Gift of Life Michigan
Donor Management Guidelines
- When the donor is on a medication, except for current antibiotic therapy, that is not consistent with the approved Gift of Life medication list, the medical director will be consulted
Donor Management Goal #1: Lung Recruitment
Follow Pulmonary Management Guidelines (age 15 to 60): Attachment A including but not limited to:
- Medications
- Narcan in conjunction with Norcuron
- Norcuron prn for peak pressures >30 cm H2O
- Albuterol and Atrovent via nebulizer or unit dose
- Mucomyst nebulizer in conjunction with Albuterol for thick secretions
- Solu-medrol
- Testing and Therapies
- Chest x-ray
- Bronchoscopy as soon as possible after brain death and consent
- ABG’s baseline and on 100% q 4 hours
- Bedside care including chest percussion therapy, turning, elevated HOB, etc (see Attachment A).
- Ventilator Associated Pneumonia Protocol
Donor Management Goal #2: Mean Arterial Pressure >60
Levothyroxine drip (T4)and Vasopressin per Hormonal Therapy Policy 5-09.
Maintenance IV Fluid:
Size/Age: / Sodium Level: / IV Fluid:< 6 months / ---- / IV should contain D10%
<10 kg / ---- / D5/ 0.2 NS/ 20 mEq/L KCl
10-20 kg / ---- / D5/ 0.3 NS/ 20 mEq/L KCl
>20 kg to age 15 / ---- / D5/ 0.45 NS/ 20 mEq/KCl
15 and older / <148 / D5W/0.45 NS, NS, LR, (can add KCl as needed)
15 and older / >148 / D5W, 0.45NS, (can add KCl as needed)
Hourly Maintenance Amounts:
Adjust rate on a case by case basis based on fluid balance status
Size: / Calculation:<10 kg / 100 mL/kg/24hours
10-20 kg / (1000 mL + 50 mL/kg for each kg >10)/24 hours
>20 kg / (1500 mL + 20 mL/kg for each kg >20)/24 hours
Adults (15 and older) / 100 mL/hr adjusted to patient status and condition
Hypovolemia: CVP < 6; PAWP <8
- Bleeding/Coagulopathy:
- Hematocrit < 30% or Hemoglobin <10 g/dL: Packed Red Blood Cells
- PT >15 or INR > 1.5: Fresh Frozen Plasma
- Platelets <100,000: Platelets
- Fibrinogen <2.9 : Cryoprecipitate
- Consult Medical Manager if diagnosed with Heparin Induced Thrombocytopenia (HIT)
- Consider ordering a functional HIT assay
- Avoid Heparin in management of donor
- Consider the use of Argatroban 15 minutes before cross-clamp 350mcg/kg IV over 15 minutes
- Utilize routine cold flush of the allograft
Age: / PRBC’s / FFP / Platelets / Cryo
Pediatric / 10-15 mL/kg / 10-15mL/kg / 10-20 mL/kg / 5-10 mL/kg
Adult / 1-2 units / 4 units / 5 units / 6 units
- Dehydration:
- Adults: Fluid bolus
- Pediatrics:
- 10-20 mL/kg NS or 5-10 mL/kg 0.2NS bolus
- 5% Albumin 5-10 mL/kg
- Diabetes Insipidus: urine output >4 mL/kg/hr
- Manage electrolyte imbalances
- Replace fluid loss as needed
- Vasopressin or Desmopressin titrated to achieve u/o 1-3 mL/kg/hr
- A Creatinine Clearance is not required but may be requested by a transplant center:
- Creatinine Clearance: volume of urine
- Urine Creatinine x min. of collection X1.73
- Serum CreatinineBSA
Hypervolemia: CVP > 10; PAWP >12
- Lasix, Bumex or Mannitol
- Consider decreasing hourly intake rate
Donor Management Goal #3: Less than 2 Vasopressors
Levothyroxine drip (T4) and Vasopressin per Hormonal Therapy Policy 5-09.
