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:

  1. Neosynephrine
  2. Epinephrine
  3. Levophed
  4. 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 / >360
Insulin / 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 change
70-79 / 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 or
Albuterol
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 1
Rev. 7/11/11
Page 1
Rev. 7/11/11