ICU器官捐献的供体管理

doi:10.3877/cma.j.issn.2096-1537.2017.02.002

器官移植是提高终末期器官衰竭患者生存率和生活质量的最佳治疗方法，因此器官短缺也成为严峻的医疗和社会问题。器官捐献供体的早期识别和ICU的目标导向管理，可以增加器官获取率和改善器官功能。

关键词: 器官移植, 供体, 管理, 重症监护病房

Organ transplantation is the best way to improve survival and quality of life in patients with end-stage organ failure. The shortage of organs has become a serious health-care issue and social problem. Early identification of potential organ donor and goal-directed management in intensive care unit can increase the rate of donate organ harvesting and improve organ function.

Key words: Organ transplantation, Donor, Management, Intensive care units

表1 国际DCD分类及其特点^{[

3
]}

Maastricht分类	描述	特点
Ⅰ	入院前已经宣告死亡，不可能复苏	少用（主要西班牙和法国）
Ⅱ	复苏失败：院外心脏停搏和院内难治性心脏停搏	少用（主要西班牙和法国）
Ⅲ	受到严重的不可救治性损伤或住院患者有计划撤除生命支持	最常用，撤除生命支持到心跳停止时间是器官能否获取的主要决定因素
Ⅳ	BD评估期间或确认后、器官获取前出现心跳骤停	不常见，根据复苏结果选择DBD或DCD流程
Ⅴ	医疗支持下，疾病末期患者心跳呼吸停止	作为安乐死组成部分，绝大多数国家不认可

表1 国际DCD分类及其特点^{[

3
]}

Maastricht分类	描述	特点
Ⅰ	入院前已经宣告死亡，不可能复苏	少用（主要西班牙和法国）
Ⅱ	复苏失败：院外心脏停搏和院内难治性心脏停搏	少用（主要西班牙和法国）
Ⅲ	受到严重的不可救治性损伤或住院患者有计划撤除生命支持	最常用，撤除生命支持到心跳停止时间是器官能否获取的主要决定因素
Ⅳ	BD评估期间或确认后、器官获取前出现心跳骤停	不常见，根据复苏结果选择DBD或DCD流程
Ⅴ	医疗支持下，疾病末期患者心跳呼吸停止	作为安乐死组成部分，绝大多数国家不认可

表2 DBD/DBCD管理目标^{[

4
]}

系统	监测和管理
心血管	有创心血管监测维持等血容量目标MAP≥60~70 mmHg，没有证据显示某一升压药/正性肌力药优于其他，血管加压素可作为一线选择，AVP用量0.01~0.04 IU/min，减少儿茶酚胺用量尽量避免大剂量去甲肾上腺素[0.5 μg/（kg?min）]，难治性低血压可以考虑使用甲状腺激素
呼吸	保护性肺通气：潮气量6~8 ml/kg，PEEP 6~8 cmH₂O PaO₂≥80 mmHg，PaCO₂ 35~45 mmHg，pH 7.35~7.45必要时实施肺复张手法，实施包括抬高床头在内的集束化护理
液体和电解质	维持等血容量，避免高钠血症，尿量0.5~2.5 ml/（kg?h）尿量>4 ml/（kg?h）时，考虑尿崩症，使用血管加压素或去氨加压素使用胰岛素输注维持血糖<10 mmol/L
激素替代治疗	高钠血症的尿崩症，去氨加压素首次1~4 μg静脉注射，后根据尿量、渗透压和血钠，每6 h加用1~2 μg或更高剂量血流动力学不稳定的高钠血症患者，可同时使用AVP和去氨加压素脑死亡确认后甲强龙15 mg/kg静脉推注，随后每日应用T3和T4用于甲状腺激素替代治疗，T3 4 μg静脉注射，随后3 μg/h静脉输注；或者T4 20μg静脉注射，随后10 μg/h静脉输注
血液和凝血	纠正凝血病，Hb<70 g/L时输注浓缩红细胞，持续预防血栓治疗
体温	减少热量散失，维持中心温度35℃，吸入气体湿化加温静脉输注液治疗感染

表2 DBD/DBCD管理目标^{[

4
]}

系统	监测和管理
心血管	有创心血管监测维持等血容量目标MAP≥60~70 mmHg，没有证据显示某一升压药/正性肌力药优于其他，血管加压素可作为一线选择，AVP用量0.01~0.04 IU/min，减少儿茶酚胺用量尽量避免大剂量去甲肾上腺素[0.5 μg/（kg?min）]，难治性低血压可以考虑使用甲状腺激素
呼吸	保护性肺通气：潮气量6~8 ml/kg，PEEP 6~8 cmH₂O PaO₂≥80 mmHg，PaCO₂ 35~45 mmHg，pH 7.35~7.45必要时实施肺复张手法，实施包括抬高床头在内的集束化护理
液体和电解质	维持等血容量，避免高钠血症，尿量0.5~2.5 ml/（kg?h）尿量>4 ml/（kg?h）时，考虑尿崩症，使用血管加压素或去氨加压素使用胰岛素输注维持血糖<10 mmol/L
激素替代治疗	高钠血症的尿崩症，去氨加压素首次1~4 μg静脉注射，后根据尿量、渗透压和血钠，每6 h加用1~2 μg或更高剂量血流动力学不稳定的高钠血症患者，可同时使用AVP和去氨加压素脑死亡确认后甲强龙15 mg/kg静脉推注，随后每日应用T3和T4用于甲状腺激素替代治疗，T3 4 μg静脉注射，随后3 μg/h静脉输注；或者T4 20μg静脉注射，随后10 μg/h静脉输注
血液和凝血	纠正凝血病，Hb<70 g/L时输注浓缩红细胞，持续预防血栓治疗
体温	减少热量散失，维持中心温度35℃，吸入气体湿化加温静脉输注液治疗感染

