Optimisation hémodynamique des donneurs potentiels en état de mort encéphalique

Brain-death is followed by acute circulatory failure due to many reasons and its recognition and its accurate treatment are known to improve the quality and the number of transplanted organs. The pathophysiology of this circulatory failure includes an inflammatory response due to ischaemia-reperfusion injury following the neurovegetative storm and a diabetes insipidus but also a myocardial injury. The diagnosis is based on dynamic signs of hypovolaemia, assessment of cardiac output by echography (transthoracic or transoesophageal) and/or by an “invasive” approach (pulmonary flow-directed catheter, PiCCO™). The first treatment is volume expansion by colloids as far as hypovoleamia is present; then vasopressors must be used, norepinephrine is the first-line drug. If myocardial dysfunction is diagnosed, low dose dobutamine - eventually epinephrine - is able to improve organs perfusion (the heart include). Diabetes insipidus is treated by desmopressin with water balance corrected by hypotonic fluids. Treatments by steroids and/or thyroid hormones, or vasopressin use are not systematically recommended to correct hypotension.