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Xenobiotics cause brain death as a result of the unique vulnerabilities of the central nervous system. With supportive care, however, many such patients are suitable candidates for organ donation.11,12,38,47

Early identification of potential donors is critical because the viability of transplantable tissue diminishes as duration from the time of brain or cardiac death prolongs.30

Donor identification by clinicians is one barrier. Among a group of toxicologists given scenarios of brain death from poisoning due to cocaine or carbon monoxide, toxicologists had variable perceptions of donor and organ suitability.45 Such inconsistency can affect the potential pool of donors in patients with clinical signs of brain death.

Some xenobiotic poisonings can confound clinical assessments of brain stem function and mimic brain death (Table SC12–1). Published brain death protocols require exclusion of poisoning,12,43,49 but limited guidance is provided.44 Obtaining and interpreting xenobiotic concentrations is complex and, in many circumstances, not feasible. Few xenobiotics have timely and readily available assays. This is further complicated when the exposure history is unknown. Determining brain death from novel psychoactive substances (NPS) and illicit synthetic opioids is especially challenging. Routine testing for many NPS is often unavailable or uninterpretable, further complicating decisions regarding donor suitability.

TABLE SC12–1Xenobiotic Mimics* of Clinical Brain Death

Other methods of establishing brain death are utilized such as cerebral blood flow. The effects of xenobiotics on these studies are not well described.34

Once brain death is established, organ procurement personnel assist in obtaining familial consent, deciding which organs are most suitable for transplant, and maximizing physiological support and perfusion until organ procurement occurs.47 The protocols following controlled or uncontrolled donation after cardiac arrest are socially complicated and practiced extensively in Europe.42

Successful transplantation of organs is reported from poisoned donors associated with a variety of xenobiotics (Tables SC12-2 and SC12–3).2,3,6,8,11,12,18,26,29,36,38-41,46 Although some xenobiotics are highly toxic, such as cyanide and carbon monoxide (CO), transfer of clinical poisoning to the organ recipient is not reported. This is likely caused by several factors, including xenobiotic metabolism, tissue redistribution or binding prior to procurement, as well as the means of handling organs during the transplantation process. For example, some xenobiotic clearance occurs in the myocardium during organ rinsing and cardiopulmonary bypass.35 Furthermore, individual organs do not uniformly manifest ...

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