1	Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant[J]. N Engl J Med, 1999, 341(23): 1725-1730.
2	Abuanzeh R, Hashmi F, Dimarakis I, et al. Early donor management increases the retrieval rate of hearts for transplantation in marginal donors[J]. Eur J Cardiothorac Surg, 2015, 47(1): 72-77.
3	Maciel CB, Greer DM. ICU Management of the Potential Organ Donor: State of the Art[J]. Curr Neurol Neurosci Rep, 2016, 16(9): 86.
4	Citerio G, Cypel M, Dobb GJ, et al. Organ donation in adults: a critical care perspective[J]. Intensive Care Med, 2016, 42(3): 305-315.
5	中华人民共和国国家卫生和计划生育委员会, 国家卫生计生委医政医管局. 卫生部办公厅关于启动心脏死亡捐献器官移植试点工作的通知[EB/OL]. (2011-05-03) URL
6	霍枫，汪邵平，李鹏, 等. 公民心死亡器官捐献肝移植[J]. 中华消化外科杂志, 2012, 11(1): 69-72.
7	Shemie SD, Hornby L, Baker A, et al. International guideline development for the determination of death[J]. Intensive Care Med, 2014, 40(6): 788-797.
8	Potts JT, Herdman R. Non-Heart-Beating Organ Transplantation: Medical and Ethical Issues in Procurement[M]. Washington (DC): National Academies Press (US), 1997.
9	国家卫生和计划生育委员会脑损伤质控评价中心. 脑死亡判定标准与技术规范(成人质控版)[J]. 中国现代神经疾病杂志, 2015, 15(12): 935-939.
10	Bugedo G, Bravo S, Romero C, et al. [Management of the potential organ donor][J]. Rev Med Chil, 2014, 142(12): 1584-1593.
11	Anthony DC, Couch Y, Losey P, et al. The systemic response to brain injury and disease[J]. Brain Behav Immun, 2012, 26(4): 534-540.
12	Watts RP, Thom O, Fraser JF. Inflammatory signalling associated with brain dead organ donation: from brain injury to brain stem death and posttransplant ischaemia reperfusion injury[J]. J Transplant, 2013, 2013: 521369.
13	Smith M. Physiologic changes during brain stem death--lessons for management of the organ donor[J]. J Heart Lung Transplant, 2004, 23(9 Suppl): S217-S222.
14	Chen EP, Bittner HB, Kendall SW, et al. Hormonal and hemodynamic changes in a validated animal model of brain death[J]. Crit Care Med, 1996, 24(8): 1352-1359.
15	Al-Khafaji A, Elder M, Lebovitz D J, et al. Protocolized fluid therapy in brain-dead donors: the multicenter randomized MOnIToR trial[J]. Intensive Care Medicine, 2015, 41(3): 418-426.
16	Kotloff RM, Blosser S, Fulda GJ, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement[J]. Crit Care Med, 2015, 43(6): 1291-1325.
17	Wood KE, Becker BN, McCartney JG, et al. Care of the potential organ donor[J]. N Engl J Med, 2004, 351(26): 2730-2739.
18	Schnuelle P, Gottmann U, Hoeger S, et al. Effects of donor pretreatment with dopamine on graft function after kidney transplantation: a randomized controlled trial[J]. JAMA, 2009, 302(10): 1067-1075.
19	Wang Z, Guan W, Han Y, et al. Stimulation of Dopamine D3 Receptor Attenuates Renal Ischemia-Reperfusion Injury via Increased Linkage With Galpha12[J]. Transplantation, 2015, 99(11): 2274-2284.
20	Munshi L, Keshavjee S, Cypel M. Donor management and lung preservation for lung transplantation[J]. Lancet Respir Med, 2013, 1(4): 318-328.
21	Mascia L, Pasero D, Slutsky AS, et al. Effect of a lung protective strategy for organ donors on eligibility and availability of lungs for transplantation: a randomized controlled trial[J]. JAMA, 2010, 304(23): 2620-2627.
22	Minambres E, Perez-Villares JM, Chico-Fernandez M, et al. Lung donor treatment protocol in brain dead-donors: A multicenter study[J]. J Heart Lung Transplant, 2015, 34(6): 773-780.
23	Minambres E, Ballesteros MA, Rodrigo E, et al. Aggressive lung donor management increases graft procurement without increasing renal graft loss after transplantation[J]. Clin Transplant, 2013, 27(1): 52-59.
24	Prodhan P, Casavant D, Medlock MD, et al. Inhaled nitric oxide in neurogenic cardiopulmonary dysfunction: implications for organ donation[J]. Transplant Proc, 2004, 36(9): 2570-2572.
25	Ware LB, Landeck M, Koyama T, et al. A randomized trial of the effects of nebulized albuterol on pulmonary edema in brain-dead organ donors[J]. Am J Transplant, 2014, 14(3): 621-628.
