Adult Organ Donor Order Set

Labs: (stat and q6h)

  • CBC with differential
  • BMP, Mg, Phos, Ca
  • Amylase, Lipase
  • Pregnancy test x1 on all females
  • hepatic panel, LDH, GGTP, direct bilirubin
  • PT/PTT, Fibrinogen
  • Cardiac panel with troponin
  • USG and serum osmolality
  • Blood CS x 1 now and q24h
  • urine CS x1 now and q24h
  • Sputum CS x1 now and q24h
  • sputum GS
  • Others:  A1C, type and screen x1
  • ABG now, then q6h and PRN

 

Respiratory:

  • AC, TV @8cc/Kg, +5 PEEP
  • APRV or PRVC if indicated
    • P high 5 cmH20 below patients plateau pressure not to exceed 30 cm H20
    • P low 0 cm H20
    • T high 4.4-5.4 secs
    • T low 0.6-0.8 secs
  • Recruit Manuevers
    • Switch to CPAP of 0 dial PEEP up to 30 cm H20, give 1 breath and hold x 30 seconds x2 q4h then ABG in 30 minutes
    • Pressure control ventilation with PIP 25 cm h20 and PEEP of 15 cm H20 x 2 hours then switch back to volume control ventilation followed by O2 challenge
    • O2 challenge on all potentail lung donors:  Increase FiO2 to 100% + PEEP 5 x 30 minutes, draw ABG, decraese FiO2 to 40% plus PEEP 5 x 30 minutes, draw ABG and return to original ventilator settings, Desired PaO2/FiO2 30 minutes post lung recruitment is 300 mm Hg or greater

Medications:

  • Zosyn 3.375 g now then q6h for prophylaxis
  • bronchodilator q4-6h
  • 10% mucomyst q4h and PRn for thick secretions
  • diflucan 400mg IV now and daily (if +yeast at any site)
  • levaquin 750mg IV stat then q24h if intubated .5d with GNR on GS
  • vancomycin 1g IV now then q12h if MRSA identified
  • artificial tears: 2 drops to B eyes q2h to maintain lubrication
  • replace K:
    • 3.6-4.0 = KCl 20mEq x1 over 1 hour
    • 3.0-3.5 = KCl 20mEq x2 over 2 hours
    • <3.0       = KCl 20mEq x3 over 3 hours
  • Magnesium sulfate 2g max IVPB over 1 hour for Mg <1.5
  • Calcium chloride 1g IVPB over 1 hour for corrected calcium <7.8 or less
  • consider ISS as per hospital protocol if glu >180

Fluids and Medication Drips:

  • Calculate water deficit
    • if hypernatremic, give D5W boluses over 12 hours
    • if no results noted in 12 hours, add 250-300cc free water per NGT
  • transfuse 1 unit pRBC if Hct < 20%
  • maintenance IV:  0.45% NaCl at 100ml/hr
  • inotropic medications to maintain SBP >100mmHg or MAP >60
    • dopamine 1-50 ug/kg/min
    • neosynephrine 40-180ug/min
    • levophed 0.5-12 ug/min
    • dobutamine 0.5-5 ug/kg/min

Hormonal Replacement:

  • levothyroxine 20ug IV bolus over 3 minutes then continuous infusion of 200 ug in 500NS at 25 ml/hr (10ug/hr) to stimulate cellular metabolism donor management; titrate to maintain SBP >100mm Hg or MAP >60 to max of 50ml/hr (20 ug/hr)
  • solumedrol (15mg/kg) in 100ml D5W over 15 minutes and q24h to stimulate cellular metabolism (max 1g/24h)
  • vasopressin:  initial bolus 1 u IV then continuous infusion 25 u in 250ml D5W to start at 5ml/hr (0.5 u/hr) and titrate to as high as 40ml (4u/hr) for DI

 

Other orders:

  • Stat EKG and PRN
  • echo after 6 hours of levothyroxine infusion
  • cardiology consults for Echo, EKG readings and cardiac cath if indicated
  • surgical consult for:
    • central venous access
    • PA catheter placement
    • arterial line placement
    • placement of dialysis catheter
  • pulmonary consult for bronchoscopy, lung evaluation stat, send specimen for GS/CS (no bronchial alveolar lavage)

Radiologic Testing:

  • stat portabls CXR for line placement and status of heart and lungs, for lung donors, repeat CXR daily adn 3h before allocation adn PRN
  • bedside liver biopsy if indicated
  • full body CT scan or thoracic / abd / pelvic
  • abdominal ultrasound
  • cardiac cath
  • echocardiogram on all potential thoracic donors

Nursing:

  • Strict VS CVP I and O and O2 sats q1h
  • NGT / OGT to low intermittent suction
  • PA wedge pressure, CO, CI, SVR q1h when available
  • chest percussion q2h
  • HOB 30deg
  • normothermia within 36-37.5C with heating/cooling devices
  • suction q1h and turn q2h

 

Reference:

*adapted from LiveOnNY Adult Organ Donor Set

 

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