Page 1589 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1108 PART 10: The Surgical Patient

further enhance outcomes. Having an approach to unique presenta-
tions of common conditions as well as rare infections, which may lead • The goals of management of the multiorgan donor are to maximize
to intensive care unit admission can allow for prompt administration of organ function by maintaining organ perfusion and oxygenation,
appropriate therapy to minimize end-organ damage. Thus the critical and to promptly recognize and treat potential complications such
care of the transplant patient requires the intensivist to be an expert in as hypotension, dysrhythmia, pulmonary edema, massive diuresis,
acute physiology and to have an understanding of the important medical coagulopathy, hypothermia, and sepsis.
issues facing the recipient, but also requires someone who can coordi-
nate with other professionals involved in the patient’s care, and identify
the medical and social needs of both the patient and the family. It is only
through such a multidisciplinary approach, coordinated by the intensiv- Organ transplantation has evolved rapidly from the first early successes
ist, that transplant patients will continue to achieve excellent outcomes. to the current widespread use of donated organs for the treatment of
end-stage kidney, liver, heart, and lung failure. The success of solid
1
KEY REFERENCES organ transplantation has increased the need for an expanded supply of
organ donors. In response to this need, the age limit for deceased donors
• Boffini M, Ranieri V, Rinaldi M. Lung transplantation: is it still has been increased, and donors over the age of 65 years are frequently
an experimental procedure? Curr Opin Crit Care. 2010;16:53-61. successfully utilized. The use of organs from living-related donors,
2
• Christie J, Edwards L, Aurora P, et al. The Registry of the living-unrelated donors, and non–heart-beating donors (ie, donation
International Society for Heart and Lung Transplantation: after cardiac death [DCD]) has also increased. Nevertheless, there
3
twenty-sixth official adult lung and heart-lung transplantation has been a progressively widening gap between the number of patients
report—2009. J Heart Lung Transplant. 2009;28:1031-1049. waiting for transplants and the number of transplantations performed.
• Haddad E, McAlister V, Renouf E, Malthaner R, Kjaer M, Gluud L. According to the United States Organ Procurement and Transplantation
Cyclosporin versus tacrolimus for liver transplanted patients. Network (OPTN) as of December 31, 2010, the number of patient reg-
Cochrane Database Syst Rev. 2006;(4):CD005161. istrations was 100,597 with the majority of patients in the 18 to 64 year
• Lowell J, Shaw Jr B. Critical care of liver transplant recipients. In: age range. In 2008, there were 14,203 donors available (deceased =
7984, living = 6219) and a total of 27,961 transplants were performed in
Maddrey WC, Schiff ER, Sorrell MF, eds. Transplantation of the 4
Liver. Philadephia, PA: Lippincott, Williams & Wilkins; 2001:385. the United States. In cadaveric donors, the largest increase has been
in donors older than 50 years of age for last 10 years (170%). One conse-
• McGilvray I, Greig P. Critical care of the liver transplant patient: an quence of the increased proportion of older and more diverse donors has
update. Curr Opin Crit Care. 2002;8:178. been the increase in organs discarded after being procured. 3
• Moon DB, Lee SG. Liver transplantation. Gut Liver. 2009;3(3):145-165. The relevance of a properly functioning transplanted organ cannot be
• O’Grady J, Alexander G, Hayllar K, Williams R. Early indica- overemphasized and it is clearly crucial for the success of transplanta-
tors of prognosis in fulminant hepatic failure. Gastroenterology. tion of organs requiring immediate function such as the heart and lung.
1989;97(4):439. Acute lung allograft dysfunction is the leading cause of death within
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• Stehlik J, Edwards L, Kucheryavaya A. Diagnosis in adult heart 30 days of lung transplantation. Temporary failure of the liver, kidneys,
transplants: heart lung registry slides from ISHLT website. J Heart and pancreas may be tolerated with supportive measures such as hemo-
Lung Transplant. 2010;29(10):1083-1141. dialysis and pharmacologic interventions.
At a time when transplant surgeons are facing an increasing number
• Stravitz R. Critical management decisions in patients with acute of deaths on the waiting list, and as the size of the list continues to grow,
liver failure. Chest. 2008;134:1092-1102. there has never been a greater drive to utilize a higher percentage of
older or otherwise extended donors, minimize the incidence of primary
graft dysfunction, and develop organ donor management strategies that
REFERENCES continue to increase the number of organs available for transplant. 6-9
Complete references available online at www.mhprofessional.com/hall To increase the number of transplantable organs, UNOS created the
Critical Pathway for the Organ Donor, a blueprint of an organ donor’s treat-
ment plan. The Critical Pathway is a concise, one-page document designed
to help critical care staff and procurement coordinators understand and
CHAPTER Care of the Multiorgan follow the steps required for effective donor management. After brain
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116 Donor death has been declared in potential organ donors and consent is given for
donation, donors need to be medically managed to keep their organs viable
11
Masaki Anraku until organ recovery can occur. The Critical Pathway describes optimal
care for the organ donor and maps the process to improve the outcome
Shaf Keshavjee for successful organ transplantation. The Pathway promotes collaboration
between organ procurement coordinators and critical care staff, and delin-
eates roles to prevent duplication of effort or confusion.
KEY POINTS Studies have shown that the Critical Pathway, which has been
• Increasingly successful solid organ transplantation has increased endorsed by four major transplantation associations, significantly
the need for organ donors. increased the number of organs procured and transplanted from brain-
7,8
• Maximizing organ procurement and expanding donor acceptance dead donors. There is no sacrifice in the quality of the transplanted
criteria should decrease the organ shortage. organs or an increase in donor management time.
The two major limiting factors in organ donation today are (1) failure
• Aggressive ongoing critical care of the multiorgan donor is essential to identify patients that are potential organ donors and lack of referral of
to improve organ retrieval and posttransplant graft performance. those patients to the organ procurement organization, and (2) refusal of
• Understanding the process of brain death is essential for directing patients’ families to consent to donation. A proactive donor detection
donor treatment strategies to ensure preservation and function of program maintained by well-trained transplant coordinators, the intro-
donor organs. duction of systematic death audits in hospitals, combined with a positive
social atmosphere, appropriate management of mass media relations,

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