**11. Conclusion**

**10. Physiological optimization of the organ donor**

80 Organ Donation and Transplantation - Current Status and Future Challenges

helps facilitate performance improvement from an OPO system standpoint [7].

As previously mentioned, there are multiple adverse physiologic events that may occur when the brain ceases to function (**Figure 3**). These include reflexive hypertension and subsequent hypotension; systemic "endocrine failure" leading to significant hormonal derangements including diabetes insipidus; and finally secondary phenomena such as acute lung injury and neurogenic pulmonary edema [85–88]. When managing patients, who succumbed to BD following TBI and multi-system trauma, special care must be dedicated to preventing any secondary insults

**Figure 3.** A diagram showing the most important and most commonly reported systemic manifestations following brain death. In the management of an organ donor consideration must be made to all of the above changes, including

proactive approaches to normalize any deleterious physiologic disturbances.

Throughout the process of organ procurement, it is critical to achieve physiologic normalization and maintain systemic homeostasis in order to optimize the number of organs procured from each donor [6, 7, 83]. With this in mind, it is essential that potential donors be attentively managed in order to prevent systemic hypoxia and hypoperfusion to vital organs [7]. As in the current chapter's vignette, the ICU is the ideal location for the resuscitation of organ donors and the associated complex physiological and management needs [56, 84]. Cessation of brain function sets off a myriad of multi-system manifestations (e.g. cardiac arrhythmia, hypotension, profound acid-base and electrolyte imbalances) many of which can result in subsequent end-organ insufficiency and/or failure [56]. Consequently, ICU teams must be cognizant of these considerations and proactively work to counteract deleterious effects of BD through a number of intensive interventions. Adherence to strict protocols for management of the organ donor is of utmost importance to ensure optimal conversion rates and graft survival among recipients [7, 84]. Because such protocols may differ from center to center, it is essential for ICU teams to work with local OPOs to ensure standardization in the approach taken to optimize the organ donor prior to the procurement procedure [7, 84]. This alliance can help standardize the care received by each patient, regardless of the institution, and also provide important feedback on what is working and what may not be working. This then

> In summary, the field of transplantation has made significant strides throughout the years. Following its humble beginnings as an experimental science, it evolved into the primary therapeutic option for patients suffering from end-stage-organ failure. Modern transplantation offers hope to those who even a few decades ago would have none. Going hand-in-hand with that hope are the ethical and legal ramifications related to the donor and their families. With the demand for organs far exceeding the current availability, a better framework is needed for both maximizing the procurement of organs from eligible donors and better allocation of these gifts-of-life across patients on transplant waiting lists. Closer examination of all available organ donation avenues is warranted, including the assessment of opportunities offered by the use of expanded criteria donors and greater utilization of donation after cardiac death.
