Chapter 91

• Increasingly successful solid organ transplantation has increased the need for organ donors.
• Maximizing organ procurement and expanding donor acceptance criteria should decrease the organ shortage.
• Aggressive ongoing critical care of the multiorgan donor is essential to improve organ retrieval and posttransplant graft performance.
• Understanding the process of brain death is essential for directing donor treatment strategies to ensure preservation and function of donor organs.
• The goals of management of the multiorgan donor are to maximize organ function by maintaining organ perfusion and oxygenation, and to promptly recognize and treat potential complications such as hypotension, dysrhythmia, pulmonary edema, massive diuresis, coagulopathy, hypothermia, and sepsis.

Organ transplantation has evolved rapidly from the first early successes to the current widespread use of donated organs for the treatment of end-stage kidney, liver, heart, and lung failure.1 The success of solid organ transplantation has increased the need for an expanded supply of organ donors. In response to this need, the age limit for cadaveric donors has been increased, and donors over the age of 50 years are now routinely used. The use of organs from living related donors, living unrelated donors, and non–heart-beating donors (those declared dead on the basis of cardiopulmonary criteria) has also increased. Nevertheless, there has been a progressively widening gap between the number of patients waiting for transplants and the number of transplantations performed. The number of patients on the national waiting list was 25% higher than the number of transplantations in 1988.2 According to the United Network for Organ Sharing (UNOS), as of April 24, 2003, the number of patient registrations was 81,208, with the majority of patients in the 18- to 64-year age range. In 2002 a total of 24,847 transplants were performed, thus the number of patients on the waiting list was about 325% higher than the number of transplanted patients.3

In the past 10 years, the waiting list has increased 229%, and waiting list deaths have increased 192%. In contrast, during this same time period, the number of cadaveric organ donors has increased only 32%, with donors younger than 50 years of age increasing only 10.3%. The largest increase in cadaveric donors has been in donors older than 50 years of age (135%). One consequence of the increased proportion of older and more diverse donors has been the increase in organs discarded after they had been procured.3

The relevance of a properly functioning transplanted organ cannot be overemphasized and is clearly crucial for the success of transplantation of organs requiring immediate function such as the heart and lung. Temporary failure of the liver, kidneys, and pancreas may be tolerated with supportive measures such as hemodialysis and pharmacologic interventions. Early graft failure accounts for approximately 30% of all deaths of cardiac and lung recipients, and the deaths of 30% of liver and 5% of renal recipients.4

At a time when transplant surgeons are facing an increasing number of ...

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