Organ Donation & Management of the Deceased Donor

ABPN Neurocritical Care Study Guide Exam

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1 Chapter 1: Neurologic Examination & Coma Assessment in the ICU

Current Examination, Blueprint & Preparation Neurologic Examination in Critically Ill Patients Coma Evaluation & Consciousness Alterations Delirium & Toxic-Metabolic Encephalopathy in the ICU

2 Chapter 2: Cerebral Physiology & Intracranial Dynamics

Cerebral Blood Flow, Metabolism & Autoregulation Intracranial Pressure & Compliance Cerebral Edema & Herniation Syndromes

3 Chapter 3: Intracranial Hypertension & Cerebral Perfusion Management

Tiered ICP Management Protocols Hyperosmolar Therapy & Fluid Management Advanced & Refractory ICP Interventions

4 Chapter 4: Airway, Mechanical Ventilation & Pulmonary ICU Management

Emergency Airway Management & Neuro-Intubation Mechanical Ventilation Strategies in Acute Brain Injury Tracheostomy & Ventilator Weaning in Neurocritical Care Pulmonary Complications in the Neuro-ICU Obstructive Lung Disease, Pulmonary Hypertension & Bronchoscopy

5 Chapter 5: Hemodynamics, Shock & Cardiovascular Management

Hemodynamic Monitoring & Blood Pressure Targets Vasoactive Agents: Inotropes, Vasopressors & Antihypertensives Cardiac Complications of Brain Injury

6 Chapter 6: Neuropharmacology, Analgesia & Sedation

ICU Sedation & Analgesia Neuromuscular Blockade & Monitoring Propofol Infusion Syndrome & Drug Toxicities Antiseizure Drug Pharmacology in the ICU

7 Bleeding, Thrombosis & Hematologic Emergencies

Warfarin & Heparin Reversal Direct Oral Anticoagulant (DOAC) Reversal Antiplatelet Management & Platelet Dysfunction Venous Thromboembolism Prophylaxis & Management Transfusion, Coagulopathy, TMA & Cellular-Therapy Neurotoxicity

8 Chapter 8: Systemic ICU Care, Fluids, Electrolytes & Endocrine

Hyponatremia & Osmoregulation: SIADH vs Cerebral Salt Wasting Diabetes Insipidus, Hypernatremia & Endocrine Crises Critical Care Prophylaxis, Nutrition & Infection Prevention

9 Systemic Trauma & Environmental Injury

Polytrauma, Chest Injury & Abdominal Hemorrhage Burns, Electrical Injury & Hanging

10 Cardiac Emergencies & Mechanical Support

IABP, Ventricular Devices & ECMO Acute Coronary, Valvular, Rhythm & Aortic Emergencies

11 Kidney Injury, Acid–Base & Renal Replacement

Acute Kidney Injury & Renal Drug Clearance Acid–Base Disorders, Electrolytes & Renal Replacement

12 Systemic Infection & Endocrine Emergencies

Sepsis, Endocarditis & Antimicrobial Principles Thyroid, Adrenal & Dysglycemic Emergencies

13 Gastrointestinal & Hepatic Emergencies

Acute Abdomen, GI Bleeding & Abdominal Compartment Syndrome Acute Liver Failure, Cirrhosis & Hepatic Drug Effects

14 Chapter 9: Neuroimaging in the Neuro-ICU

Non-Contrast CT & CT Angiography CT Perfusion & Advanced Perfusion Imaging Magnetic Resonance Imaging in Critical Illness

15 Chapter 10: Electrophysiology & Neuromonitoring

Continuous EEG & ACNS Standardized Critical Care Terminology Invasive Neuromonitoring: ICP & External Ventricular Drains Multimodal Monitoring: PbtO2, Microdialysis & Transcranial Doppler

16 Angiography, Electrodiagnosis & CSF Analysis

Conventional Angiography & Cranial–Spinal Shunts EMG, Nerve Conduction & Acute Muscle Disease CSF Analysis: Infection, Inflammation & Hemorrhage

17 Chapter 11: Bedside Procedures, Ultrasound & Death by Neurologic Criteria

Critical Care Procedural Skills Critical Care Ultrasound & Echocardiography Determination of Death by Neurologic Criteria

