Scholar
  48. 48.
    Bonten MJ, Bergmans DC, Stobberingh EE, van der Geest S, De Leeuw PW, van Tiel FH, Gaillard CA (1997) Implementation of bronchoscopic techniques in the diagnosis of ventilator-associated pneumonia to reduce antibiotic use. Am J Respir Crit Care Med 156:1820–1824CrossRefPubMedGoogle Scholar
  49. 49.
    Levy JH (2006) Massive transfusion coagulopathy. Semin Hematol 43(1 Suppl 1):S59–S63CrossRefPubMedGoogle Scholar
  50. 50.
    Talving P, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D (2009) Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma 66:55–61, discussion 61–62CrossRefPubMedGoogle Scholar
  51. 51.
    Barklin A, Tønnesen E, Ingerslev J, Sørensen B, Fenger-Eriksen C (2009) Coagulopathy during induced severe intracranial hypertension in a porcine donor model. Anesthesiology 110:1287–1292CrossRefPubMedGoogle Scholar
  52. 52.
    Hefty TR, Cotterell LW, Fraser SC, Goodnight SH, Hatch TR (1993) Disseminated intravascular coagulation in cadaveric organ donors. Incidence and effect on renal transplantation. Transplantation 55:442–443CrossRefPubMedGoogle Scholar
  53. 53.
    Valdivia M, Chamorro C, Romera MA, Balandín B, Pérez M (2007) Effect of posttraumatic donor’s disseminated intravascular coagulation in intrathoracic organ donation and transplantation.Transplant Proc. Sep;39:2427–8Google Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of Cardiac SurgeryIRCCS Fondazione Policlinico San MatteoPaviaItaly
  2. 2.Department of Surgery and Abdominal TransplantationTransplant Center, Niguarda Ca’ Granda HospitalMilanItaly

Personalised recommendations