Intraoperative Brain Monitoring During Thoracoabdominal Normothermic Regional Perfusion: Practical and Ethical Considerations

This article aims to review unresolved ethical issues and raise additional questions to be answered regarding the use of intraoperative brain monitoring during thoracoabdominal normothermic regional perfusion (TA-NRP). We discuss the following ethical questions, as well as offer preliminary recommendations to advance the discourse around use of brain monitoring during TA-NRP: (1) Does brain monitoring admit violation of the dead donor rule? (2) Which monitoring techniques should be implemented during TA-NRP? (3) How should we manage positive findings? (4) How should we manage ambiguous findings on brain monitoring? (5) What procedural and institutional barriers remain to utilizing intraoperative brain monitoring for TA-NRP on a wider scale? We argue that preventing inadvertent brain reperfusion is central to ensuring TA-NRP complies with ethical standards, and that blood flow monitoring is the most direct monitor for reperfusion. We assess potential brain monitors during TA-NRP and suggest that transcranial doppler (TCD) with cerebral oximetry may be the closest existing tests to an ideal monitor for this application. We likewise review remaining questions regarding diagnostic uncertainty around these tests and the implications of this uncertainty or positive findings of brain reperfusion on the donor, their families, and public trust. To begin addressing these questions, necessary first steps include standardization of surgical protocols to include venting and consolidating data around TA-NRP.