The process of organ procurement: prior to the surgeryWritten by Ivo Mitsiev at in "Transplant Surgery".
There are many ways performing most of the surgical procedures. Everyone of the surgeons has established a way to go for a particular surgery that s/he is most familiar with and trusts most. In this series of postings ("The process of organ procurement") I will describe the way I perform the liver and kidney procurements in a Standard Criteria Donation (SCD) situation.
The donor information should be always reviewed prior to the procedure. The declaration of dead for the donating person is surely the most critical part of the documentation as no one of us would like to live with the idea of having procured organs from and exsanguinated a body of a living human being.
Having said this, I remember a situation where I had to be reassured by the Neurology attending on call in the procurement hospital that the patient is really brain dead.
I came to the bed of the donor and did a short examination of the abdomen which included palpation. As I pressed on the abdomen, the patient made movements of all of the extremities. I realized that I am a surgeon and therefore a Neurology lamer but I thought that the abdominal reflexes should not include movements of the extremities. Therefore I decided to call the Neurology attending on call and let her reassess the brain function of the donor. She came, I demonstrated my finding and she took a look by herself. After that she looked at me almost condescending and told me with a slight smile that these are regular abdominal reflexes and I could proceed with the organ procurement.
The consent for organ donation should be checked for legal purposes. It could be given for only one, more than one, and all organs and tissues. I always make sure that the consent includes the organs that are planned to be procured even if I am not the primary surgeon for a particular organ (e.g. heart, lungs, pancreas, kidneys). A special situation represents here the dedicated donation. This is the situation when the family of the donor consents for a donation of an organ to a particular person who is on the waiting list for transplantation.
I had a case with a 16 yo girl having died by a motor vehicle accident whose parents consented for a donation of the liver to a family friend with a low MELD score (which is the currently single most important factor for liver allocation after the geographic one). In this situation the liver was placed for a recipient who was far back on the waiting list.
On the medical part I review the (HBV, HCV, HIV, EBV, CMV, Toxo) Serologies, the Cultures, the Labs (exp. Na, K, Cre, LFT's, TBil, APH), and the given Medications (esp. pressors which might affect the organ function in high doses due to ischemia) as well as Vitals (esp. episodes of low blood pressure => ischemia again).
A donor hypernatremia of > 170 mEq/L should be treated aggressively as the osmotic gradient dries out the organ cells otherwise. This is significant: once I was on the way to a procurement in another city and at arriving at the airport, our team received a call that the Na was just reported to be 182 mEq/L. We came back and did not procure this liver.
Edit (Nov. 2009): Recently I had the opportunity to talk to Goran Klintmalm who is one of the most famous transplant surgeons and co-editor (together with Ronald Busuttil) of the "bible" in liver transplantation: "Transplantation of the Liver".
He said that he never looks at the sodium taking a liver. I asked him how far up would he go in order to accept a liver and he said that 180 mEq/L would not prevent him from taking the organ. I was surprised but he said that he never had a problem with it. And Goran Klintmalm never had to be that aggressive as other transplant centers have to be, e.g. in New York.
After assuring that the paper part is correct, I proceed with the procurement surgery.
The organ procurement procedure from a diseased donor is generally divided in two parts: