Donation Facts

Always refer to your hospital policy for declaration of death by neurological criteria.
Read more:

1. 1. Guidelines for the Determination of Brain Death in Infants and Children (2011)

Studies have shown that the use of naloxone (Narcan) in an intravenous bolus of 8 mg, can reduce and/or reverse neurogenic pulmonary edema in the brain dead organ donor and improve gas exchange for better oxygenation. It is given in an effort to prevent or minimize neurogenic pulmonary edema. A 10-mg intravenous bolus of vecuronium bromide (Norcuron) is given simultaneously (and repeated PRN) with the naloxone to decrease spinal reflexes and relax the diaphragm and other respiratory muscles to improve ventilation. Other paralytic agents are used if vecuronium bromide is not available.

HonorBridge employs lung recruitment maneuvers to improve the oxygenation status of brain dead organ donors which includes high dose steroids (2 grams of Solumedrol) and vent management.

• Step 1: Set pressure support to 0 and CPAP mode on ventilator
• Step 2: Increase PEEP to 25 -40 cm H2O as tolerated for 30-40 seconds (terminate if not tolerated)
• Step 3: Return to previous or desired setting
• Step 4: Obtain ABG in 30 minutes

HonorBridge coordinators medically manage brain dead organ donors using standing interventions prescribed by our Medical Director, Nancy Knudsen, MD. All of our orders comply with industry standards and critical care medicine guidelines. These interventions are given to maintain organ system function via normothermia, adequate hydration, gentle diuresis, adequate organ perfusion, thorough oxygenation, while also preventing infection. They are designed specifically to counteract the sequelae of brain death. Questions on dosaging and concerns about toxicity or ill side effects of the interventions use for organ donors sometimes arise. It is important to note that it typically takes only 12-24 hours from the time authorization is given to the time of organ recovery. Given this very short treatment window, even when the medications requested are known to be hepato- or nephron-toxic, they are not typically used long enough to damage the organ or cause a problem in the organ recipient.

HonorBridge will order Norcuron for several different reasons. Every brain dead organ donor requires good ventilation. Because there is an increased capillary permeability that occurs with brain death, many organ donors will have developed neurogenic pulmonary edema. Bilateral basilar atelectatisis is also common. Many times these conditions require aggressive pulmonary recruitment to maximize oxygenation. Administering a paralytic facilitates relaxation of the chest wall allowing for greater expansion of the lungs and better oxygenation. Though rare, it is not unusual for a brain dead organ donor to exhibit spinal reflexes. This can be unnerving to both hospital staff and the family. Norcuron can eliminate these reflexes. In some cases, Narcan therapy for the treatment of neurogenic pulmonary edema is used. Studies show that Narcan therapy can not only prevent but also reverse neurogenic pulmonary edema. However, at 8 times the normal dose given to a living patient, the Narcan can cause and/or increase spinal reflexes in the brain dead patients. Whenever Narcan therapy is used, it is typically paired with Norcuron as needed to eliminate/ reduce spinal reflexes. HonorBridge will order Norcuron to be administered just prior to going to the operating room or as soon as we enter. Because transplant surgeons will be dissecting in the abdomen, Nocuron paralyzes the peristalsis function of the gut, reducing the possibility of surgical damage to intestinal wall, which could lead to contamination of the organs with bowel contents. 

T-4 Protocol involves the following medications administer in rapid succession:

• 1 amp D50 IVP (hold if blood glucose >250)
• 2 gm Solumedrol (1 gm if previously administered)
• 20 units Regular Insulin (subcutaneously)
• 20 mcg of Levothyroxine IVP
• Levothyroxine IV Infusion – reconstitute 200 mcg Levothyroxine in 5 ml
• 0.9%NaCl, dilute mixture further in 500 ml 0.9%NaCl, deliver at 10-20 mcg/hr to MAP 60-110

In a normal patient, the hypothalamus releases Thyroid Release Hormone (TRH) into the blood stream. TRH stimulates the pituitary into secreting Thyroid Stimulating hormone (TSH). The thyroid secretes 80% T4 and 20% T3 into the bloodstream. T4 binds to protein and is metabolized into T3.  T3 is the active hormone. Following brain death, neither the hypothamlamus nor the pituitary gland are working therefore  there is a decreased level of T4, T3, plasma cortisol, insulin and Antidiuretic Hormone (ADH). This results in a reduction in myocardial energy stores (Adensine Triphosphate (ATP) and Creatine Phosphate (CP), causing anaerobic metabolism to begin, which increases myocardial lactate levels and free fatty acids which not only decreases cardiac output causing hemodynamic instability but also causes rapid phosphate depletion from all major organs leading to organ deterioration. T4 protocol helps to correct all of this. The rapid drug succession pushes T4 into T3 to eliminate the need to wait for the impaired metabolism.

