Salvage of an Unstable Brain Dead Donor with Prompt Extracorporeal Support

Abstract

Maximizing the support of the marginal donor is an approach to optimizing the donor pool. Thirty-two percent of brain dead donors are hemodynamically unstable and 25% of donors under the age of 60 with traumatic brain injuries expire before organs can be procured (1, 2). When standard donor management protocols are insufficient to salvage a potential donor, aggressive attempts to save the organs can be considered. We present a case of an unstable brain dead donor who suffered premature cardiac death and the use of ECMO (extra-corporeal membrane oxygenation) perfusion in the successful salvage of organs for transplantation. Shortly after being declared brain dead, a 25-year-old patient became hypoxic and hemodynamically unstable. The patient’s family strongly desired organ donation. Despite hormonal replacement and three vasopressors, his mean arterial pressure (MAP) was less than 45 mm Hg. The situation was reviewed with the family, who gave consent for ECMO. The ECMO team was called for an emergent cannulation. The patient was placed on venous-arterial ECMO via cannula placement in the common femoral artery, the internal jugular vein, and the common femoral vein. The patient had a significant improvement in hemodynamics and resumed making urine (MAP 60 to 75). Approximately 75 min later and for unclear reasons, the patient had a cardiac arrest. The MAP was maintained at 53 via ECMO support following cessation of cardiac activity. The patient was transported to the operating room. ECMO flow was not interrupted during this transport. Shortly after arriving into the operating room, cold University of Wisconsin solution was infused through the ECMO circuit. The femoral venous cannula was cut and allowed to drain into a waste bucket. The abdomen was opened and cold slush was poured into the abdominal cavity. The perfusate return soon cleared and the kidneys were procured in the standard fashion. The kidneys were placed on pulsatile pump perfusion. Both kidneys were transplanted and functioned immediately. At our center, we have had success with a protocol using extracorporeal support for NHBDs (non-heart beating donors) (3). In our experience with NHBD, balloon aortic occlusion and a mean ECMO flow of 3.0 L/minute provides physiologic flow to the intra-abdominal organs. Failure of physiologic support to prevent early cardiac death was the second most frequent potentially remediable causes of procurement failure (4). Many potential donors who are unstable are not referred to the local organ procurement organization. In addition, patients who have been hemodynamically tenuous are frequently only kidney donors and the other organs are not procured. In this case, the use of ECMO salvaged the kidneys for donation. In addition, the circuit provided an expeditious means to perfuse with cold University of Wisconsin solution. Using ECMO to optimize brain dead donors is a novel strategy to increase the number of donors and the yield of organs per donor. Michael J. Englesbe Derek Woodrum Meelie Debroy Richard Chenault William Miller Judiann Miskulin Fresca Swaniker John C. Magee Juan D. Arenas Jeffery D. Punch Randall S. Sung Department of Surgery Division of Transplant Surgery and Surgical Critical Care University of Michigan Health System Ann Arbor, Michigan