Cardiac Algorithm: Attachment B:
Attempt to wean vasopressors as able in the following order:
- Neosynephrine
- Epinephrine
- Levophed
- Dopamine
Hypotension: MAP <60, CVP >6
- Initiate T4 therapy
- If CVP <6: consider treatment for hypovolemia
- Add pressors in the following order:
- Dopamine < 10 mcg/kg/min (consider tachycardia when starting)
- Levophed
- Neosynephrine
- Rule out causes of decreased preload, such as increased intra-thoracic pressure related to ventilator status.
- Consider pulmonary artery catheter to further assess hemodynamic status\
Hypertension: MAP >90,
- Wean vasopressors in the order listed above.
- CVP > 10: consider treatment for hypervolemia
- Assess for intolerance to T4 therapy (Policy 5-09)
- Rule-out temporary effects of brain stem herniation
- Hydralazine, Nitroprusside, or Nicardipine (avoid Beta-blockers if heart is being considered for transplant).
- Consider beta-blocker administration if heart has been ruled out.
Arrhythmias:
- Correct Electrolytes
- Atrial fibrillation or flutter, SVT:
- Diltiazem or cardioversion
- Lethal arrhythmias:
- ACLS Protocol
Low Ejection Fraction and/or Heart Failure: EF <45, CI < 2.2.
- See Cardiac Algorithm: Attachment B
- Consider effect ventilation settings has on cardiac output and preload.
- Consider use of Dopamine over other vasopressors
- Consider the use of Dobutamine or Primacor (Milrinone)
- Rule out coronary artery disease, cardiac contusion, myocardial stunning, etc.
Donor Management Goal #4: pH 7.35-7.45
Baseline ABG and repeat every 4-6 hours
Always treat pH, not CO2
- Respiratory Acidosis/Alkalosis: Adjust minute ventilation (rate and or/volume)
- Metabolic Acidosis:
- If Sodium is less than 140: Sodium Bicarbonate
- If Sodium is greater than 140 and donor is making urine: Tromethamine (THAM)
- If Sodium and Chloride are elevated and K is low or normal, consider using PotassiumAcetate.
Donor Management Goal #5: Final 100% FiO2 ABG= PO2 >300 or P/F ratio >3
Ventilator Settings:
- Volume Ventilation
- Tidal Volume 10-12 mL/kg of Ideal Body Weight
- Adjust rate for pH 7.35-7.45
- PEEP 5 cm H2O
- Pressure Ventilation
- Consider if peak airway pressure is greater than 35 mm H2O
- Adjust rate for pH 7.35-7.45
- PEEP 5 cm H2O
- Other setting changes to decrease peak pressure and minimize wasted ventilation:
- Flow-decrease to 40-50 Liters/min
- Inspiratory pause
Pulmonary Edema, ARDS:
- Increase FiO2 and PEEP (maximum 10 cm H2O)
- Diuretics, avoid Colloids
- Consider proning
Donor Management Goal #6: Sodium 135-155
Hypernatremia: Sodium >145
- Change IV fluids (see maintenance IV fluid chart)
- Free water down NG
- Adults: 200-400 mL every 4 hours
- Pediatrics: 50-200 mL as tolerated
Hyponatremia: Sodium <135
- Change IV Fluids to 0.9%NS
- If <128, consider 3% NS (through central line)
Hyperkalemia: Potassium > 4.5
- Remove K from IV’s
- For pediatrics, consult with Medical Manager and/or Pediatric Intensivist.
- Consider use of following for adults to push K into cells:
- D50 1 amp
- Regular Insulin 15 units
- Sodium Bicarbonate 1 amp
- Calcium Gluconate 1 amp
- Consider Kaexylate down NG (consult with Medical Manager)
- If renal failure is present, consult with clinical resource and medical manager regarding dialysis.
Hypokalemia: Potassium < 4.5
- If K is consistently low, consider addition of KCl to primary IV fluid
- Be aware that Insulin and Albuterol push K into the cells
Normal or High Phosphorus / Low Phosphorus / Metabolic Acidosis/ Hyperchloremia
Pediatric / KCl 0.5-1 mEq/kg over 2 hours / KPhos 0.1-0.3 mmol/kg over 4-6 hours / Kacetate 1-4 mEq/kg in 24 hours
Adult / KCl 20-60 mEq at 20 mEq an hour / KPhos 10-15 mmol over 4-6 hours / K actetate 40 mEq
Hypocalcemia: Ionized Calcium < 1.13
Calcium Chloride or Calcium Gluconate
Hypomagnesemia: < 2.0
Magnesium Sulfate
Hyperglycemia: Blood Glucose >200
- Maintain Blood Sugar between 70 and 200
- Use Regular Insulin IV, monitor K
- Consider using donor hospital’s Critical Care Continuous Insulin Infusion Protocol (or see Insulin Continuous Infusion Guidelines below)
- Avoid D5W, if possible
- Check glucose as appropriate
Insulin Continuous Infusion Guidelines:
Initiate drip:
Glucose / 121-180 / 181-240 / 241-300 / 301-360 / >360Insulin / 1-3 units/hr / 2-3 units/hr / 6 units IVP
4-5 units/hr / 8 units IVP
5-6 units/hr / 10 units IVP
6-8 units/hr
Adjust According to Blood Glucose Levels every 1-2 hours
Glucose / Current Infusion:1-5 units/hr / Current Infusion:
6-10 units/hr / Current Infusion:
11-16 units/hr / Current Infusion:
>16 units/hr
111-140 / Increase by 0-1 unit/hr / Increase by 0-2 unit/hr / Increase by 0-3 unit/hr / Call MM
141-180 / Increase by 1-2 unit/hr / Increase by 1-3 unit/hr / Increase by 3-5 unit/hr / Call MM
181-240 / Increase by 1-2 unit/hr / Increase by 1-3 unit/hr / Increase by 4-6 unit/hr / Call MM
240-300 / 3 units IVP
Increase by 2-3 unit/hr / 5 units IVP
Increase by 3-5 unit/hr / 6 units IVP
Increase by 4-6 unit/hr / Call MM
301-360 / 4 units IVP
Increase by 2-4 unit/hr / 7 units IVP
Increase by 3-5 unit/hr / 8 units IVP
Increase by 4-6 unit/hr / Call MM
>360 / 5 units IVP
Increase by 2-4 unit/hr / 9 units IVP
Increase by 4-6 unit/hr / 10 units IVP
Increase by 5-7 unit/hr / Call MM
If blood glucose is below desired range:
80-110 / No change70-79 / Decrease rate by 50% and recheck in 1 hour
60-69 / Hold infusion for 1 hour and restart at 50% previous rate then recheck in 1 hour
Less than 60 / Discontinue infusion, consider giving D50
Hypoglycemia: Blood Glucose <50
- Administer D50
- If trouble controlling blood glucose, consider infusion of Dextrose in primary IV fluids, with Insulin infusion.
