Organ Recovery Services
UNOS ID: / OPO ID#:
Donor name:
ORC name: / Phone/pager:
The following therapies or exams are requested to stabilize the potential donor and assess organ function. If the patient has not yet been declared dead, the orders must be reviewed and authorized by a physician. For any questions, please contact the DNA organ recovery coordinator.
Vital signs: Monitor vital signs hourly Monitor vital signs every 15 minutes
Vent settings:
Oxygen challenge: increase FiO2 to 100% and draw ABG after 30 minutes, then decrease FiO2 to 40% and draw repeat ABG after 30 minutes, then return to original vent settings.
Labs: CMP total bili Amylase Lipase
Magnesium CBC with differential UA PT PTT
Troponin CPK CK/MB
Cultures: Blood (x2 from fresh sticks) Urine Sputum (with stat gram stain)
Medications: Administer 8 mg/kg ciprofloxacin IV now and every 8 hours
Alternate antibiotic therapy:
Solumedrol: 30 mg/kg (maximum dose 2 gm) IV now and every 12 hours
Levothyroxine protocol: ______mcg/kg Levothyroxine IV bolus, then start Levothyroxine IV drip at ______mcg/kg/hr.
Narcan 8mg IV bolus
Albuterol via neb every four hours
Titrate Dopamine drip for MAP >60 mmhg
Administer 2 drops gentamycinopthalmic solution and 0.6cm Lacrilube (or other corneal lubricant) to each eye, tape eyes shut
IVF: D5W with 20 mEq KCl/Liter
Alternate IVF:
infusion rate:______
Consults: For the following items, consent must be completed prior to ordering
Request arterial line placement
Request central line placement Request PA catheter placement
Cardiology: request echocardiogram, indication: cardiac donor evaluation
Pulmonology: request fiber-optic bronchoscopy, indication: lung donor evaluation. Send bronchial washings from each lung for gram stain and culture
Authorizing ORC:______
Revised October 2009
DP-OR25.06 – PEDIATRIC ORGAN DONOR MANAGEMENTPage 1 of 1
Attachment I REV. 10/2010