Study guide
27.4 Donation After Cardiac Death and Care of the Organ Donor (05.H–I)
ABIM Neurocritical Care Subspecialty Certification Exam
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1 Introduction & Exam Overview
1.1 Current Exam Facts 1.2 Eligibility, Practice Pathway, and the IM Training Route 1.3 Format, Scoring, Pearson VUE, and Score Reports 1.4 How to Use This Independent Study Guide
2 ICU Neurologic Exam, Cerebral Physiology, and CSF
2.1 Neurological Examination in the ICU 2.2 Cerebral Physiology, ICP, CBF, and Autoregulation 2.3 CSF Physiology
3 Core Neuropharmacology
3.1 Osmotic Agents 3.2 Anti-Seizure Drugs 3.3 Anesthetics, Sedatives, Analgesia, and Paralytics 3.4 Antihypertensives, Vasopressors, and Inotropes
4 Reperfusion Drugs, Airway, and Ventilation
4.1 Thrombolytics, Anticoagulants, and Antiplatelets 4.2 Reversal of Anticoagulation After Acute Hemorrhage 4.3 Airway Management and Tracheostomy 4.4 Mechanical Ventilation
5 Hemodynamics and Shock
5.1 Hemodynamic Monitoring 5.2 IABP, Temporary VADs, LVAD, and ECMO 5.3 Diagnosis and Management of Shock
6 Nutrition, Temperature, and ICU Prophylaxis
6.1 Nutrition (01.J) 6.2 Temperature Control (01.K) 6.3 ICU Prophylaxis, Delirium, and Early Mobility (01.L)
7 General Trauma
7.1 Emergency Evaluation of Polytrauma, Chest, and Abdominal Trauma 7.2 Long-Bone Fractures and Fat Embolism 7.3 Burns, Electrical Injury, and Hanging/Strangulation
8 Pulmonary Critical Care
8.1 Pulmonary Physiology and ARDS (01.N.1–2) 8.2 PE, Pneumonia, and Pulmonary Edema (01.N.3, 7–8) 8.3 COPD, Asthma, PAH, and Bronchoscopy Basics (01.N.4–6, 9)
9 Cardiovascular Critical Care
9.1 Cardiovascular Physiology, Stress Cardiomyopathy, ACS, and Valves 9.2 Arrhythmias and Pacing 9.3 Acute Aortic Dissection and Cardiac Ultrasound
10 Renal and Infectious Disease
10.1 AKI, RRT, and Renal Drug Dosing 10.2 Acid-Base and Electrolyte Disorders 10.3 Severe Sepsis, Septic Shock, and Infective Endocarditis 10.4 Antimicrobial Use and Infection in the Immunosuppressed
11 Endocrine and Salt-Water Disorders
11.1 Pituitary Apoplexy, DI, and Panhypopituitarism (01.R.1–4) 11.2 SIADH and Cerebral Salt Wasting (01.R.5–6) 11.3 Thyrotoxicosis, Myxedema, Adrenal Crisis, and Dysglycemia (01.R.7–9)
12 Gastrointestinal Critical Care
12.1 GI Physiology, Acute Abdomen, Bleed, Ileus, and Perforation (01.S.1–5) 12.2 Mesenteric Ischemia and Abdominal Compartment Syndrome (01.S.6–7) 12.3 Fulminant Liver Failure, Cirrhosis Decompensation, and Hepatic Dosing (01.S.8–10)
13 Hematologic Disorders
13.1 Anemia, Transfusion, Thrombocytopenia, Coagulopathy, and DIC (01.T.1–4) 13.2 VTE in the Neuro ICU (01.T.5) 13.3 Chemo/Immune, SCT, CAR-T, Sickle Cell, and TMA (01.T.6–10)
14 Neuroimaging
14.1 CT of Brain and Spine 14.2 MRI and CT/MR Perfusion 14.3 Noninvasive Angiography and Catheter Angiography
15 EEG, EMG, and CSF Analysis
15.1 EEG, Standard and Processed (02.B) 15.2 Basic EMG Interpretation (02.G) 15.3 CSF Analysis (02.H)
16 ICP, TCD, and Multimodality Monitoring
16.1 ICP Monitoring (02.C) 16.2 Transcranial Doppler (02.D) 16.3 Brain-Tissue Oxygen and Multimodality Monitoring (02.E–F)
17 Brain Death and Bedside Procedures
17.1 Brain Death Prerequisites and Clinical Exam (02.I) 17.2 Apnea Testing and Ancillary Studies (02.I) 17.3 Vascular Access, Thoracic Echo, and Lung Ultrasound (02.J–L)
18 Coma, Anoxia, and Intracranial Hypertension
18.1 Coma and Other States of Altered Consciousness (03.A) 18.2 Global Anoxia-Ischemia and Post-Resuscitation Encephalopathy (03.A.1) 18.3 Toxidromes, ICU Delirium, and Hypertensive Encephalopathy (03.A.2–4) 18.4 Intracranial Hypertension as a Disease State (03.B)
