Management of potential organ donor: Indian Society of Critical Care Medicine: Position statement
The position statement for management of organ donors is prepared by the Indian Society of Critical Care Medicine (ISCCM) with an objective of providing the standard perspective for the management of potential organ/tissue donors after brain death in adults only, regardless of the availability of technology. This document should be used as guidance only and does not a substitute for proper clinical decision-making in particular circumstances of any case. The endorsement of ISCCM does not imply that the statements given in the document are applicable in all or in a particular case; however, they may provide guidance for the users thus utilizing maximum organs from brain-dead patients. Thus, care of potential brain-dead organ donor is "caring for multiple recipients" [Table 1].
The grading of recommendations is as follows:
Quality of evidence is:
In India, the deceased donor organ donation rate is only 0.8 per million (while USA at 25.6 per million, UK at 18.3 per million, and Spain at 32 per million). 
On the background of increasing organ demand,  compared to the number of organs available for transplantation, the responsibility to care for potential donor increases. A multidisciplinary team approach is necessary for successful organ donation.  The physiology of all the available organs in the donor should be normalized and maintained till the time of organ retrieval. Often older people and marginal donors are also potential donor candidates, such cases need to be managed carefully, to improve the conversion rate and graft survival after donation.  Intensivists play a vital role in identification, declaration of brain death, and providing medical care to potential organ donors, thereby improving rates of graft survival, i.e., quality of organ donation. ,,
The ISCCM has recently released guidelines for end-of-life and palliative care in Indian intensive care units.  However, currently, there are no guidelines for the identification of potential donor and management of identified potential organ donor in India.
A potential organ donor is defined by the presence of either brain death or a catastrophic injury to the brain which could progress beyond reversibility and may fulfill brain death criteria. 
Historically, death was defined by the presence of putrefaction or decapitation, failure to respond to painful stimuli, or the apparent loss of observable cardiorespiratory action. However, with development in resuscitation measures and invention of mechanical ventilators, respiratory arrest was prevented. Vital functions can now be maintained artificially after the brain has ceased to function. Increasing incidence of medicolegal cases necessitated the definition of brain death. ,,
In 1959, Mollaret and Goulon coined the term on brain death "le coma deepasse."
In 1968, an ad hoc committee at Harvard Medical School reexamined the definition of brain death.
Uniform determination of death act gave statutory recognition to the concept of brain death and equated this concept with traditional cardiorespiratory death. The fundamental tenet of this criterion is based on a "cessation of the integrative functioning of the organism as whole." An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead.
In 1976, the Conference of Medical Royal colleges published the statement on the diagnosis of brain death, and clinical diagnostic testing for brain death became more refined.
In 1981, the US President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research published guidelines regarding brain death. The guidelines recommended the use of supplementary diagnostic tests to augment the clinical examination in brain death.
India follows the UK code. In India, the legal framework for organ donation is in place. According to the Transplantation of Human Organ Act (THOA-1994) legislation, deceased donation is a legal option (THOA 1994). ,
The Central Government has established a National Human Organs and Tissues Removal and Storage Network named NOTTO, which stands for National Organ and Tissue Transplant Organization. NOTTO has five regional networks Regional Organ and Tissue Transplant Organization (ROTTO), and each region of the country will develop State Organ and Tissue Transplant Organization (SOTTO) in every state/union territory. This was based on the Transplantation of Human Organs and Tissues Rules, 2014.
Each hospital of the country related to transplant activity, either as retrieval or transplant center or both, has to link with NOTTO, through ROTTO/SOTTO as a part of National Networking.
1.3. What does brain death mean?
The THOA, 1994 (Central Act 42 of 1994),  - definition of death:
"Deceased person" means a person in whom permanent disappearance of all evidence of life occurs,
"Brain stem death" means the stage at which all functions of the brain stem have permanently and irreversibly ceased. However, the cause of irreversible coma has to be established, preconditions should be met, and confounding factors are to be ruled out [Figure 1]. ,,,,
Brain death is commonly caused by: ,,
1.4. How does brain death occur?
Brain death occurs in response to increased intracranial volume caused by any of the following: ,
The intracranial pressure (ICP) rises. As the skull is a closed box, blood flow to the brain falls due to rising ICP and finally stops:
The brain dies ⇒ Irreversible ⇒ Patient dies.