*Alternative therapies and medications may be utilized with Medical Manager approval on a case by case basis.*
Gift of Life Michigan Medication List
Medication / Adult Dose / Pediatric Dose <40kg or <16 years orAlbuterol
Nebulizer or unit dose / 2.5-5mg Q4 hours / 1.25-5 mg Q4 hours
Amiodarone / Life threatening arrhythmia:
150 mg IV bolus over 10 min; repeat if needed in 10 and 30 min; then 1mg/min for 6 hrs; then 0.5 mg/min for 18 hours. / Pulse less V-fib or V-tach: 5mg/kg rapid IV bolus not to exceed 300 mg
Perfusing Tachycardia: 5 mg/kg IV over 50 min; repeat twice up to total loading dose of 15 mg/kg
Ancef / 1 gm Q 8 hours IV / 50-100 mg/kg/day IV split into 3 doses every 8 hours
Argatroban / 350 mcg/kg IV over 15 min prior to cross-clamp / 350 mcg/kg IV over 15 min prior to cross-clamp
Atrovent
Nebulizer or unit dose / 0.5 mg, typically given with Albuterol / 0.25, typically give with Albuterol
Calcium Chloride / 0.5-1 gram IV / 10 mg/kg IV
Calcium Gluconate / 0.5-1 gram IV / 100 mg/kg IV
Clindamycin / 600 mg Q8 hours IV / 25-50 mg/kg/day IV split into 4 doses every 6 hours
Desmopressin (DDAVP) / 4-8 mcg/day IV in 2 divided doses / 2-4 mcg/day IV in 2 divided doses
Diltiazem (Cardizem) / 0.25 mg/kg IV bolus then 10-15 mg/hr / 0.25 mg/kg IV over 2 min then 5-15 mg/hr
Dobutamine
*consult MM / 3-20 mcg/kg/min IV / 3-20 mcg/kg/min IV
Dopamine / 3-20 mcg/kg/min IV / 3-20 mcg/kg/min IV
Epinephrine / 1-4 mcg/min IV / 0.05-0.3 mcg/kg/min IV
Furosemide (Lasix) / 20-120 mg IV / 0.5-1 mg/kg IV
Glucose 25% (D50) / 1 amp (25 grams) / 1-2 mL/kg IV
Hydrocortisone
(Solu-Cortef) / 15 mg/kg Q6 hours / 6 mg/kg IV Q6 hours
Hydralazine
(Apresoline) / 5-10 mg IV q 10-15 min
(max of 10-15 mg Q4-6 hours / 0.1-0.2 mg/kg/dose IV q 4-6 hours up to 1.7-3.5 mg/kg/day
Insulin- regular / 2-10 units/hr IV can be titrated higher to maintain blood glucose 70-200. / 0.05-0.2 unit/kg/hr IV, titrated for blood glucose 70-200.
Lidocaine / 50-100 mg IV bolus; then 10-20 mcg/kg/min / 1 mg/kg bolus IV; repeat in 15 min x2 then 20-50 mcg/kg/min
Levothyroxine / 20 mcg bolus; then 10-20 mcg/hr / Refer to Policy 5-09
Magnesium Sulfate / 1-2 grams IV / 25-50 mg/kg/dose IV diluted to 20% solution
Mannitol / 50-200 gm/24 hours IV in divided doses / 0.25-0.5 g/kg IV every 4-6 hours
Methylprednisolone
(Solu-Medrol) / 15 mg/kg Q6 hours / 6 mg/kg Q6 hours
Mucomyst
*Nebulizer only given when combined with Albuterol / 3-5 mL of 20% solution or
10 cc of 10% solution Q4 hours / 3-5 mL of 20% solution or
10 cc of 10% solution Q4 hours
Mucomyst
*as needed to minimize contrast related renal toxicity / 600 mg PO pre-procedure / ------
Narcan
*follow dose immediately with Norcuron / 8 mg IVP / Not commonly given
Nicardipine / 5-15 mg/hr until desired BP reached, then maintenance of 3 mg/hr / ------
Nitroprusside
(Nipride) / 0.3-10 mcg/kg/min IV / 0.5-8 mcg/kg/min IV
Norcuron
(Vecuronium) / 10 mg IVP / 0.08-0.1 mg/kg IV; then 0.05-0.1 mcg/kg/min maintenance
Norepinephrine
(Levophed) / Initially 0.5-12 mcg/min / 0.05-0.3 mcg/kg/min IV
Potassium Acetate / 20-60 mEq / 1-4 mEq/kg in 24 hours
Potassium Chloride / 40 mEq/L IV / 0.5-0.1 mEq/kg over 2 hours
Potassium Phosphate / 10-15 mmol IV / 0.08-0.36 mmol/kg/dose over 4-6 hours
Primacor
(Milrinone)
*Consult MM / 50 mcg/kg IV over 10 min
0.375-0.75 mcg/kg/min
Mixed with 0.45 or 0.9 NS / 50 mcg/kg IV over 10 min
0.375-0.75 mcg/kg/min
Mixed with 0.45 or 0.9 NS
Saline 3% / 40 mL/hr for 3 hours / 5 mL/kg IV to raise Na by 4 mEq/L
Sodium Bicarbonate / 1 amp or 50 mEq IV / 1 mEq/kg/dose of 0.3 molar solution over 20-30 minutes
THAM
(Tromethamine / Base deficit x kg x 1.1= amount in mL of 0.3 molar solution / 1mL/kg for each pH unit below 7.4
Vasopressin / 0.008-0.67 units/min / 0.5-10 miliunits/kg/hr
Pulmonary Management Guidelines
Attachment A
CRITERIA:
- This lung donor management routine will be considered on donors between the ages of 15-60 years old.
