Organ Donation Toolkit


This page is designed to provide practical guidance for clinicians on the immediate steps to be taken when they are caring for a dying ventilated patient who may be a possible organ donor.

Always consider organ donation when caring for dying patients who are receiving mechanical ventilation at the point when the inevitability of death is recognised, regardless of whether the patient is in an intensive care unit, emergency department or another critical care area. Specialist nurses – organ donation are available 24 hours a day to give advice and travel to hospitals to support organ donation.

Key messages:

  • Refer to the specialist nurse – organ donation before withdrawal of ventilation
  • Follow the three stages of the family approach in collaboration with the specialist nurse
    • plan family approach with specialist nurse – organ donation
    • confirm a family’s understanding and acceptance of loss before raising organ donation
    • present donation in a positive way
  • Instigate donor optimisation early

 


Refer to the Specialist Nurse – Organ Donation (SN-OD) before the withdrawal of ventilation

Donation is possible after the diagnosis of brain-stem death, and also from gravely ill patients whose imminent death is expected to follow the withdrawal of life-sustaining treatments that are considered to be of no overall benefit. Although most potential donors will have suffered an acute catastrophic brain injury (including hypoxic brain injury), donation is also possible in other circumstances. The common feature is that they are mechanically ventilated.

 

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Approaching the families of potential organ donors

There are three distinct stages to approaching the family of a potential donor:

  • Planning the approach
  • Confirming understanding and acceptance of loss
  • Discussing donation.

As a standard of care, the SN-OD should be involved in all three stages, preferably in person. Although there may be circumstances that prevent the SN-OD from attending at this point, as a minimum they should be involved in the planning by telephone.

 

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Instigate donor optimisation early

Brain-stem death can be associated with profound physiological instability that both interferes with brain-stem death testing and also limits the possibility for organ donation should death be confirmed. There are a number of simple steps that should be taken as soon as possible to correct this instability and thereby stabilise the patient:

  1. Assess fluid status and correct hypovolaemia with fluid boluses
    Hypovolaemia is common, and can be caused by osmotic therapies, diabetes insipidus and neurogenic pulmonary oedema.

  2. Introduce vasopressin infusion and where required introduce flow monitoring
    Brain-stem death is associated with profound vasodilatation that is often refractory to standard vasoconstrictors such as nor-epinephrine and phenylephrine. Patients who fail to respond to vasopressin may also require inotropic therapy with dopamine or dobutamine.

  3. Perform lung recruitment manoeuvres (e.g. following apnoea tests, disconnections, deterioration in oxygenation or suctioning)
    Neurogenic pulmonary oedema is common, and may lead to substantial atelectasis and hypoxaemia that will be worsened should PEEP be inadequate or temporarily released.

  4. Identify, arrest and reverse effects of diabetes insipidus
    Uncorrected diabetes insipidus results in hypovolaemia, cardiovascular instability, hypernatraemia and hypokalaemia. Treat with crystalloid resuscitation (0.45% NaCl or 5% dextrose), parenteral potassium replacement and DDAVP.

  5. Institute / maintain active warming manoeuvres
    Brain-stem dead patients are profoundly vasodilated and have lost central control of body temperature. Hypothermia is very common and may be difficult to reverse without active warming measures and effective vasoconstrictor therapy (see b.).

  6. Administer methylprednisolone
    Systemic inflammation is a feature of brain-stem death. Once death has been confirmed, methylprednisolone, 15mg/kg to maximum of 1g, should be given to all donors.

Additional Resources

 

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Next section: Living Donation

On-call SN-OD pager numbers:

East of England – 07659 117499

London – 07659 100103

Midlands – 07659 137821

Northern – 07659 146757

Northern Ireland – 07699 748246

North West – 07659 184748

Scotland – 07659 594979

South Central – 07659 183499

South East – 07659 590529

South West – 07659 591642

Wales – 07659 591889

Yorkshire – 07659 171979

 

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