Lazzeri Chiara, Bonizzoli Manuela, Guetti Cristiana, Fulceri Giorgio Enzo, Peris Adriano
Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence 50134, Italy.
World J Transplant. 2021 Oct 18;11(10):410-420. doi: 10.5500/wjt.v11.i10.410.
Donor management is the key in the complex donation process, since up to 20% of organs of brain death donors (DBD) are lost due to hemodynamic instability. This challenge is made more difficult due to the lack of strong recommendations on therapies for hemodynamic management in DBDs and more importantly to the epidemiologic changes in these donors who are becoming older and with more comorbidities (marginal donors). In the present manuscript we aimed at summarizing the available evidence on therapeutic strategies for hemodynamic management (focusing on vasoactive drugs) and monitoring (therapeutic goals). Evidence on management in elderly DBDs is also summarized. Donor management continues critical care but with different and specific therapeutic goals since the number of donor goals met is related to the number of organs retrieved and transplanted. Careful monitoring of selected parameters (possibly including serial echocardiography) is the clinical tool able to guarantee the achievement and maintaining of therapeutic goals. Despide worldwide differences, norepinephrine is the vasoactive of choice in most countries but, whenever higher doses (> 0.2 mcg/kg/min) are needed, a second vasoactive drug (vasopressin) is advisable. Hormonal therapy (desmopressin, corticosteroid and thyroid hormone) are suggested in all DBDs independently of hemodynamic instability. In the single patient, therapeutic regimen (imprimis vasoactive drugs) should be chosen also according to the potential organs retrievable ( heart liver and kidneys).
供体管理是复杂捐赠过程中的关键，因为高达20%的脑死亡供体（DBD）的器官因血流动力学不稳定而丢失。由于缺乏关于DBD血流动力学管理治疗的有力建议，更重要的是由于这些供体的流行病学变化，即年龄越来越大且合并症越来越多（边缘供体），这一挑战变得更加困难。在本手稿中，我们旨在总结关于血流动力学管理（重点是血管活性药物）和监测（治疗目标）的治疗策略的现有证据。还总结了老年DBD管理的证据。供体管理延续重症监护，但有不同的特定治疗目标，因为实现的供体目标数量与获取和移植的器官数量相关。仔细监测选定参数（可能包括连续超声心动图）是能够保证实现和维持治疗目标的临床工具。尽管全球存在差异，但去甲肾上腺素在大多数国家是首选的血管活性药物，但是，每当需要更高剂量（>0.2 mcg/kg/min）时，建议使用第二种血管活性药物（血管加压素）。建议在所有DBD中使用激素治疗（去氨加压素、皮质类固醇和甲状腺激素），无论血流动力学是否不稳定。对于单个患者，治疗方案（首先是血管活性药物）也应根据可获取的潜在器官（心脏、肝脏和肾脏）来选择。