- Individuals > 60 or < 15 will be assessed on an individual basis.
- Medical history does NOT rule out lung donation.
- DCD Donors/No lung consent does not rule out utilization of pulmonary management guidelines. Bronchoscopy will be assessed on a case by case basis.
- For DCD Donation, certain aspects of guidelines will be utilized on a case by case basis.
MEDICATIONS:
- 15 mg/kg Solu-medrol IVP at start of case as initial dose. Repeat with 15 mg/kg of Solu-medrol every 6 hours thereafter. If the patient is already on a T-4 drip, do not repeat the dose but follow with the 15 mg/kg dose 6 hours after the drip was hung.
- Ancef 1 gram Q 8 hours, if allergic to PCN, use Clindamycin 600 mg Q 8 hrs.
- Call Pharmacy after sputum gram stain result is returned to see if antibiotic adjustments need to be made.
- Narcan 8 mg IVP at BEGINNING of case combined with Norcuron 10 mg IVP.
- Narcan Rationale: Used in effort to prevent or minimize Neurogenic Pulmonary Edema
- Norcuron can be given before or after Narcan.
- Norcuron may be repeated prn. (Half-Life is 25-40 minutes)
- Norcuron rationale: Helps to decrease spinal reflexes and relaxes the diaphragm and other respiratory muscles to help ventilate.
- If Norcuron is not available consider: Pavulon 0.05- 0.2 mg/kg IV (half-life is approx 110 min),Nimbex 0.15-0.2 mg/kg IV (half-life is 20-45 min)
- Albuterol 2.5 mg or 5 mg and 0.5 mg Atrovent Q 4 hours. In-line nebulizer is first choice, if unavailable use unit/dose puff. Do not break ventilator circuit if possible; use a spring loaded nebulizer adaptor. Rationale: Every time you break the circuit de-recruiting of the lungs takes place.
- .Observe for Sinus Tachycardia.
- Mucomyst nebulizer, 3-5cc of 20% solution or 10cc of 10% solution Q 4 hours. Use ONLY in conjunction with Albuterol, never alone. Use only if patient has thick secretions.
DIURETICS:
- Lasix 20-80 mg IV, Bumex 0.5-1 mg IVP
- Mannitol-Adult dose 300-400 mg/kg, usually given in conjunction with lasix
- Consider if PO2 is worsening and/or fluid balance is positive.
- Patient is hemodynamically stable ( minimal pressors) see Policy 5.6
VENTILATOR SETTINGS:
- Volume Ventilation (AC Mode)
- Suggested Tidal Volume (10-12cc/kg) ideal body weight. May go up to 15cc/kg.
- Ideal body weight calculations: Male:50 kg + 2.3 kg per in. >60 inches, Female:45 kg + 2.3 kg per in. > 60 inches
- Peak airway pressure should be kept < 35. (Reduce TV if > 35 or change to Pressure Control)
- Adjust A/C rate to deep PCO2 between 35-45 mmHg (as long as PH is 7.35-7.45)
- PEEP of +5-8 cm H2O
- FiO2 at 40%
- If ABGs are WNL, maintain current settings or increase volumes/and or rate to optimize donor management guidelines. I.E. PO2 > 300, P/F Ratio > 3. (P/F Ratio = maintenance FIO2 x 3).
