A stroke volume‐based fluid resuscitation protocol decreases vasopressor support and may increase organ yield in brain‐dead donors

Abstract

Brain‐dead donors are frequently hypovolemic and hypotensive requiring vasopressor support. We studied a stroke volume‐based fluid resuscitation and vasopressor weaning protocol prospectively on 64 hypotensive donors, with a recent control cohort of 30 hypotensive donors treated without a protocol. Stroke volume was measured every 30 minutes for 4 hours by pulse contour analysis or esophageal Doppler. A 500 mL saline fluid bolus was infused over 30 minutes and repeated if the stroke volume increased by 10%. No fluid was infused if the stroke volume did not increase by 10%. Vasopressors were weaned every 10 minutes if the mean arterial pressure was greater than 65 mm Hg. The protocol group received 1937 ± 906 mL fluid compared to 1323 ± 919 mL in the control group (P = .003). Mean time on vasopressors was decreased from 957.6 ± 586.2 to 176.3 ± 82.2 minutes (P<.001). Donors in the protocol group were more likely to donate four or more organs than donors in the control group (OR = 4.114, 95% Confidence Interval (CI) = 1.003‐16.876). While more organs were transplanted per donor in the protocol group (3.39 ± 1.52) than in the control group (2.93 ± 1.44) (P = .268), the difference did not reach statistical significance. A goal‐directed fluid resuscitation protocol decreased organ ischemia and may increase organs transplanted.

Clinical outcomes of a prospective randomized comparison of bioreactance monitoring versus pulse‐contour analysis in a stroke‐volume based goal‐directed fluid resuscitation protocol in brain‐dead organ donors

“…The donors received on average 2.2 L of intravenous fluid over 4 h, which is very similar to our previous study in which they received 1.9 L of fluid. 1 The number of donors off vasopressors at the end of the protocol was less than in the previous study (28.6% vs. 39.1%). This is likely due to the fact that in the previous study being on a vasopressor was an inclusion criteria, which was not a criteria for this study.…”

“…We have previously published our 4‐h goal‐directed stroke‐volume (SV) based fluid resuscitation protocol in BD donors which demonstrated a significant decrease in vasopressor time from 16 h to 3 h and was associated with an increase in transplanting four or more organs 1 . The SV was measured with either a pulse‐contour analysis (PCA) monitor via an arterial line or an esophageal doppler monitor (EDM) with no significant difference in clinical outcomes between the two devices 7 .…”

“…Eighty percent of brain-dead (BD) organ donors develop hypotension and require vasopressors to maintain an adequate mean arterial pressure (MAP). [1][2][3] The cause of the hypotension is multifactorial and includes hypovolemia, vasoplegia, depressed cardiac systolic function, and systemic inflammation. The hypovolemia is due to blood loss from trauma, polyuria from diabetes insipidus, osmotic diuresis from mannitol therapy for cerebral edema, and the lack of aggressive fluid resuscitation after the diagnosis of brain death.…”

The benefits of initiating continuous renal replacement therapy after brain death in organ donors with oligoanuric acute kidney injury

“…Between January 2017 and June 2021, all BD organ donors in Mid‐America Transplant's ORC with AKI were eligible for the study. Oligoanuria was defined as urine output ≤ 600 ml/24 h. All donors underwent a stroke volume‐based fluid resuscitation protocol over 4 h to optimize cardiac output and to wean off vasopressors 7 . Donors with oligoanuric AKI after fluid resuscitation were treated with furosemide 40–120 mg intravenously.…”

“…Oligoanuria was defined as urine output ≤ 600 ml/24 h. All donors underwent a stroke volume-based fluid resuscitation protocol over 4 h to optimize cardiac output and to wean off vasopressors. 7 Donors with oligoanuric AKI after fluid resuscitation were treated with furosemide 40-120 mg intravenously. Donors with persistent hyperkalemia, acidosis, fluid overload and/or anuria were considered for CRRT (CRRT group) under the direction of an experienced nephrologist (M.R.…”