18 Chapter 12: Acute Ischemic Stroke & Reperfusion Therapies

Acute Ischemic Stroke Management & Thrombolysis Endovascular Thrombectomy & Large Vessel Occlusion Malignant Hemispheric & Cerebellar Infarction

19 Chapter 13: Spontaneous Intracerebral Hemorrhage & Intraventricular Hemorrhage

Acute Intraparenchymal Hemorrhage Management Intraventricular Hemorrhage & Hydrocephalus Surgical Evacuation & Minimally Invasive Surgery in ICH

20 Chapter 14: Aneurysmal Subarachnoid Hemorrhage & Delayed Cerebral Ischemia

Aneurysmal Subarachnoid Hemorrhage: Acute Resuscitation & Securing Delayed Cerebral Ischemia & Cerebral Vasospasm Non-Aneurysmal Subarachnoid Hemorrhage & Vascular Malformations

21 Venous, Spinal & Traumatic Vascular Disease

Cerebral Venous Thrombosis & Spinal Cord Infarction Traumatic Dissection, Carotid–Cavernous Fistula & Penetrating Injury

22 Chapter 15: Traumatic Brain & Spinal Cord Injury

Severe Traumatic Brain Injury & Contusions Acute Traumatic Spinal Cord Injury & Neurogenic Shock Spine Trauma, Fractures & Cord Syndromes

23 Chapter 16: Status Epilepticus, Seizures & Neuromuscular Emergencies

Status Epilepticus: Convulsive & Non-Convulsive Refractory & Super-Refractory Status Epilepticus Acute Neuromuscular Respiratory Failure

24 Chapter 17: Post-Cardiac Arrest Care, CNS Infections & Encephalitis

Targeted Temperature Management & Post-Cardiac Arrest Care Post-Cardiac Arrest Neuroprognostication Acute CNS Infections, Encephalitis & Inflammatory Emergencies

25 Neuroinflammation & Neurooncology

Fulminant Demyelination & Autoimmune Encephalitis Brain, Spinal & Leptomeningeal Cancer Emergencies

26 Pregnancy, Transplantation & Pediatric Care

Pregnancy, Postpartum & Post-Transplant Neurologic Care Pediatric Neurocritical Care

27 Chapter 18: Neurosurgical & Perioperative Emergencies

Postoperative Neurosurgical Complications Device Complications: EVDs, Shunts & ICP Monitors Cerebral Hyperperfusion Syndrome & Post-Interventional Emergencies

28 Chapter 19: Ethics, Palliative Care & Organ Donation in the Neuro-ICU

Communication, Surrogate Decision-Making & Conflict Resolution Neuroprognostication Ethics, Withdrawal of Life Support & Palliative Care Organ Donation & Management of the Deceased Donor

Organ Donation & Management of the Deceased Donor

Key Takeaways Explain This Topic AI

Hospitals use timely OPO referral criteria defined through their agreement; federal regulation does not impose one universal GCS-and-one-hour rule.

Donation discussions use OPO representatives or appropriately trained designated requestors under the hospital agreement.

DCD requires a withdrawal decision independent of donation, continued comfort care, and valid circulatory death determination under the applicable protocol.

The 2023 randomized donor trial found no increase in transplanted hearts with routine IV levothyroxine and more hypertension or tachycardia.

If donation cannot proceed, continue the agreed end-of-life care plan without diminishing comfort or dignity.

Last updated: October 2026

Keep Treatment, Authorization, and Death Determination Distinct

Organ donation may follow death determined by neurologic criteria or by circulatory criteria. The treating team remains responsible for the patient's care, valid death determination, communication, and respect for the patient's wishes. Donation eligibility must not determine whether treatment is withheld or withdrawn. Severe disability, a poor prognosis, and death are different concepts.

Coordinate early with the designated organ procurement organization (OPO) under the hospital's agreement. Federal hospital requirements address timely notification, OPO collaboration, and appropriate requestors. They do not define one universal federal rule requiring notification within one hour of GCS 5 or loss of exactly two reflexes. The locally agreed referral triggers and notification process must be known and followed; do not wait for the treating clinician to decide that no organs could be usable.

