Recognition of brain death: The onset of any of the following should be an indication of possible brain death
Diabetes insipidus
Hypotension requiring more than 1 pressor / inotrope
Hypothermia
Pupils becoming nonreactive should not trigger the process.
Stop drugs: When the patient has not required muscle relaxants for at least 2 hours, check for a cough reflex. If absent, stop
Sedation
Narcotics
Restart at first sign that patient is not brain dead
Blood pressure: Aggressive management combination of volume, inotropes, pressors and other drugs (as below) to maintain MAP between 70 and 80 mmHg.
Start Hydrocortisone at 50mg q6h
Begin support with dopamine and dobutamine starting from 5 and ifnecessary increasing to 15 mcg/kg/min, if pressure still low - addnoradrenaline. Dobutamine is started as after dopamine has beenincreased to 10 mcg/kg/min. Increasing dose of dopamine results intachycardia.
If available add levothyroxine bolus of 20 mcg followed by an infusion of 10 mcg/hr if dose of dopamine crosses 10 mcg/kg/min
Keep pressor dose at a minimum to avoid visceral Ischemia
Frequently before final brain death there is a surge in blood pressure; the MAP must be kept below 100 mmHg at this time by
Rapidly reducing dose of dopamine / noradrenaline
Metoprolol 5 mg IV boluses with 5 minute intervals between doses
Fluid electrolytes: Recognize DI early do not wait for formal fulfillment of output or serum sodium criteria as applicable for sellar-suprasellar lesions. Target sodium <150 mEq/L and potassium >3 mEq/L
A triple lumen line and a large bore peripheral line are mandatory
Keep CVP over 10 cms
If output very high check and replace volume every 30 minutes
Judge replacement fluid sodium concentration based on output and last serum sodium level
High output states cause significant potassium depletion remember to replace adequately
Check electrolytes every 4 hours
Once the patient develops DI begin a pitressin infusion at 3mcg/hour and titrate
Temperature: If patient identified as potential donor keep covered with blanket at all times. If
Patient develops hypothermia or
After first test completed
cover with warming blanket, cover head completely. There is no need to warm IV fluids.
Ventilation: Once the patient is suspected to be brain dead andsedation has been stopped change ventilator settings to a tidal volumeof 6 ml/kg predicted body weight
Family: Once secondtest is positive, permit family to see patient in batches. This helpsavoid congestion and obstruction on the way to the OR.
Transfer to OR: To be made only with the following criteria fulfilled
Accompanied by consultant anesthetist who is aware of status of preparedness in the OR
Portable monitor and ventilator
Fully charged infusion pumps
New oxygen cylinder
Transfer patient onto trolley without disconnecting bedsidemonitor. Take as long as necessary to stabilize patient on the trolleybefore moving to the OR.
Certification: Cooperate with transplant coordinator to ensure thatdonor's family does not suffer any procedural delays in release of body. Editors Note - The above form is a simple form that is followed in some hospitals including CMC, Vellore; the hospital can modify the formas per their own or other International guidelines.