Families are not responsible for any costs associated with organ donation.  When there is an organ donor at a hospital, HonorBridge pays for donor-related expenses.  As a 501(c)3 non-profit organization, we are highly regulated and audited annually.  We are service-driven, and we take great care in the complex process of facilitating organs for transplant.  Much of our funding comes from transplant centers and tissue partners who reimburse us for our service in managing this highly skilled work.  

Death cannot be declared by the transplant physician because of the potential conflict of interest.  Pronouncement of circulatory death is performed by the primary health care team or his/her designee, per hospital policy, whether by a licensed physician or by two nurses. The Society for Critical Care Medicine recommends a 5 minute observation period confirmed with monitoring to ensure there is no auto-resuscitation of the heart after asystole. 

When a patient has a devastating non-survivable neurologic injury or illness (such as ALS) and has a Glascow Coma Score (GCS) of 5 or less, it is time to refer the patient to HonorBridge.  After initial screening questions determine that the patient may be a candidate for organ donation, HonorBridge will travel to the referring hospital, review the medical record, and collaborate with the health care team to establish a plan at that time. If the patient has not deteriorated to brain death, the HonorBridge coordinator will usually leave the hospital and follow the case by calling once per shift to assess any changes. If at any time there are significant changes in the patient’s medical condition, such as unstable blood pressure, if the patient appears to be herniating, or if brain death testing is planned, you should contact HonorBridge with an update.

If there are any plans for the physician to speak to the family about withdrawal of the vent, palliative care options, or if the family is considering DNR, de-escalation or non-escalation of care that would compromise the option for organ donation, HonorBridge should be contacted prior to acting on any of those orders. 

If HonorBridge has been following a patient for a few days and there does not seem to be any deterioration in the patient’s condition and the family is not considering withdrawal of support, HonorBridge may decide it is no longer appropriate to follow the patient. In these cases, the HonorBridge coordinator may ask the hospital to re-refer the patient if the situation changes.

Regardless of the patient’s medical condition, if the family mentions donation at any time, please call HonorBridge. A Family Support Coordinator (FSC) will be happy to answer any questions they may have about their donation options. 

HonorBridge seeks to work collaboratively with the healthcare team to ensure donation options are offered to the family in a caring and sensitive manner and at the most appropriate time.

DNR orders may affect donation options depending on what type of DNR order is signed. Simple DNR orders, where the family does not want shocks or compressions in the event that the patient’s heart stops, do not usually affect the donation options. However more specific DNR orders, such as those that do restrict the use of pressors and/or fluids to maintain blood pressure, may not allow for a patient to maintain circulation through the herniation process or may restrict/reduce organ perfusion and oxygen delivery rendering the organs unsuitable for transplant. Initiation of restrictive HonorBridge would prefer to be notified of any potential organ donor prior to initiation of DNR orders so we can collaborate with the healthcare team to determine the best approach for the family and to maintain the option for organ donation when the time comes.

Organs are recovered by attending transplant surgeons or transplant fellows credentialed by their transplant programs and by the organ procurement program’s medical advisory board. Most thoracic organs are recovered by the transplant surgeon from the recipient’s transplant center.  Abdominal organs are often recovered by either the transplant surgeon from the recipient’s transplant center or a local transplant surgeon who agrees to recover the organ on their behalf. Organs for research may be recovered by the researcher, who are typically also physicians, or HonorBridge’s Research Coordinator, who has been trained to recover such organs. Tissue is recovered by highly trained Tissue Recovery Specialists employed by HonorBridge. 

HonorBridge is committed to responding to the needs of a potential donor’s family whenever they are ready to talk to us.  If a family member initiates this conversation with you, please thank them for thinking about helping others and then call HonorBridge so we can connect with them.  Every case is very different, so we ask that hospital staff please allow us to have this conversation with the family.