To the Editor
Lele et al’s description of anesthesiology practice during care for brain-dead donors is useful to the transplant community given the limitations of previous survey-based findings.1 The authors discuss variability in practice patterns, especially for steroid and diuretic administration, and allude to the impact of different local organ procurement organization (OPO) protocols, likely the primary driver of specific local practice. While administration of medications to facilitate the donation process and continuation of existing vasopressor infusions leave little opportunity for anesthesiologist intervention, responsibility for anesthesia-specific agents is within our purview. This dataset provides an opportunity to further describe the use of traditional anesthetic agents.
While variation between centers for these agents is small (data in Figure 3), 63.5% received halogenated anesthetic gases, 23.2% received opioids, 6.1% a sedative/hypnotic, and 3.4% a benzodiazepine. Further description of these findings would be informative. By definition of brain death, anesthetic agents are not required although a summary of prior survey data suggests that volatile and opioid use is similar to that reported by Lele.2 Reasons for use include control of spinal reflexes, responses to incision, possible protection against pending ischemia, and the innate anesthesiologist reflex to provide nociception and amnesia, albeit at a subanesthetic dose. Details of agent and dose in this cohort may offer further insights into anesthesiologist practice patterns. The 9.5% use of a hypnotic or benzodiazepine is also noteworthy.
The author describes frequent hypotension, which may be inevitable during sternotomy and cardiac manipulation in the context of possible relative hypovolemia related to polyuria and the need to avoid excessive fluid administration if the lungs are being recovered. The authors investigated for an association between hypotension and several variables but did not include exposure or dose effect of volatile agent and opioid use. Even small doses of either agent may negatively affect hemodynamic stability in a donor and determination of such would be useful to clinicians.
Lele’s data are a welcome addition to the sparse literature for anesthetic management of brain-dead donors and further description of use and association with hypotension would be valuable.
Evan G. Pivalizza, MBChB, FFASA, BTh
Department of Anesthesiology
University of Texas Tyler School of Medicine
Tyler, Texas
Evan.Pivalizza@uttyler.edu