Anaesthesia for organ donation in the brainstem dead — why bother?
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2000.055002105.x/full
‘Brainstem dead patients do not require analgesia or sedation …’ for surgery for the retrieval of donor organs. Thus begins the recommendation of the Intensive Care Society (UK) regarding Anaesthesia and Clinical Management During the Donation Operation as published in their booklet of June 1999. The booklet was published to facilitate the establishment of local guidelines for the management of the potential organ donor [1]. However, the relevant section of the document goes on to state that peri-operative neuromuscular blocking agents should be given to prevent reflex muscle contraction and that hypertension may be treated with sodium nitroprusside or a volatile anaesthetic agent such as isoflurane
Some anaesthetists responsible for the clinical management during the donation operation may be uncomfortable with this guidance. Firstly, under few circumstances do we allow operative surgery with muscle relaxation and without analgesia or anaesthesia, leading to a psychological compulsion to provide anaesthesia. Second, the hypertension and tachycardia that accompanies the donation operation can be distressing for operating theatre personnel to witness and for this reason alone one should always administer anaesthesia or agents to control these reflexes. The procedure causes a mean increase in blood pressure of 31 mmHg and a mean heart rate increase of 23 beat.min−1 [2]. This haemodynamic response could be considered to represent an organism in distress and probably occurs at a spinal level, although we are unaware of EEG studies during organ collection to confirm this. Third, death is not an event but a process and our limited understanding of the process should demand caution before assuming that anaesthesia is not required. Historically, death was easily established by the presence of coma, apnoea and pulselessness. Failure of the cardiovascular or respiratory systems invariably led to a rapid failure of the other two. Recent technology has allowed the temporary maintenance of respiration and the circulation by artificial means even when there is irreversible loss of brain function. The concept of ‘brain death’ has emerged both to establish futility and to enable beating heart cadaveric organ donation. Initially, the definition of brain death required the loss of all function of the nervous system [3]; however, it was soon realised that the cerebral hemispheres and brainstem could die with persistent function of the spinal cord.
...Whereas brainstem death is an acceptable definition of death in the UK, the position in the USA has been defined by a President's Commission and requires the ‘irreversible cessation of all functions of the entire brain, including the brainstem’. In the UK, the presence of cortical activity and/or perfusion is regarded as acceptable in the knowledge that the reticular formation will not be functional if the brainstem reflexes are absent and so the capacity for consciousness is irreversibly lost..
‘Brainstem dead patients do not require analgesia or sedation …’ for surgery for the retrieval of donor organs. Thus begins the recommendation of the Intensive Care Society (UK) regarding Anaesthesia and Clinical Management During the Donation Operation as published in their booklet of June 1999. The booklet was published to facilitate the establishment of local guidelines for the management of the potential organ donor [1]. However, the relevant section of the document goes on to state that peri-operative neuromuscular blocking agents should be given to prevent reflex muscle contraction and that hypertension may be treated with sodium nitroprusside or a volatile anaesthetic agent such as isoflurane
Some anaesthetists responsible for the clinical management during the donation operation may be uncomfortable with this guidance. Firstly, under few circumstances do we allow operative surgery with muscle relaxation and without analgesia or anaesthesia, leading to a psychological compulsion to provide anaesthesia. Second, the hypertension and tachycardia that accompanies the donation operation can be distressing for operating theatre personnel to witness and for this reason alone one should always administer anaesthesia or agents to control these reflexes. The procedure causes a mean increase in blood pressure of 31 mmHg and a mean heart rate increase of 23 beat.min−1 [2]. This haemodynamic response could be considered to represent an organism in distress and probably occurs at a spinal level, although we are unaware of EEG studies during organ collection to confirm this. Third, death is not an event but a process and our limited understanding of the process should demand caution before assuming that anaesthesia is not required. Historically, death was easily established by the presence of coma, apnoea and pulselessness. Failure of the cardiovascular or respiratory systems invariably led to a rapid failure of the other two. Recent technology has allowed the temporary maintenance of respiration and the circulation by artificial means even when there is irreversible loss of brain function. The concept of ‘brain death’ has emerged both to establish futility and to enable beating heart cadaveric organ donation. Initially, the definition of brain death required the loss of all function of the nervous system [3]; however, it was soon realised that the cerebral hemispheres and brainstem could die with persistent function of the spinal cord.
...Whereas brainstem death is an acceptable definition of death in the UK, the position in the USA has been defined by a President's Commission and requires the ‘irreversible cessation of all functions of the entire brain, including the brainstem’. In the UK, the presence of cortical activity and/or perfusion is regarded as acceptable in the knowledge that the reticular formation will not be functional if the brainstem reflexes are absent and so the capacity for consciousness is irreversibly lost...
Management of the heartbeating brain-dead organ donor
http://bja.oxfordjournals.org/content/108/suppl_1/i96.full
Maybe in Britain, but I have not seen that here. I’ve only done anesthesia for a few organ harvests thankfully, but I can assure you where I practice an ‘anesthetic’ is given, not just muscle-relaxants (paralytics) and agents to control hemodynamics. I would wager this would be the case at most all US hospitals.