The criteria involved in the diagnosis and declaration of brain death include [Figure 1]:
India follows the UK concept of brain stem death, and the THO Act was passed by the Indian Parliament in 1994 which legalized the brain stem death.  In 1995, THO rules were laid down which describe brain death certification procedure.
The state of Maharashtra has passed a resolution making it mandatory to declare and certify "brain death." The Government resolution underlines the responsibilities of hospitals registered under THO Act 1994, that is authorized transplant centers. As the large number of brain death occurs in nontransplant hospitals, it makes for the appropriate authority (Director of Health Services) to register all hospitals in the state that have an operation theater and intensive care unit (ICU) as nontransplant organ retrieval centers (NTORCs). These hospitals are permitted to certify brain death as per procedure and then conduct organ retrieval for therapeutic purposes, but not permitted to perform actual transplantation. Thus, it is mandatory now for all NTORCs and authorized transplant centers in the State to certify and notify the brain death cases to Zonal Transplantation Co-ordination committee. This is a strong step to streamline the procedure for cadaveric organ retrieval and transplantation. 
The readers are advised to refer to the amendments and adoptions made to the act by their respective states in regard to the structure of the deceased donor organ donation process.
1.5. Determination of brain death/tests to be done for the diagnosis of brain stem death certification [Figure 2] ,,,,,
Clinical examination is important for the determination of brain stem death.
1.5.1. History taking and Physical examination findings that provide a clear etiology of brain dysfunction should be done, including a review of computed tomography/magnetic resonance imaging films
The determination of brain death requires the identification of the proximate cause and irreversibility of coma. The evaluation of a potentially irreversible coma should be established with appropriate clinical or neuro-imaging evidences.
1.5.2. Exclusion of confounding factors that interfere in the clinical diagnosis of brain death [Table 2]
1.5.3. Performance of a complete neurological examination [Figure 2]
Labyrinthine injury or disease, anticholinergics, anticonvulsants, tricyclic antidepressants, and some sedatives may alter response [Figure 2]b.
1.5.4. Absent respiratory efforts in the presence of hypercarbia: Apnea test
I. The following prerequisites must be met before carrying out the apnea test ,
II. Steps for apnea test [Figure 2]b and c
Preoxygenate the patient with 100% O 2 for 10-15 min (to ensure denitrogenation of lungs) and do a baseline arterial blood gas analysis
IV. Queries about apnea test [Table 3]
1.6. Observations which are compatible and incompatible with brain stem death
Reason for spinal reflexes according to one hypothesis: the reflex movements represent hypoxia- and hypercapnia-induced activity of cervical cord neurons. Alternatively, they might be due to disinhibition of movement generators of the spinal cord. Another hypothesis is that mechanical compression/decompression of the spinal root or cervical spinal cord by neck flexion/extension can generate movement. ,
1.7. Ancillary tests
When the full clinical examination, including both assessments of brain stem reflexes and the apnea test, is conclusively performed, no additional testing is required to determine brain death (Grade 1A). ,, Confirmatory tests such as EEG, cerebral angiography, transcranial Doppler, and radionuclide scan are not mandatory. As per the TOHA, the ancillary tests are not mentioned at all, hence its legal acceptability is challenging. ,
Indications for ancillary tests are:
2.1. Who can certify and how many doctors required? ,,,
Registered medical practitioners with appropriate authority should do apnea test and can certify brain stem death.  The diagnosis of brain death is established and recorded by two doctors not belonging to the retrieval and transplantation teams (Grade 1A). ,,,, Out of the two doctors, one must be a specialist in neurology (Grade 1A). The order of examination is irrelevant, i.e., it does not matter whether the neurologist performs the first or the second examination. 
For certification of brainstem death, it requires a panel of four doctors.
Form 10 should be filled and signed by the medical experts certifying brain stem death.
Amendments in the THOA (2011) and THAO rules 2014 have allowed selection of a surgeon/physician and an anesthetist/intensivist, in the event of the nonavailability of neurosurgeon/neurologist.
2.2. How many times the clinical examination and test are needed to be done and what is the interval between two tests? ,
Clinical examination and apnea test need to be done 2 times after an interval of 6 h. After the second test, the team should start counseling the family regarding organ donation.
The time of death is the end of the second apnea test.
2.3. What needs to be included in medical record documentation? 
All phases of the determination of brain death should be clearly documented in the medical record:
All the four doctors (members from Panel of The Board of Medical Experts) should sign tests done to document the absence of brain stem function, namely, pupillary reflex, doll's head eye movement, corneal reflex (both sides), gag reflex, cough (tracheal), eye movements on caloric testing bilaterally, absence of motor response in any cranial nerve distribution, and apnea test. 
