Hypernatremia and Vasopressors in Pancreas Donor?

Robert J. Stratta, MD

Disclosures

January 17, 2002

Question

Hypernatremia and vasopressors in a pancreas donor -- is there consensus as to how much is too much?

Ivonne Daly, MD

Response from Robert J. Stratta, MD

There is currently no consensus regarding the influence of hypernatremia in the pancreas donor. Extrapolating from the liver and kidney experience, most surgeons would be reluctant to accept a pancreas from a donor who has a serum Na+ in excess of 160 mEq/L. The rationale is that severe hypernatremia may result in osmotic swelling that may contribute to cellular edema, dysfunction, apoptosis, and necrosis. Cellular edema, especially after reperfusion, would be particularly deleterious to the pancreas allograft because of its sensitivity and vulnerability to pancreatitis and thrombosis (both microvascular and macrovascular).

With regard to vasopressors, a mean arterial perfusion pressure of at least 80 mm Hg and good renal (stable serum creatinine, good urine output) and hepatic function (stable enzymes) is probably indicative of an acceptable pancreas. Obviously, the greater the vasopressor requirement, the greater the level of concern; but if end-organ function appears relatively normal and stable, then this may be more important than the actual level of vasopressor requirement. Brain death may be associated with catecholamine depletion, so the use of vasopressors may be physiologic in this setting. Hyperglycemia that does not respond to insulin therapy is probably an ominous sign and an indicator of pancreas hypoperfusion. However, hyperglycemia by itself is not a good parameter of pancreatic function and is a common occurrence with brain death.

Hyperamylasemia is nonspecific, but hyperlipasemia may be a harbinger of pancreatic injury, particularly in the setting of high vasopressor requirements. My best advice is to use renal and hepatic function as surrogate markers of pancreatic function, viability, and injury.

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