26	Levin K, Kotecha S, Westall G, et al. How can we improve the quality of transplantable lungs[J]? Expert Rev Respir Med, 2016, Oct 3: 1-7.
27	Dikdan GS, Mora-Esteves C, Koneru B. Review of randomized clinical trials of donor management and organ preservation in deceased donors: opportunities and issues[J]. Transplantation, 2012, 94(5): 425-441.
28	Sharpe MD, van Rassel B, Haddara W. Oral and intravenous thyroxine (T4) achieve comparable serum levels for hormonal resuscitation protocol in organ donors: a randomized double-blinded study[J]. Can J Anaesth, 2013, 60(10): 998-1002.
29	Pinsard M, Ragot S, Mertes PM, et al. Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study[J]. Crit Care, 2014, 18(4): R158.
30	Mi Z, Novitzky D, Collins JF, et al. The optimal hormonal replacement modality selection for multiple organ procurement from brain-dead organ donors[J]. Clin Epidemiol, 2014, 7: 17-27.
31	Lumbreras C, Sanz F, Gonzalez A, et al. Clinical significance of donor-unrecognized bacteremia in the outcome of solid-organ transplant recipients[J]. Clin Infect Dis, 2001, 33(5): 722-726.
32	Singh N. Impact of donor bacteremia on outcome in organ transplant recipients[J]. Liver Transpl, 2002, 8(10): 975-976.
33	Fishman JA, Greenwald MA, Grossi PA. Transmission of infection with human allografts: essential considerations in donor screening[J]. Clin Infect Dis, 2012, 55(5): 720-727.
34	Westphal GA, Garcia VD, Souza RL, et al. Guidelines for the assessment and acceptance of potential brain-dead organ donors[J]. Rev Bras Ter Intensiva, 2016, 28(3): 220-255.
35	Lewis JD, Sifri CD. Multidrug-Resistant Bacterial Donor-Derived Infections in Solid Organ Transplantation[J]. Curr Infect Dis Rep, 2016, 18(6): 18.
36	Simkins J, Muggia V. Favorable outcome in a renal transplant recipient with donor-derived infection due to multidrug-resistant Pseudomonas aeruginosa[J]. Transpl Infect Dis, 2012, 14(3): 292-295.
37	Fischer SA, Lu K. Screening of donor and recipient in solid organ transplantation[J]. Am J Transplant, 2013, 13 Suppl 4: 9-21.
38	McKeown DW, Bonser RS, Kellum JA. Management of the heartbeating brain-dead organ donor[J]. Br J Anaesth, 2012, 108 Suppl 1: i96-i107.
39	Niemann CU, Feiner J, Swain S, et al. Therapeutic Hypothermia in Deceased Organ Donors and Kidney-Graft Function[J]. N Engl J Med, 2015, 373(5): 405-414.
40	Fan X, Chen Z, Nasralla D, et al. The organ preservation and enhancement of donation success ratio effect of extracorporeal membrane oxygenation in circulatory unstable brain death donor[J]. Clin Transplant, 2016, 30(10): 1306-1313.
41	Migliaccio ML, Zagli G, Cianchi G, et al. Extracorporeal membrane oxygenation in brain-death organ and tissues donors: a single-centre experience[J]. Br J Anaesth, 2013, 111(4): 673-674.
42	Teng-Wei C, Chung-Bao H, Chan DC, et al. Marked elevation of hepatic transaminases in recipients of an orthotopic liver transplant from a brain-dead donor receiving extracorporeal membrane oxygenation[J]. Ann Transplant, 2014, 19: 680-687.
43	Bernat JL, Capron AM, Bleck TP, et al. The circulatory-respiratory determination of death in organ donation[J]. Crit Care Med, 2010, 38(3): 963-970.
44	Reich DJ, Mulligan DC, Abt PL, et al. ASTS recommended practice guidelines for controlled donation after cardiac death organ procurement and transplantation[J]. Am J Transplant, 2009, 9(9): 2004-2011.
45	Detry O, Le Dinh H, Noterdaeme T, et al. Categories of donation after cardiocirculatory death[J]. Transplant Proc, 2012, 44(5): 1189-1195.
46	Bernat JL, D′Alessandro AM, Port FK, et al. Report of a National Conference on Donation after Cardiac Death[J]. Am J Transplant, 2006, 6(2): 281-291.
47	Maciel CB, Hwang DY, Greer DM. Organ donation protocols[J]. Handb Clin Neurol, 2017, 140: 409-439.

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ICU management of organ donor