trauma question - operate on brain dead patients for organs?

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europeman

Trauma Surgeon / Intensivist
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Does your institution or do you personally take an obviously brain dead patient or virtually hopeless from a neurologic standpoint trauma to the OR (for say ex lap in penetrating trauma to belly or FAST positive blunt trauma patient or something) if you think they are a viable organ donor (i.e. young, etc)?

How do you justify this? Have you been successful? Is this unethical? or is it the opposite... incumbant upon us?

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I'm confused....

what's unethical? Are you suggesting that people take patients to the OR without permission for organ harvest?

If the patient/family has given permission for organ donation, the scenario you've described is common, ethical and needs no justification. Frankly, IMHO we need justification NOT to seek donation from otherwise healthy patients with an unrecoverable injury.
 
I'm confused....

what's unethical? Are you suggesting that people take patients to the OR without permission for organ harvest?

If the patient/family has given permission for organ donation, the scenario you've described is common, ethical and needs no justification. Frankly, IMHO we need justification NOT to seek donation from otherwise healthy patients with an unrecoverable injury.

I think he means. Patient stabbed once in the belly and beat with a sledgehammer in the noggin till unsalvageable from a neuro standpoint. Do you take him to the OR to stop his bleeding/belly wound (if needed) in order to keep his body alive/viable long enough to declare him brain dead, get ahold of family and make him an organ donor.

Is that the question?
 
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Does your institution or do you personally take an obviously brain dead patient or virtually hopeless from a neurologic standpoint trauma to the OR (for say ex lap in penetrating trauma to belly or FAST positive blunt trauma patient or something) if you think they are a viable organ donor (i.e. young, etc)?

How do you justify this? Have you been successful? Is this unethical? or is it the opposite... incumbant upon us?

Demetriades and the LA County crew have an interesting approach to this dilemma, and have published on the topic. Here is the link.

We've sort of discussed this before in this thread.

I think it will be obvious from my posts in that thread how I feel about the topic.
 
Demetriades and the LA County crew have an interesting approach to this dilemma, and have published on the topic. Here is the link.

We've sort of discussed this before in this thread.

I think it will be obvious from my posts in that thread how I feel about the topic.

For those who don't want to click the link, here are the results:

"During the 42-month study period, a total of 263 patients underwent EDT. Return of a pulse was achieved in 85 patients (32.3%). Of those patients, 37 (43.5%) subsequently died in the operating room and 48 (56.5%) survived to the surgical intensive care unit. Overall, 5 patients (1.9%) survived to discharge and 11 patients (4.2%) became potential organ donors. Five of the 11 potential organ donors had sustained a blunt mechanism injury. Of the 11 potential organ donors, 8 did not donate: 4 families declined consent, 3 because of poor organ function, and 1 expired due to cardiopulmonary collapse. Eventually 11 organs (6 kidneys, 2 livers, 2 pancreases, and 1 small bowel) were harvested from 3 donors. Two of the 3 donors had sustained blunt injury and 1 penetrating mechanism of injury."

Keep in mind though, the OP's question is about any operative intervention to keep the trauma patient alive for potential donation. Many penetrating injuries requiring surgical intervention to the save the patient's life are far more survivable than injuries requiring an ED thoracotomy. So, a patient shot in the head and right common iliac artery can be kept alive with a simple laparotomy to control the abdominal bleeding (assuming the brain injury leads to brain death but not cardiopulmonary collapse).
 
To a certain degree, a lot of trauma intervention (e.g. ER thoracotomy, or emergent cranis) consume a lot of resources in patients with predictably bad outcomes. But we expend these resources (e.g. 100 units of PRBCs in the exsanguinating penetrating trauma patient) in order to attempt to save lives. The utility of this is debatable.
 
I think he means. Patient stabbed once in the belly and beat with a sledgehammer in the noggin till unsalvageable from a neuro standpoint. Do you take him to the OR to stop his bleeding/belly wound (if needed) in order to keep his body alive/viable long enough to declare him brain dead, get ahold of family and make him an organ donor.