In India, Form 10 is necessary for brain death certification. 
The medical expert registered with appropriate authority need to have a dialog with the relatives about carrying out the tests for brain stem death. Given the situation and delicate sentiments of family/caregivers, the person responsible for breaking news to family/caregivers about patient's brain stem death should be sensitive to the responses and feelings of the family members/caregivers.
The ICU physician should communicate the confirmation of brain stem death to transplant coordinator who in turn can communicate to family and make request for the organ donation (Grade 1A). Simultaneously, the administrators of the hospital should be communicated to stop the further billing once diagnosis of brain stem death is confirmed and family has consented for the organ donation.
3.1. The process of consent for organ and tissue donation involves ,,
The deceased wishes must be ascertained through hospital staff/relatives/donor coordinator (driving license, etc., wherein the provision for donation may be incorporated after notification of the THOA rules). In India, even if the deceased wishes are known, the next of kin need to formally consent and sign the consent form. 
The NOTTO Organ Donor Register is a computerized database which records the wishes of people who have pledged for organ and tissue donation and decided that, after their death, they want to leave a legacy of life for others. There are many hospitals and organizations those are also maintaining the list of persons who have pledged organ donation with them, all this will be a part of NOTTO website for National Register.
Next of kin consent
Hospital staff need to speak with the relatives about organ donation on behalf of the deceased.
The surrogate decision-making authority includes:
In case of dispute in the family or a difference of opinion in the family, ample amount of time should be given to the family to discuss, settle, and give a final decision.
Form 8 need to be filled and signed to record the status of the cum consent by near relative or lawful possessor of brain stem dead person.
It is necessary to inform police about organ donation consent to the station house officer or superintendent of police or deputy inspector general, if it is a documented medicolegal case.
Once the consent for organ donation is achieved, the cost for maintenance of cadaver or retrieval or transportation or preservation of organs or tissues, their transportation, and preservation may be borne by the recipient or institution or government or nongovernmental organization but not by the donor family (Grade 1A).
3.2. Areas of controversy
Data protection and confidentiality of recipients has to be maintained. Donor's family cannot have access to recipient's name.
As mentioned earlier, the police need to be informed about organ donation consent in case of medicolegal cases. A copy of consent should also be sent to the designated postmortem doctor. It shall be ensured that by retrieving organs the determination of the cause of death is not jeopardized. The medical report in respect of the organs or tissues retrieved and prepared by retrieving doctors shall be taken on record in postmortem notes.
The patient must be medically suitable to donate organs for transplantation. Criteria for suitability change over time and vary according to recipient circumstances. Early determination of the suitability for transplantation of specific organs facilitates the development of focused medical management strategies (e.g., more aggressive fluid therapy when lung donation is contraindicated).
4.1. Exclusion criteria for organ donation
Bacteremia or fungemia is not an absolute contraindication to donation. 
Acute organ dysfunction, in particular acute renal failure, in a potential donor with prior renal function is not a contraindication to donation.
4.2. What is the accepted age range for multiple organ and tissue donors?
There is no maximum age for donation; however, comorbidities that develop together with aging make donation less acceptable. Marginal or expanded criteria donors are those presenting clinical conditions that might reduce graft survival, impair its function, or are at a high risk of disease transmission (Grade 1A) [Table 6]. 
The use of marginal donors is only justified when the life expectancy after transplantation is higher compared with conventional clinical treatment. 
For recipients under 45 years old, the ideal age of deceased donors is depicted in [Table 6].
Older persons (e.g., up to 80 years of age) (Grade 2B)  and those with a history of hypertension and diabetes mellitus need to be worked up for individual organ function such as albumin: creatinine ratio for kidney function.
Intensive care specialists assist critically ill patients to recover from illness and lead a good quality of life. Brain stem death usually results in complex multiple organ failure. In such cases, the decision to stop or remove specific brain-related intensive treatments needs to be taken. However, extra-cranial physiological support may be continued till the determination of brain death or very severe irreversible brain damage. Appropriate management of donor before and after brain death may result in increasing the frequency and improving quality of donor organs. ,
All health-care personnel and ICU attendants should have a responsible and professional behavior at the bedside of the patient. Medical procedures and investigations should only be done if they are required to facilitate the donation procedure.
