Solid organ transplantation remains the only lifesaving option for an increasing number of patients. Transplantation is now the treatment of choice for end-stage kidney, liver, pancreas, heart, lung, and intestine failure patients who have no contraindications to transplantation. In addition, there is an increasing demand for bone, skin, and other tissues from brain dead donors used in the treatment of other disease processes. However, the number of people requiring organ transplants is simply higher than the number of organs available. Newer approaches such as xenotransplantation and bioengineering are still in experimental stages,¹ and despite advances in living-related solid organ transplantation the majority of transplant recipients remain dependent on cadaveric organ donors. With improved supportive care for patients with advanced organ failure and expanded indications for transplantation the gap between demand and supply of organs is continually increasing (Fig. 50-1). Every 10 minutes, someone is added to the national transplant waiting list and on average, 21 people die each day while waiting for a transplant [http://optn.transplant.hrsa.gov]. Currently in the United States, there are 123,337 patients active on the waiting list. In the year 2014, a total of 29,533 solid organ transplants were performed from 14,412 donors, of whom 8594 were deceased donors and 5818 were living donors. One promising strategy to decrease the gap between the organ donation need and supply is to increase the available donor pool. It is estimated that the actual number of donors in the United States represents about one-third of the potential number of donors, and there certainly is room for improvement.²

Traumatic brain injury is the second most common cause of death leading to cadaveric solid organ donation closely following cerebrovascular accidents/stroke (Fig. 50-2). Clinicians caring for severely injured patients play a key role in the initiation and implementation of the organ donation process. Early recognition of potential organ donors is critical to maximizing the available pool of donor organs and the number of transplantable organs per donor. It is essential for those caring for potential organ donors to be knowledgeable about the criteria and process for declaring brain death and the physiologic effects of brain death. Familiarity with local organ procurement organizations (OPOs) is important because of the vital role they play in counseling the families of potential organ donors and coordinating the transplant process. Lastly, following the declaration of brain death, treatment priorities aimed at minimizing brain injury require adjustment. Physiologic support is then directed at maintaining perfusion of potentially transplantable organs assumes priority, and timely initiation of this support is crucial to increasing the probability of successful transplantation.

Under the National Organ Transplant Act, the US Congress established The Organ Procurement and Transplantation Network (OPTN). The OPTN is a unique public–private partnership linking professionals involved in the organ donation and transplantation system. The OPTN is governed by the United Network for Organ Sharing (UNOS). UNOS is a private nonprofit charitable organization contracted by the Health Resources and Services Administration of the US. Department of Health and Human Services (DHHSs) to develop organ transplantation policy. UNOS facilitates organ transplantation by organizing the medical, scientific, public policy, and technologic resources required to maintain an efficient national transplantation system. UNOS is responsible for developing recipient priority policies and for managing the national transplant waiting lists. UNOS maintains the national transplant database; plays a very important role in raising public awareness of the importance of organ donation, and helps to keep patients informed about transplant issues and policy.

To alleviate the shortage of organs available for transplantation, the Revised Uniform Anatomical Gift Act requires OPOs and donor hospitals to have the necessary policies and procedures in place to preserve the option of donation for all patients and their families.⁴ In an effort to maximize donation opportunities, the American College of Surgeons (ACS) qualitatively evaluates each hospital’s organ donation practices during the trauma center verification process.⁵ Specifically, the ACS requires verified trauma centers to establish a relationship with an OPO; develop policies and clinical triggers for notification of the OPO about patients with the potential for neurologic death; have a formal process to review organ donation rates; and implement protocols for the declaration of neurologic death. Organ donation, allocation, and procurement require a closely coordinated and complex series of efforts. In the United States, this process is coordinated by independent local OPOs. There are 58 OPOs in the United States. OPOs are responsible for two main functions within their designated service area: (1) increasing the number of registered donors, and (2) coordinating the donation process when actual donors become available. OPOs employ specially trained professionals who assist with the evaluation of potential organ donors, the declaration of brain death, counseling of donor family members, management of the donor, organ allocation, and the procurement process. When an organ donor is identified, the local OPO serves to ensure that brain death has been established and assists in obtaining consent for organ donation. Thereafter, coordination of organ placement and the procurement of the organs are facilitated by the OPO. For organ allocation, UNOS maintains a centralized computer network, UNet, which links all OPOs and transplant centers in a secure, real-time environment using the Internet. Each organ waiting list incorporates specific criteria to establish individual patient ranking on the list. However, in general, waiting lists incorporate factors such as geography, patient’s blood type, waiting time, severity of illness and human lymphocyte antigen (HLA) matching in case of kidney allocation.