19 Acute Ischemic Stroke
19.1 IV Reperfusion Therapy (03.C.3) 19.2 Mechanical Thrombectomy Windows and Imaging Selection (03.C.3) 19.3 Malignant Hemispheric Infarction and Basilar Artery Occlusion (03.C.1–2)
20 Intraparenchymal Hemorrhage
20.1 Intracerebral Hematoma (03.D.1) 20.2 Cerebellar Hematoma (03.D.2) 20.3 Intraventricular Hemorrhage (03.D.3)
21 SAH, CVST, and Spinal Cord Infarction
21.1 Aneurysmal Subarachnoid Hemorrhage (03.E.1) 21.2 Non-Aneurysmal SAH (03.E.2) 21.3 Cerebral Venous Sinus Thrombosis (03.F) 21.4 Spinal Cord Infarction (03.G)
22 Vascular Anomalies and Traumatic Brain Injury
22.1 Unruptured Aneurysm, Cavernoma, AVM, and Dural AVF (03.H) 22.2 Diffuse Axonal Injury and Cerebral Contusions (03.I.1–2) 22.3 Epidural Hematoma, Subdural Hematoma, and Penetrating Injury (03.I.3–4, 7) 22.4 Arterial Dissection and Carotid-Cavernous Fistula (03.I.5–6)
23 Spine, Hydrocephalus, and CNS Infection
23.1 Spinal Cord Injury, Central Cord, and Neurogenic Shock (03.J) 23.2 Unstable Spine Fractures (03.K) 23.3 Hydrocephalus and CSF Diversion (03.L) 23.4 Acute CNS Infections (03.M)
24 Seizures and Neuromuscular Emergencies
24.1 Status Epilepticus and Seizures (03.N) 24.2 Guillain-Barré Syndrome (03.O.1) 24.3 Myasthenic Crisis (03.O.2) 24.4 Motor Neuron Disease, Acute Myopathies, Rhabdomyolysis, and CINM (03.O.3–6)
25 Inflammatory Disease, Neuro-Oncology, and Special Populations
25.1 Fulminant Demyelinating Diseases (03.P) 25.2 Autoimmune Encephalitis and Acute Autonomic Hyperactivity (03.Q–R) 25.3 Neuro-Oncology and Treatment Complications (03.S) 25.4 Pregnancy/Post-Partum, Post-Transplant, and Pediatric Patients (03.T–U)
26 Neurosurgical and Perioperative Complications
26.1 Postoperative Seizures, Hemorrhage, Ischemia, and Hyperperfusion (04.A, C, D, H) 26.2 Infection, CSF Leak, and Pneumocephalus (04.B, E, F) 26.3 Complications of EVD and Lumbar Drain (04.G, I)
27 Ethics, Prognostication, and Organ Donation
27.1 Communication, Decision-Makers, Advance Directives, and DNR (05.A, B, G) 27.2 Uncertainties of Prognostication and the Self-Fulfilling Prophecy (05.C) 27.3 Palliative Care, Withdrawal, Withholding, and Futility (05.D–F) 27.4 Donation After Cardiac Death and Care of the Organ Donor (05.H–I)
27.4 Donation After Cardiac Death and Care of the Organ Donor (05.H–I)
Key Takeaways Explain This Topic AI
Donation after brain death (DBD) follows BD/DNC. Donation after circulatory death (DCD) follows planned withdrawal and a declared circulatory death. The dead-donor rule requires that recovery wait until death has been determined by the applicable standard.
Keep the treating team’s death or WLST conversation separate from the OPO’s donation conversation. The clinician who declares death must not be a member of the transplant or OPO recovery team.
Donor management is still ICU care: perfusion, oxygenation, temperature, and treatment of diabetes insipidus. Conceptual hormone support includes thyroid hormone (T3 or T4), vasopressin, and corticosteroids; desmopressin (DDAVP) treats DI. Do not treat the donor as “already gone” while organs still need a MAP and a PaO2.
After circulatory arrest in controlled DCD, institutions observe a no-touch interval often in the 2–5 minute range before incision (professional statements commonly: at least 2 minutes and not more than 5). If death does not occur within the organ-specific waiting window after withdrawal, recovery is aborted and comfort care continues.
Authorization may come from a first-person registry, a surrogate, or both, depending on state law and hospital practice. Do not invent UNOS allocation scores or teach match-run math as intensivist work.
