Optimal Thoracic Organ Donor Management

Dan M. Meyer, Michael A. Wait, Michael E. Jessen, W. Steves Ring

Donor Selection (General) 94

Donor Selection (Organ Specific) 101

Donor Preoperative Management 105

The success of heart and lung transplantation begins with the careful selection of suitable donors. This is achieved by developing a database of donor specific factors likely to influence either the short term or long term survival following transplantation. The transplant physician and surgeon must then balance the risk of transplanting a particular organ into a specific recipient against the risk to both the recipient and all other recipients of not using the organ. This judgment is based on the projected natural history of the potential recipient's underlying disease process (i.e., likelihood of survival on the waiting list), along with that of all others on the waiting list. The ultimate goal should be the best long-term survival and quality of life for the greatest number of recipients.

The database of donor characteristics which can influence outcomes includes both general and organ specific donor factors (Table 7.1). General donor factors have been dealt with in previous chapters but will be discussed with regards to both heart and lung transplantation. For medical-legal protection, a careful documentation of brain death is essential and should be reviewed by the organ procurement team and the transplant surgeon prior to proceeding with further evaluation. The on-site organ procurement organization representative collects the information for completion of the donor database, requests additional testing as indicated, assists in donor stabilization and management, facilitates placement of all suitable organs, communicates with the remainder of the procurement teams, and coordinates the entire procurement process.

Based on the original experience at Stanford,1 specific guidelines have been adopted to maximize long-term function of cardiac allografts2 (Table 7.2). Similar guidelines have been developed for lung allografts3-6 and are summarized in Table 7.3. As the results of heart and lung transplantation have improved over the past decade, more patients are being considered for transplantation. This has caused a sharp rise in the number of recipients listed for transplant, contributing to prolonged time on the waiting list, a greater need for pretransplant intensive care with inotropic or mechanical support, and an increased waiting list mortality. As the shortage of suitable donors has become apparent, efforts have been made to

Organ Procurement and Preservation, edited by Goran B. Klintmalm and Marlon F. Levy. © 1999 Landes Bioscience

Table 7.1. Thoracic donor database

General

Documentation of brain death Demographics: Age, Sex, Race, Size History

Current: Cause of death, Resuscitation, Procedures, Monitoring, Hemodynamics, Medications, Infection

Past: Medical, Surgical, Social, Medication, Transfusion, Malignancy, Infection, Substance Abuse

Laboratory: ABO type, Toxicology, Viral serology, Cultures, Chemistry, Hematology, Coagulation Organ Specific Heart

Current history: Trauma, CPR, Arrhythmias Past History: Cardiac disease/symptoms, Risk factors Function: ECG, ECHO, Hemodynamics, Pressors, Angiography Laboratory: CKMB, Troponin I Lung

Current history: Trauma, Aspiration, Ventilation Past history: Pulmonary disease/symptoms, Smoking Function: Ventilation mechanics, O2 challenge, Bronchoscopy Laboratory: CXR, ABG, Sputum gram stain, Cultures

Table 7.2 Standard heart donor criteria

ABO compatible Age < 50 years

ECHO: EF > 50%, no significant wall motion or valve abnl

Inotropes: < 15 mcg/kg/min Dopamine

D/R Weight Ratio 0.7-1.5

Ischemic Time < 4 hours

ECG: normal or minimal ST changes

No active infection or malignancy

Seronegative for HBV, HCV, and HIV

Table 7.3. Standard lung donor criteria

ABO compatibility Age < 55 years CXR clear

Bronchoscopy: normal airways and mucosa

Mechanics: normal compliance

Normal gas exchange: pO2 > 300 on FIO2 = 1.0

No history primary lung disease

No active infection or malignancy extend these donor guidelines to increase the donor pool.7 Newer strategies have included extending the donor age limits,8-13 accepting longer donor ischemic times,1,8,10 using donors on high inotropic support or with wall motion abnormalities on echocardiogram,10 using cardiac donors with reconstructable coronary artery disease, using living-related lung donors16,17 and using nonbeating heart donors.18-20

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