5.1. Physiological and metabolic changes during brain death [Figure 5]
5.1.1. Cardiovascular system
Hemodynamic instability and cardiac dysfunctions are always encountered in patients after brain death. , Myocardial dysfunction often occurs as a result of severe brain injury. ,, The exacerbated stress response, i.e. "sympathetic storm,"results in hypertension, tachycardia, and arrhythmias. Though usually of short duration, it may lead to cardiac dysfunction, cardiac ischemia, myocardial and conduction system necrosis. ,,, Further, spinal cord ischemia is followed by deactivation of sympathetic storm and loss of cardiac stimulation. This leads to vasodilatation and cardiac dysfunction, clinically presenting as hemodynamic instability in potential donor. Other factors contributing to hypotension are diuretics (mannitol), hyperglycemia-induced osmotic diuresis, DI, hypothermic "cold" diuresis, inadequate fluid resuscitation and decreased oncotic pressure after crystalloid resuscitation, ongoing blood loss, rewarming of patient, relative adrenal insufficiency as a result of trauma, and critical illness. 
5.1.2. Diabetes insipidus
DI is a common problem in brain-dead patients. It occurs in about 80% of the patients with brain death. However, absence of DI does not mean that the patient is not brain dead. DI results from the deficiency of anti-diuretic hormone due to loss of posterior pituitary function  leading to polyuria. In patients with urine output more than 200 ml/h for consecutive 2 h, diagnosis of DI should be suspected. If left untreated, DI often leads to hypovolemia and hypernatremia. Hypernatremia may adversely affect the outcomes for renal and liver transplants (Grade 2A). ,,,
Brain death results in hypothermia due to loss of thermoregulation, reduced metabolic rate, excessive heat loss, and loss of protective mechanisms such as vasoconstriction or shivering.  Exposure and administration of cold fluids may further increase the risk of hypothermia. Hypothermia is best avoided or prevented rather than treated. Once hypothermia sets in, it is difficult to warm patients and it has direct effect on cardiac function, arrhythmias, coagulation cascade, and oxygen delivery to tissues.
5.1.4. Hormonal dysfunction
Circulating triiodothyronine (T 3 ) may be low in patients with brain death.  Thyroid hormone deficiency along with cortisol deficiency may contribute to hemodynamic instability.  The data also suggest that function of anterior pituitary is partially preserved, with normal levels of cortisol and thyroid hormone, or low thyroid hormone with normal/raised thyroid-stimulating hormone levels consistent with sick euthyroid syndrome.  Hyperglycemia is common in brain stem death patients because of reduced insulin concentrations and insulin resistance. 
5.1.5. Anemia, coagulopathy, and immunological changes
Traumatic bleeding commonly results in anemia. Furthermore, coagulopathy and fluid administration may cause exacerbation of anemia. Significant rise in pro-inflammatory cytokines such as interleukin-6 has been observed in brain-dead potential organ donors which could be one of the causes of coagulopathy. , The other possible causes include dilutional coagulopathy due to fluid administration, and it may be worsened by hypothermia. 
6.1. General care 
General measures of infection control should be applied. These include:
6.2. Monitoring 
Monitoring is a crucial part of the medical management of potential organ donor. Routine monitoring includes ECG, BP, pulse oximetry, core temperature, hourly urine output, and central venous pressure (Grade 1A). Bedside echocardiography for the assessment of fluid deficit (Grade 1A), and use of Swan-Ganz catheter/cardiac output monitors should be reserved for unstable donors, who have persistent acidosis with the evidence of tissue hypoperfusion (Grade 2B).
6.3. Laboratory 
Arterial blood gas, lactate, electrolytes, and blood sugar levels need to be monitored every 2-4 hourly (Grade 1A).  Parameters such as hemoglobin, hematocrit, complete blood count, blood glucose, urine analysis, blood urea nitrogen, serum creatinine, serum electrolytes, liver function tests, coagulation profile, and microbiological screening for hepatitis B, C, hepatitis B core antigen, HIV, and IgM and IgG for cytomegalovirus are necessary (Grade 1A).
Mandatory investigations include blood group, HIV antibody, hepatitis B surface antigen, and hepatitis C virus antibody (Grade 1A).
However, risk of transmission of infection may still remain.