Last updated: September 2026
Why donation is an intensivist topic, not a transplant-board topic
Quick Answer: Donation after brain death (DBD) occurs after BD/DNC . Donation after circulatory death (DCD) occurs after withdrawal of life-sustaining treatment and circulatory death . Keep death talk and donation talk apart; notify the OPO early; a designated requestor asks. Manage DBD donors as unstable ICU patients : MAP , oxygenation , euvolemia , diabetes insipidus (DI) with desmopressin (DDAVP) and/or vasopressin , and a conceptual hormone package ( T3 or T4 , vasopressin , corticosteroid ). After DCD arrest, wait an institutional no-touch interval often 2–5 minutes (commonly taught as at least 2 and not more than 5 ). The treating physician , not the transplant team, declares death. Do not invent UNOS allocation scores.
Independent ExamFinch teaching in this section covers donation after circulatory death and care of the organ donor listed under Ethics, research, and practice-based learning in the ABPN Content Specifications. This is not an OPTN, UNOS, HRSA, ABIM, or ABPN product. How a given OPO writes MAP targets and thyroid-hormone doses is protocol , not a number you should fake on the examination. The scoring knowledge is the pathway , the separation of roles , and the refusal to abandon perfusion .
The dead-donor rule is the ethical floor: vital organs are recovered from a patient who has been determined dead, either by neurologic or by circulatory criteria. DCD is not a loophole around that rule. It is a different clock.
DBD versus DCD, and who is allowed to ask
DBD: catastrophic brain injury → BD/DNC determined as in the brain-death chapter → death is declared → organ support continues only as donor care if donation will proceed → recovery in the operating room with a beating heart and a ventilator. Families must hear that the patient has died before they hear about donation, as the 2023 BD/DNC communication recommendations emphasize: once death has occurred, continuation of therapies including the ventilator is not treatment of a living person unless donation is planned.
Controlled DCD: a living patient with a devastating injury who will not meet BD/DNC, or whose family has chosen WLST for other reasons → the WLST decision is independent of donation → OPO evaluates medical suitability and obtains authorization → typically move to an operating room or a nearby ICU → the treating team withdraws the ventilator and pressors → if circulation stops within the organ-specific time window, observe the no-touch interval, declare circulatory death , then the recovery team may begin. If the patient does not die within that window (often on the order of 60–90 minutes , varying by organ and center), the recovery is called off and the patient receives comfort care wherever planned. Kidneys tolerate longer waiting than livers or lungs; do not memorize a fake universal minute count as if OPTN published one number for every organ.
Uncontrolled DCD after unexpected arrest exists in some systems and is uncommon in many U.S. neuro ICUs. Do not make it the default story.
CMS hospital conditions of participation require timely OPO referral for individuals whose death is imminent or who have died. Referral is not the same as asking the family. Designated requestors , typically OPO staff trained for this conversation, make the request. Intensivists who blur “I’m sorry, he has died, and also we need the liver” coerce, even if they mean well.
Authorization: many people are on a first-person donor registry . State law on whether that authorization can be overridden by family varies . In practice, OPOs still work with families. Do not invent a single national override rule. The examination point is: someone with legal authority must authorize , and you are not that authority by default just because you run the unit.
The physician who declares death in DCD must not be part of the OPO or transplant recovery team. That firewall is in professional DCD statements (including ASA language on controlled DCD) and is the item you should be able to recite.
- Feature DBD Controlled DCD
- Death standard BD/DNC Circulatory (after WLST)
- Heart at recovery Typically beating, ventilated Arrested after the no-touch wait
When the family decides about donation After death has been determined After an independent WLST decision, before withdrawal
- Risk if death is slow Not applicable in the same way Stand-down if death is outside the organ window
- Who declares death Treating clinicians meeting BD/DNC policy Treating clinician, not the recovery team
Allocation of recovered organs is performed through Organ Procurement and Transplantation Network (OPTN) systems operated with United Network for Organ Sharing (UNOS) . Those systems use organ-specific match algorithms that have changed over time (kidney, liver, lung, and heart each have their own current framework). Do not invent a numeric allocation score, a points formula, or a “UNOS grade” to teach at the bedside. Your job is donor physiology and ethics, not running a match list.
Care of the donor: still a patient for the purpose of perfusion
Herniation and BD/DNC produce a catecholamine storm , then vasoplegia , diabetes insipidus , neurogenic pulmonary edema , hypothermia , and coagulopathy . If you treat the body as “already gone,” MAP collapses, the sodium rockets, the lungs flood or atelectasis, and organs are lost. Nursing care, suctioning, turning, bronchoscopy, antibiotics for the donor’s infection, and temperature control all continue.