- Slow flows to 40-50 lpm and/or increase inspiratory pause. RATIONALE: This decreases peak inspiratory pressure, minimizes “wasted ventilation” (time between exhalation and initiation of next breath), and increases mean airway pressure resulting in less trauma and increased oxygenation.
- All lung offers will be made on a PEEP of 5, according to UNOS Policy.
Pressure Control Ventilation
- Maintain peak airway pressures of less than 35 cm H2O.
- Adjust rate to keep PCO2 between 35-45 mmHg. (even if TV drops <10 cc/kg) and as long as PH is between 7.35-7.45
- PEEP +5-8 cm H2O
MANEUVERS TO IMPROVE LUNG FUNCTION:
- Alveolar Recruitment Maneuver- Place vent in CPAP for 30 sec @ 40 cm of H20
- Decrease peak flows to 40-50 lpm (slower inspirations) Rationale: Decreases lung damage and increase mean airway pressure which affects oxygenation.
- Alveolar Recruitment Maneuvers (ARM): CPAP 40 cm H20 for 30 Seconds
- Do every 20 minutes x 3.
- May be done at a lower pressure if vent is not able, or if the patient doesn’t tolerate 40 cm H20.
- In order to RE-RECRUIT alveoli, perform once every time the circuit is broken, or patient is suctioned.
- DO NOT PERFORM ARM IN THE PRESENCE OF: Severe Bronchospasm, Bullous emphysema, Untreated Pneumothorax, Unilateral Lung Disease (not suspected of being atelectasis), and Hemodynamic Instability.
- Use a PEEP valve when going to OR (set PEEP at +10 cm H20)
- Prone patient (If other treatments have failed and patient is hemodynamically stable)SJAA, WBRO, and Spectrum have proning beds available-contact resource manager
- Nitric Oxide @ 40 ppm may be indicated as salvage therapy to treat refractory hypoxia that may be due to high pulmonary vascular resistance. Contact resource manager.
ARTERIAL BLOOD GASES:
- Baseline ABG on settings listed above
- Follow with O2 challenge on 100% FiO2
- Repeat baseline ABG Q 4-6 hours
- Always treat PH, not CO2
- Repeat O2 challenge within 2 hours of procurement surgery and prn
- Treat Metabolic Acidosis with NaHCO3 unless Sodium is >140.
- If Sodium is greater than 140, use THAM (acid-base buffer without sodium). Consult Pharmacist for dosing. PT MUST BE MAKING URINE PRIOR TO USING THAM.
CHEST X-RAYS:
- Baseline CXR within 4 hours of consent
- Repeat CXR within 4 hours of procurement surgery
BRONCHOSCOPY:
- As soon as possible after consent and brain death
- Evaluate the endo-bronchial tree, right and left side, for lesions, signs of infection, and overall condition of the endo-bronchial tissue
- Obtain bronchial washings for culture and gram stain
- USE VERY LITTLE SALINE DURING BRONCH. (10cc may be used to clear plug)
BEDSIDE CARE:
- Chest PT Q 2-4 hours as indicated
- Q 1-2 hour tilting side to side- Rationale: Allows mobilization of secretions and opens atelectatic regions
- Q 2-4 hour ET Tube suctioning as indicated
- Place patient on specialty bed if possible. (Percussion and rotation)
- Oral care q 1-2 hours
- No ETT cuff leak-Ask RT to add 2-3 cc air to minimal occluding volume. Rationale: Reduces ventilator associated pneumonia
- HOB elevated at least 30 degrees- Rationale: Drops the diaphragm and reduces ventilator associated pneumonia and opens lungs.
- Deep glottic suctioning and oral care. Rationale: prevents aspiration.
HEMODYNAMICS:
- Transduced central line/swan for CVP/PAP/PCWP monitoring. (Thoracic not femoral for adequate readings)
- Maintain CVP 6-8 mmHg
- Maintain PAWP 8-12 mmHg
Page 1
Rev. 7/11/11
Attachment B
Page 1Rev. 7/11/11
Page 1
Rev. 7/11/11