Trauma surgeons play important role in organ donation. It has been shown that hospitals with trauma surgeons on their organ donor councils had a significantly higher number of donors per trauma admissions as well as significantly more donors per admissions.⁶

UNOS has developed “The Critical Pathway” for management of organ donors, which is available through local OPOs and UNOS.⁷ Preliminary data from a pilot study utilizing this pathway showed an increase in the number of organs procured per donor. The Critical Pathway has five distinct but partially overlapping phases:

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  Phase I (referral): When a patient with a severe brain injury is identified as a potential organ donor, critical care staff should initiate the Critical Pathway. This initial step establishes contact between the hospital and the local OPO, and initiates referral before the potential organ donor becomes brain dead.

  
  
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  Phase II (declaration of brain death and acquisition of consent): Once the potential donor is confirmed brain dead, the patient’s choice about organ donation is evaluated through the donor registry (usually through the motor vehicle registry) and the family is provided with this information. If no first person consent is found, the family is approached about the option of organ donation. First person consent supersedes a family declining the option of donation in many states and OPOs in the US.

  
  
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  Phase III (donor evaluation): After consent for organ donation is obtained or confirmed through a donor registry, donor evaluation and management protocols are initiated.

  
  
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  Phase IV (donor management): As the donor is being evaluated, optimal management needs to be started simultaneously to achieve adequate perfusion and oxygenation of organs.

  
  
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  Phase V (organ recovery): Organ procurement takes place after potential recipients are identified. Various procurement teams work together to maximize organ recovery.

Federal law requires that every death in a hospital be called in to respective OPO, and the OPO coordinators evaluate every call to assess suitability for donation. All patients who have suffered severe brain injuries and are either brain dead or likely to progress to brain death should be considered for organ donation regardless of their age, underlying cause of illness, and overall social history.

According to CMS, hospitals and respective OPOs must agree upon “triggers” to identify potential brain dead donors, although CMS does not specify these “triggers.” For instance some OPOs consider an intubated patient with a GCS of five or less a potential organ donor. If a patient meets initial criteria, the donation case moves on to the next step in the process, which is referral to the local OPO. Although perceived contraindications to donation may exist, they should be discussed with a representative of the local OPO before concluding that a given patient is not a candidate for organ donation (Table 50-1). Bacteremia, fungemia and high-risk social history are not absolute contraindications. For increased-risk donors, nucleic acid test (NAT) is performed to detect recently acquired HIV, HCV, and HBV infections wherein routine serology tests are negative. Sometimes, donors with HCV, HBV, and HIV are considered suitable for organ donation. For instance, an otherwise normal liver or a kidney from a donor with HCV infection can be transplanted into HCV infected recipient. Trauma to chest and/or abdomen is not uncommon in potential organ donors. Appropriate surgical management is required to control bleeding and prevent complications such as pneumothorax. Typical interventions include chest tube insertion, laparotomy, splenectomy etc. Retroperitoneal hematoma, liver and splenic lacerations, open abdomen are not contraindications to abdominal organ utilization; however such circumstances demand careful evaluation of organs at the time of procurement. A CT scan utilizing intravenous contrast is important in assessment of severity of injury and vascular integrity.

The physician caring for potential organ donor is responsible for notifying the local OPO of such patients. All OPOs employ personnel who are responsible for advising health care providers on the suitability of an individual patient for organ donation. Communication with local forensic authorities is extremely important. The OPO will contact the medical examiner or coroner in order to obtain permission to proceed with organ donation. Once a donor is identified, the OPO is responsible for obtaining family consent for organ donation. Organ procurement specialists are trained in counseling families about the importance and process of organ donation, and it is advisable to refer families to these specialists when potential organ donation is discussed. These individuals also perform a careful review of the potential donor’s social and past medical history. The circumstances leading to brain death are very important, as is any history of the occurrence and duration of cardiopulmonary arrest. Screening also includes an extensive laboratory and serologic evaluation to exclude chronic disease and transmissible infections. A donor profile is then generated and includes current hemodynamics as well as an assessment of current organ function. The assessment of organ function is individualized to the donor based on the donor profile, the specific organs under consideration, and the level of medical support required to maintain the donor. The overall profile that is generated is crucial for transplant physicians who must evaluate the suitability of a given organ donor for the individual recipient.