Role of the intensivist for organ donation

The shortage of organs for transplantation is a serious medical problem. More than 90% of organ donors are patients who die after the irreversible cessation of all brain function in Intensive Care Units (ICUs) but 5–10% of these patients who fulfill the criteria of brain death suffer cardiac arrest before becoming an organ donor therefore their organs can no longer be utilized(1). Reasons why a potential donor does not become a utilized donor includes failure to identify/refer a potential donor, hemodynamic instability/unanticipated, and cardiac arrest with consecutive organ damage amongst others. Because the majority of potential organ donors are in the ICU, the critical care management guided by the intensivist plays a key role. The intensivist's responsibilities include the timely identification and referral of the potential organ donor for Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), optimization of the brain-dead donor by early goal-directed management of the physiological consequence of brain death, in addition to development and implementation of protocols and clinical pathways for DCD in collaboration with the organ transplant team in the hospital(2). Identification and referral should be done as early as possible and should be guided by best available evidence guidelines e.g. the NICE Clinical Guidelines “Organ Donation for transplantation”. If not yet addressed, the organ donation team will approach the family to obtain their consent for organ donation. The clinical picture of physiological changes that follow brain death is not uniform. Severity and occurrence of dysfunctions are related to the etiology and time course of brain death. Most common are hypotension, diabetes insipidus, hypothermia, and plasma electrolyte imbalance in comparison to pulmonary edema, metabolic acidosis, cardiac arrhythmias, and disseminated intravascular coagulation(3). The general management principles in the ICU regarding DBD and DCD are similar. The donor management goals shall ensure physiological homeostasis to maintain the best possible organ function at the time of organ harvesting and includes cardiovascular, respiratory, fluid, electrolyte, hormone, blood, coagulation and temperature management to maintain normovolemia, hemodynamic stability, and normothermia(4). A recent prospective study investigated the effect of the implementation of a Donor Management Goals (DMG) bundle that focused on maintaining parameters like blood pressure, central venous pressure, ejection fraction, arterial blood gas, PaO2/FiO2 ratio, sodium, blood glucose with support of low dose vasopressors within normal limits. The achievement of any 7 of 9 DMGs was associated with a substantial increase in the number of organs available for transplantation(5). Meanwhile, many countries recognized that the principle of organ donation should be a routine component of end-of-life (EOL) care. By implementing strategies of early identification and evidence-based goal-directed management protocols to preserve organ function, the critical care team guided by an experienced intensivist in collaboration with the organ donation team can help to improve organ availability and quality to overcome shortage of organs for transplantation.