The principles of donor management described above should be continued into the intraoperative period. To avoid reflex neuromuscular activity a muscle relaxant that does not depress the cardiovascular system (e.g. pancuronium bromide) should be used. Nitroglycerin, nitroprusside, and isoflurane have all been recommended to control reflex hypertension. Hypotension may be precipitated by manipulation of the heart and great vessels or flushing donor organs with cold preservation solution. Administration of pressor agents, particularly in high doses, may jeopardize organ perfusion, and some recommend pulmonary artery catheterization during retrieval surgery in multiple organ donors to minimize the use of inotropes and vasopressor drugs. If cardiac arrest occurs, cardiopulmonary resuscitation should be instituted while procurement of liver and kidneys proceeds rapidly with cross-clamping of the aorta at diaphragm level and infusion of cold preservation solution into the distal aorta and portal vein.
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