Authorization and Communication

Verified donor registration or another valid anatomical gift has legal significance, but the applicable state law and actual documentation govern. The OPO helps assess authorization, possible revocation, and the appropriate decision-maker when no prior authorization exists. Avoid presenting every state's law or every special circumstance as identical. A healthcare surrogate's authority over treatment and authority regarding an anatomical gift may arise under different rules.

Discuss diagnosis, prognosis, treatment goals, and death clearly and sensitively. The donation request process is handled by OPO representatives or trained designated requestors as specified in the hospital agreement; a trained hospital clinician may be a designated requestor. This is different from saying that physicians and nurses are universally forbidden to participate. Keep roles clear, avoid coercion, and use interpreters or other communication support when needed.

Donation After Neurologic Determination of Death

A potential donor must first satisfy the complete BD/DNC process under law and policy. Organ suitability is assessed separately. Once death is determined, circulatory and respiratory support may preserve organs while the authorized donation plan proceeds. Hemodynamic instability can reflect vasoplegia, myocardial dysfunction, hypovolemia, diabetes insipidus, infection, or other causes; not every donor has complete pituitary failure.

Problem Management reasoning

Hypotension Assess volume, cardiac function, vascular tone, bleeding, and infection; use individualized support

Polyuria and rising sodium Evaluate DI versus osmotic or other diuresis; replace losses and use appropriate antidiuretic therapy

Hypoxemia Use lung-protective ventilation and assess recruitment, secretions, edema, or infection

Hyperglycemia or electrolyte abnormality Correct and monitor without creating hypoglycemia or abrupt osmotic change

Hypothermia or fever Follow coordinated donor-temperature and organ-specific protocols

Use vasopressin or desmopressin according to the combination of DI and circulatory needs. Track urine output, sodium, glucose, potassium, temperature, and perfusion. A historical rule of 100s is not a validated universal set of mandatory targets, and a sodium value above 155 does not by itself prove inevitable liver-graft failure. Transfusion, oxygenation, and fluid goals depend on clinical and organ considerations.

Hormonal Therapy and Evidence

Older observational donor bundles often included thyroid hormone, steroids, vasopressin, and insulin. Their association with organ yield does not establish that every component independently improves transplantation. In the 2023 randomized trial of unstable potential heart donors , IV levothyroxine did not significantly increase transplanted hearts compared with saline and caused more severe hypertension and tachycardia. Do not describe routine thyroid hormone as a proven treatment that necessarily improves myocardial function and organ yield.

Other hormonal and hemodynamic interventions are selected with the OPO and donor-management team for the actual indication. Low thyroid-hormone measurements in critical illness do not automatically prove a replacement-responsive pituitary disorder. Treat DI, glucose disturbance, and shock while distinguishing physiologic rationale, observational evidence, and trial-proven effects.

Donation After Circulatory Determination of Death

In controlled DCD , the patient does not meet BD/DNC and a decision to withdraw life-sustaining treatment is made independently of donation, based on the patient's preferences and clinical circumstances. The injury need not be described as biologically unsurvivable for the decision to be valid. Authorization, procedure planning, and discussion of donation are separate steps.

Arrange the location, comfort plan, family access, team roles, and monitoring under the approved protocol. The treating team provides proportionate symptom relief. Clinicians determining death must satisfy independence requirements. The recovery team must not decide when a living patient's treatment should end or compromise symptom management to meet a donation timeline.

After circulation ceases, observe for the required interval and determine death using the applicable law and institutional protocol. Observation periods and monitoring requirements must be followed exactly; they are not a claim that a short interval mathematically guarantees zero possibility of any autoresuscitation in every circumstance. Any pre-death intervention requires appropriate authorization and ethical review under the local pathway.

Ischemia, Recovery Limits, and Continued Care

Functional warm-ischemia definitions and acceptable times differ by organ, recovery method, and transplant program. Do not impose one universal MAP, saturation, or minute limit on every organ. Plan in advance for what happens if circulation does not cease within the program's recovery window or an organ is not suitable. The patient continues to receive the same agreed comfort care regardless of whether donation succeeds.

Explain that eligibility and procurement are uncertain. Clear expectations help families understand that an unsuccessful donation attempt does not mean treatment or comfort was withheld. Document the independent withdrawal decision, authorization, care plan, death determination, and relevant handoffs according to policy.

Sources checked October 17, 2026: 42 CFR 482.45 and 2023 randomized levothyroxine trial .