Page 1593 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1112 PART 10: The Surgical Patient

TABLE 116-2 Relative Risk of Central Nervous System Tumor Transmission TABLE 116-3 Heart Donor Criteria
Lowest Risk Criteria Modification(s)
Benign meningiomas Age Donors >55 may be used selectively, though coexisting LVH and
Pituitary adenomas longer ischemic times may increase recipient mortality risks
Acoustic schwannomas Size Despite an increased risk associated with small donors, a normal-
sized adult male (>70 kg) donor is suitable for most recipients
Craniopharyngiomas
LVH Mild LVH (wall thickness <13 mm by echocardiography and no
Astrocytoma (grade I)
LVH by ECG criteria) does not preclude recovery, particularly with
Epidermoid cysts, colloid cysts shorter ischemic times
Low-grade oligodendrogliomas Valvular lesions Certain lesions, such as mild or moderate mitral or tricuspid
Gangliogliomas, gangliocytomas regurgitation, or a normally functioning bicuspid aortic valve may
be amenable to repair prior to transplantation
Pineocytomas, ependymomas
Congenital lesions Certain lesions, such as a secundum type ASD, may be amenable
Well-differentiated teratomas to repair
Papillomas Coronary angiography a. Male donor age 35-45 years and female donor age 35-50 years:
Hemangioblastomas perform angiography if there is a history of cocaine use or ≥3
risk factors for CAD
Moderate Risk
b. Male donor age 46-55 years and female donor age 51-55 years:
Astrocytoma (grade II) angiography recommended
Gliomatosis cerebri c. Age >55 years: angiography strongly recommended
Highest Risk CAD Donor hearts with mild coronary artery disease should be consid-
ered for recipients with relatively urgent need
Anaplastic astrocytoma (grade III)
ASD, atrial septal defect; CAD, coronary artery disease; ECG, electrocardiographic; LVH, left
Glioblastoma multiforme
ventricular hypertrophy.
Medulloblastoma Reproduced with permission from Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to
Anaplastic oligodendroglioma maximize the use of organs recovered from the cadaver donor. Am J Transplant. September 2002;2(8):701-711.
Pineoblastomas
Chordomas Ganz catheter monitoring is important to keep the central venous pres-
sure below 8 to 10 cm H O. Diuretics should be given when pulmonary
2
Malignant ependymomas edema is seen, but care should be taken to maintain stable hemodynam-
Primary cerebral lymphomas ics if diabetes insipidus also exists.
Wider application of broader criteria for donor selection and procure-
Reproduced with permission from Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to ment is possible and can clearly increase the size of the donor pool, and
maximize the use of organs recovered from the cadaver donor. Am J Transplant. September 2002;2(8):701-711.
therefore the intensivist plays an important role in identifying potential
echocardiogram. Aggressive donor management, including pulmonary organ donors and in the management of those donors. If multidisciplinary
49
artery catheterization and hormonal resuscitation, should be performed, donor management protocols were developed, increased lung utilization
especially in donors with an initial left ventricular ejection fraction less would follow. Table 116-4 shows the current criteria that are used to
50
47
than 40%. Recommended management of the organ donor Table 116-3 determine the suitability of a cadaver lung donor. A Pa O 2 : Fi O 2 ratio (P:F
shows the heart donor criteria have been recently modified to poten- ratio) is a parameter of lung gas exchange, and the ratio above 300 is pref-
tially expand the available pool of cardiac donors. 34,48 Indications for erable. However, timing of evaluation, temporal changes, and response to
coronary angiography are listed in Table 116-3. alveolar recruitment should be considered to interpret the result. The Lung
■ PULMONARY EVALUATION Transplant Working Group in United States proposed the criteria to include
virtually any donor up to the age of 65 years, in the absence of significant
The suitability of donor lungs for transplantation is determined with lung injury from smoking, and absence of cancer with metastatic potential. 34
several diagnostic tests. A chest radiograph should be interpreted by In an effort to augment the donor pool, criteria have been further
a radiologist or qualified physician. A complete history of the donor’s loosened with the retrieval of organs from donors with greater smoking
treatment while in the hospital, including the use of vasopressors and histories, infiltrates on radiography, or marginal gas exchange. Because
results of arterial blood gas analyses, are shared with centers consider-
ing the transplantation of lungs. Smoking history should be reported, TABLE 116-4 Lung Standard Donor Criteria
along with the results of Gram stains of sputum (a specimen for a
detection of yeasts and fungi is desirable), and a description of the sputum • Pa O 2 /Fi O 2 ratio >300 , Fi O 2 = 1.0, PEEP = 5 cm H O
2
characteristics. In addition, a bronchoscopic examination is performed to • Clear chest X-ray
assess for signs of aspiration, and to document evidence of a foreign body • Age <55 years
or presence of blood or other material entering the lower airways from • Absence of major chest trauma
above. It also allows assessment of the character and amount of secre-
tions in the lung and provides microbiologic specimens. A bronchoscopic • Absent aspiration, sepsis, or purulent secretions
examination will also promote pulmonary stability in the donor by • Smoking history of <20 pack-years
removing airway secretions that may have accumulated. Blood gases are • No history of malignancy
repeated every 3 hours to assess the results of interventions and to deter-
mine trends. Repeat pulmonary recruitment maneuvers (every 2 hours) FiO 2 , fraction of inspired oxygen; PEEP, positive end-expiratory pressure; PaO 2 , partial pressure of oxygen.
are performed to optimize ventilation-perfusion matching. a Arterial blood bas should be repeated if indicated after a recruitment maneuver.
Careful fluid management is critical to avoid overhydration that could Reproduced with permission from Rosengard BR, Feng S, Alfrey EJ, et al. Report of the Crystal City meeting to
cause pulmonary edema. Therefore, central venous pressure or Swan maximize the use of organs recovered from the cadaver donor. Am J Transplant. September 2002;2(8):701-711.

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