Is that the question?

Gotcha...yes, if that's the question, I understand the dilemma (and yes, we've talked about it before).
 
For those who don't want to click the link, here are the results:

"During the 42-month study period, a total of 263 patients underwent EDT. Return of a pulse was achieved in 85 patients (32.3%). Of those patients, 37 (43.5%) subsequently died in the operating room and 48 (56.5%) survived to the surgical intensive care unit. Overall, 5 patients (1.9%) survived to discharge and 11 patients (4.2%) became potential organ donors. Five of the 11 potential organ donors had sustained a blunt mechanism injury. Of the 11 potential organ donors, 8 did not donate: 4 families declined consent, 3 because of poor organ function, and 1 expired due to cardiopulmonary collapse. Eventually 11 organs (6 kidneys, 2 livers, 2 pancreases, and 1 small bowel) were harvested from 3 donors. Two of the 3 donors had sustained blunt injury and 1 penetrating mechanism of injury."

Keep in mind though, the OP's question is about any operative intervention to keep the trauma patient alive for potential donation. Many penetrating injuries requiring surgical intervention to the save the patient's life are far more survivable than injuries requiring an ED thoracotomy. So, a patient shot in the head and right common iliac artery can be kept alive with a simple laparotomy to control the abdominal bleeding (assuming the brain injury leads to brain death but not cardiopulmonary collapse).

True, but the outcomes with ER thoracotomy are more predictably bad, so the decision to operate solely for organs is more clear cut. Laparotomy on a patient with a head injury is often just appropriate triage.
 
Things could get confusing when thinking about this.

How about multiple GSW's where one has injured something fixable (let's say intrabdominal) but also crossed midline in the brain in a way that the neurosurgeon deems unsalvageable. Patient not brain dead yet, but will be without relieving the pressure (which neurosurgery rightly opts not to do to avoid creating a scenario where patient fails to achieve brain death but is neurologically devastated). By going to the OR for one operation to prolong life (the ex lap) but not the other (crani) are you wrong or right? Does it depend on how frequently people consent to donation in the population you are serving? Is it right to treat someone differently because you want their organs (isn't this idea commonly cited by many as a reason they choose NOT to designate themselves as donors)? Would it be different in a place with implied consent for donation? What about if you have limited resources-do you take this patient to the OR, or one without brain injury that has massive injuries that will certainly result in death untreated, but might result in death with treatment, or the one with a non-immediately life threatening injury, but one that will have more complications if it waits longer for operation (I'm thinking something like a bowel injury with ongoing spillage leading to worsening peritonitis and SIRS).
 
Since most brain death criteria require that you stabilize the patient before you can actually declare them brain dead, I'd say yes, you have to take them to the OR for the SW/GSW to the abdomen despite the big wound on their head. You're doing it for their sake though, not the possibility of organ donation. Organ donation shouldn't cross your mind until you've done everything you can for this patient.

Now, if their head wound is clearly incompatible with life, then no, you don't have to take them to the OR. You call it a futile attempt and abort your efforts. If their pupils are fixed and dilated, and you're looking at the brain matter coming out of their ears, I'd call it quits.
 
TheProwler

THAT'S MY EXACT QUESTION!

Say that scenario! Patient shot w/head blown to pieces, brain matter coming out, etc. But also with salvagable body from say single gunshot to belly or something.

If patient doesn't die right there, and say is actually hemodynamically okay... do you still take that person to OR when you know full well for THAT patient the brains are toast... but for potential organs (later obviously. not to go harvest the organs then!)

Is it wrong to do so?
 
The reality is that when the brain injury is that bad, the patient often doesn't survive very long. In there's brain matter everywhere, or the skull has been totally crushed by a car, or something like that, it doesn't take very long for the body to get the message that the brain is toast. It's more likely that the brain injury isn't clearly non-survivable and you're crashing them to the OR for abdominal injuries, and THEN you find out the brain is trashed. but you haven't done anything wrong in that situation because intraabdominal hemorrhage causing hemodynamic instability will always make the brain injury worse.
 
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