Cultures of blood and urine may be required, if there is evidence of infection or if the patient is hospitalized for more than 72 h (Grade 2B). Some additional tests may be required for multiorgan donors, for example, echocardiography for heart and bronchoscopy for lung transplantation.
One should aim to maintain body temperature, ensure adequate oxygenation, circulating volume, cardiovascular stability, and adequate urine output.
A simple method to maintain potential donor is "rule of 100" (Grade 1B) [Table 7]. 
The medical management of organ donor can be broadly divided into:
The treatment aspects of these parameters are summarized below.
7.1. Management of hemodynamics
Goals for management of hemodynamic status of the donor are as follows: ,
Due to the transient nature of autonomic storm, antihypertensives are usually not required. If needed, short-acting antihypertensives such as esmolol, sodium nitroprusside, hydralazine, labetalol, or nitroglycerine should be used (Grade 1B). Antihypertensive is not required for a long time.
Intravenous fluid administration is required for the management of hypovolemia. However, the decision for selection of fluid depends on serum electrolytes, sugar level, hemodynamic of the patient, estimated volume deficiency, and polyuria from DI. Organs such as lungs may require minimal fluid for optimizing function.  The suitable organs for transplantation should be identified in advance to plan focused medical management of fluid replacement. Significant positive fluid balance is associated with progressive pulmonary dysfunction. 
One should check for signs of continuing hemorrhage (external, GI, urinary, abdominal, etc.) (Grade 1A).
Discontinue medications that may contribute to hypotension (e.g., antihypertensives, beta-blockers) (Grade 1A).
Three management strategies are commonly adopted, and treatment is escalated depending on the clinical response. These strategies are: 
Volume expansion/preload 
Central venous pressure measurement alone is a poor guide for directing resuscitation, and alternative techniques can be used to assess effective fluid administration responsiveness (Grade 1A).
An adequate perfusion pressure should be maintained. The targets for SBP and mean arterial pressure should be >100 mmHg and >70 mmHg, respectively (Grade 1A). 
Vasopressor medicines may be required frequently to support mean arterial pressure once hypovolemia has been excluded/corrected. Vasopressin in pressor dose (1-2 U/h) plays an important role in stabilizing the hemodynamic of brain-dead patients (Grade 1A). , Vasopressin up to 2.4 units/h may reduce the requirement of other ionotropes.  The utility of low-dose vasopressin to treat DI, aid restoration of vascular tone, and reduce epinephrine requirement was first identified in brain-dead patients receiving long-term support. When the loss of vascular tone is preventing the achievement of donor goals, low-dose vasopressin may allow reduction or elimination of catecholamine use, as in other ICU patients.  Canadian guidelines recommend vasopressin as the first-choice vasopressor for donor resuscitation. ,
Norepinephrine is also commonly used for this purpose (Grade 1A).  Norepinephrine is required in higher doses compared to epinephrine. As far as possible, high doses of norepinephrine >0.05 mg/kg/min should be avoided (Grade 2B).
A study of brain-dead patients has shown that pressor dose of vasopressin and epinephrine combination effectively increases the mean arterial BP with increase in total peripheral resistance index and cardiac index. Dopamine can be used as well, but has an increased incidence of arrhythmias.  Intravenous fluids and inotropes/vasopressors (dopamine, dobutamine, epinephrine, vasopressin, and norepinephrine) should be administered based on the central venous pressure and bedside two-dimensional echocardiography (Recommendation Grade 1B).
There are no clear recommendations regarding T 3 administration for improving hemodynamic status and cardiac function in potential donors and also the results are not clear. , Moreover, T 3 is not easily available in India. Thyroxine (T 4 ) 300-400 mcg through nasogastric route can be given in hemodynamically unstable patients, but absorption and clinical effect are not proven (Grade 2B).
Efforts should be made to prevent arrhythmia or promptly treat it, because of problems associated with them. It is more commonly seen in cases of longer lag between brain death and organ removal.
Prevention of arrhythmia
Electrolytes, BP, fluid volume, and body temperature should be carefully monitored and maintained within normal range to reduce the risk of development of cardiac arrhythmia (Grade 1A).
Treatment of tachyarrhythmia
If arrhythmia occurs, it can be treated with standard therapy such as amiodarone or cardioversion (Grade 1B).
Atropine is not useful in the management of bradycardia whereas adrenaline, isoprenaline, or pacing may be effective (Grade 2B). 
