Position: Supine
Time: 2-4 hours (long)
Blood Loss: Very Low (5-10 ml)

Maintenance Paralytic: Yes

Understand Your Role – As an anesthesia provider, you should not be involved with the decision to cease life support, calling time of death, or involved with discussing organ donation with family or decision makers. It is prudent to familiarize yourself with the state-specific laws and institutional rules about organ donation.

Optimize – Anesthesia plays an important role in these cases after the declaration of brain/cardiac death. It is important to review labs and correct any electrolyte abnormalities as well as optimize blood-gases before going to the OR.

ICU transport – These patients are most often brought from the ICU with an ETT already in place. It is vital to make sure transport monitors are set up and working. Have a mobile ventilator or bag-mask for transport.

Maintain the Patient – Prior to the harvest, the team managing the donation will typically communicate the specific blood pressure parameters and what organs will be procured. In the case of lung harvesting, specific instructions from the surgery team will be given for ventilation.

OR Arrival – Once in the OR, it is vital to maintain the predetermined parameters to adequately perfuse the organs being harvested. Place the patient on the ventilator and administer paralytic. Some neurological function, including brain stem reflexes, can remain intact. Opioids, such as fentanyl, are often used to blunt sympathetic reflexes such as tachycardia.

Ventilation – Ventilating the lungs with lung protective volumes (4-8mL/kg) and PEEP of 5-10 is also associated with better organ procurement outcomes per the National Health Service (NHS).

Arterial Line – Depending on case and institution, invasive blood pressure monitoring can be used if not already in place from the ICU.

BP Support – The American College of Cardiology recommends using vasopressin as first line for hemodynamic support. Norepinephrine and epinephrine can also be used if needed.

Anticoagulation – Coagulopathy is also associated with brain death and most surgeons will discuss use and dosage of heparin that is desired during the procurement.

Mannitol – Mannitol is also something to keep on hand as it’s use is common in these surgeries to increase renal blood flow.

Case Completion – At some point during the case, the surgeon will cross-clamp the aorta. At that junction, there’s no longer perfusion to the brain. Anesthesia is no longer needed, so the anesthesia machine and all pumps can be disconnected and turned off. In most cases, you’ll leave the OR before the case has finished.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.