Hemodynamics and oxygen. Follow the OPO protocol in front of you. Conceptual targets taught across donor-management reviews include an adequate MAP (many protocols use a floor in the 60–70 mm Hg region, sometimes higher for abdominal perfusion), euvolemia rather than drowning the lungs , and adequate PaO2 / PaO2:FiO2 especially if lungs are being considered. Lung-protective tidal volumes still matter. Do not invent a single national MAP that every OPO uses; do invent the idea that hypotension and hypoxemia are organ-losing events .
Diabetes insipidus. Posterior pituitary failure is common after BD/DNC. Suspect DI when urine output is huge (often >300 mL/h in adults), urine is dilute, and serum sodium is rising . Treat with DDAVP (desmopressin) and free-water replacement, and/or vasopressin infusion, which also supports vascular tone. Uncontrolled DI produces hypernatremia and hypovolemia that injure livers and kidneys you were trying to donate.
Hormone package, conceptually. Brain death can disrupt thyroid and adrenal axes and ADH. A commonly taught combined hormonal approach, historically associated with UNOS cardiac-donor pathways and observational organ-yield analyses, includes:
Thyroid hormone — triiodothyronine (T3, liothyronine) or thyroxine (T4, levothyroxine) ; T3 is shorter-acting and often preferred in unstable donors when a protocol uses thyroid replacement.
Vasopressin — DI plus vasodilatory shock.
Corticosteroid — often methylprednisolone in donor protocols (anti-inflammatory effects on grafts are part of the rationale).
Insulin — donor hyperglycemia is common; many protocols target a critical-care glucose band (a frequently cited range is about 120–180 mg/dL ).
Evidence for the entire cocktail in every donor is mixed if you read randomized lung-donor trials against older observational UNOS analyses. The examination still expects you to recognize the cocktail conceptually and to treat DI and shock , not to recite a milligram dose as if it were ACLS. If the stem says “hormone replacement after BD/DNC,” think T3/T4 + vasopressin + steroid , plus DDAVP when the problem is DI.
Do not stop turning, warming, and ventilating because “they’re a donor.” That is the “already gone” error.
DCD wait time and the operating-room choreography
After pulselessness in controlled DCD, there is an obligatory observation period to show that circulation will not auto-resuscitate . U.S. professional statements (ASA statement on controlled DCD; similar Institute of Medicine and critical-care society language) commonly locate that interval at longer than 2 minutes and not more than 5 minutes . UNOS educational material likewise describes 2–5 minutes of sustained cessation before declaration, with state and hospital variation . Teach the range and the local policy , not a fake national second-count. Two minutes is the usual lower bound in those statements because auto-resuscitation after that interval is not supported by the DCD literature they cite; five minutes is the usual upper bound to limit warm ischemia.
Declaration uses circulatory and respiratory criteria required by law — typically absent pulse, pressure, and breathing, often confirmed with an arterial line. Then incision. Heparin and other antemortem DCD interventions (and evolving practices such as normothermic regional perfusion ) require authorization and local policy ; they are ethically debated and are not a national checklist you should invent. If a stem mentions them, the safe moves are: authorization , separation of the declaring team from the recovery team , and follow the institutional OPO protocol .
Worked bedside scenarios
BD/DNC is just determined. Urine output is 500 mL/h, sodium 158 mEq/L, MAP 52 mm Hg on a little phenylephrine, and someone has stopped the warmer “because they’re gone.” Start DDAVP or vasopressin, replace water, raise MAP per OPO protocol, restart temperature care, and notify the OPO if not already done. Do not add a donation ask to the death disclosure you are about to give.
A family chooses WLST for a devastating TBI that does not meet BD/DNC. They are open to donation. The OPO obtains authorization. In the OR, asystole occurs. The intensivist watches the agreed 2–5 minute no-touch window, declares circulatory death, and only then does recovery start. The transplant surgeon does not declare.
WLST for DCD begins. At 90 minutes the patient still has a pulse. The liver team stands down per protocol. Return to comfort care. That is a successful ethical process, not a failed intensivist.
A fellow tries to calculate “the UNOS score” to tell the family where the kidneys will go. Stop. Explain that allocation is an OPTN process after recovery. You can explain that organs are matched; you cannot invent the formula.
Exam traps
Asking for donation in the same sentence as the first death news. Letting the transplant surgeon declare DCD death. Starting recovery at 30 seconds of asystole because “warm ischemia.” Treating a DBD donor as a morgue case with no MAP or DI treatment. Inventing a numeric UNOS allocation score. Forgetting DDAVP/vasopressin in catastrophic DI. Calling DCD “brain death.” Skipping OPO notification because the family “seems too upset to donate.”