7.2. Management of hormonal and metabolic derangement
7.2.1. Hormonal resuscitation
Some studies have recommended its use in persistent hemodynamic instability and/or when ejection fraction is <45% on echocardiography and when heart donation is planned. ,, However, there is no strong evidence for use of hormonal resuscitation. ,, There is limited data on the benefit of hormone administration in humans. Small studies with thyroid hormone have not shown benefit on hemodynamic status in brain-dead patients. ,,, Thus, the evidence on anterior pituitary or thyroid dysfunction in brain death is conflicting.
In patients in whom lung transplant is a distinct possibility, use of methylprednisolone has shown some benefits.  The results of a retrospective analysis of 118 consecutive organ donors, of which eighty received high-dose methylprednisolone during donor management, demonstrated improved oxygenation at organ recovery. With high-dose steroid treatment, significant increase in the number of lung utilization was seen possibly because of the anti-inflammatory benefits of steroid.
We suggest (Grade 1B): ,,,
7.2.2. Diabetes insipidus
Desmopressin or vasopressin should be used early in the management of DI. The dose of desmopressin and vasopressin is given along with acceptable urine output as shown in [Table 8].
Early use of antidiuretic agents in suspected DI may prevent physiological instability due to hypovolemia and hypothermia. Large amount of fluid loss in the urine should be replaced by intravenous fluids using balanced salt solution or fluids with low-sodium content (5% dextrose or 0.45% saline) to maintain sodium level between 135 and 145 mEq/l (Grade 1A).
7.3. Metabolic derangement
Intravenous fluids are also required to maintain normal fluid volume and electrolyte balance. Serum sodium and potassium should be monitored every 2-4 h (Grade 1B). Insulin infusion may be required for maintenance of normal blood glucose. Doses of insulin required for maintaining glucose control may be higher than normal. Blood sugars must be maintained in the range of 80-150 mg/dl (Grade 1A). 
7.4. Temperature, respiration, and hematological management
Prevention of hypothermia is easier compared to its reversal. Active warming helps to prevent hypothermia. Efforts should be made to maintain temperature >35°C (Grade 1A).  Surface warming should be done in all patients with hypothermia. The patients with body temperature of <34°C should be given core warming. In such cases, inhaled gases should be warmed and humidified using humidifier (Grade 2B). Intravenous fluid should also be warmed if large volumes are to be administered (Grade 2B).
Respiratory passage should be clear without any obstruction. To achieve this, routine measures such as suctioning, positioning, and turning should be continued. A technique such as positive end-expiratory pressure helps to maintain oxygen delivery to the organs due to reduction in atelectasis. Interstitial fluid overload should be avoided. Oxygen saturations within normal limits and normocapnia should be maintained (Grade 1A).
7.4.3. Hematological management
In case of active bleeding, the cause of bleeding should be corrected at the earliest.  Sometimes, transfusion of blood, coagulation factors, and platelets may be needed to correct severe anemia and/or coagulopathy (Grade 1B). In case of worsening coagulopathy, organ removal should be expedited.  Transfusion of blood or blood products should be done only if necessary (Grade 2B).
7.5. Infection management
Donor should be infection free. Routine use of antibiotic prophylaxis is not warranted (Grade 2B). Antibiotic agents should be used on the basis of results of Gram's staining of aspirated secretion and positive cultures.
7.6. Management of nutrition
Nutrition should be continued as per standard ICU protocol (Grade 1B). Nutrition should be continued in patients awaiting consent for organ donation from the caregivers. Continuing enteral feeding in the potential donors may help in providing beneficial effects for organ functioning. ,
Drugs may cause adverse events related to different organs. Patient- and drug-related factors may be responsible for the toxic effects induced by medicines.  Drug-related factors responsible for organ damage include drug's pharmacology, mechanism of action, dose, frequency of administration, duration, form of administration, and drug interaction potential. Medicines causing liver or kidney toxicity are listed in [Table 9].
Brain stem death is usually followed by an expected pattern of complex multiple organ failure, hence an appropriate support to the donor before and after brain death can increase the number and quality of donor organs. The medical management of organ donor can be broadly divided into cardiovascular management, hormonal or management of metabolic derangement, management of temperature, respiration, hematological parameter, and nutritional support. Early identification of organs for donation helps to optimize the medical strategies. The guidance provided in this statement does not substitute proper clinical decision-making in particular case, but will help intensivists for the management of brain death for organ and tissue donation. [Table 10] shows the checklist for the management of potential organ donors.
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Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]