Gift of Life Michigan
Donor Management Guidelines
Donor Management Goal #1: Lung Recruitment
Follow Pulmonary Management Guidelines (age 15 to 60): Attachment A including
but not limited to:
 Medications
o Narcan in conjunction with Norcuron
o Norcuron prn for peak pressures >30 cm H2O
o Albuterol and Atrovent via nebulizer or unit dose
o Mucomyst nebulizer in conjunction with Albuterol for thick secretions
o Solu-medrol
 Testing and Therapies
o Chest x-ray
o Bronchoscopy as soon as possible after brain death and consent
o ABG’s baseline and on 100% q 4 hours
o Bedside care including chest percussion therapy, turning, elevated HOB,
etc (see Attachment A).
o 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:
< 6 months
---<10 kg
---10-20 kg
--->20 kg to age 15
---15 and older
<148
IV Fluid:
IV should contain D10%
D5/ 0.2 NS/ 20 mEq/L KCl
D5/ 0.3 NS/ 20 mEq/L KCl
D5/ 0.45 NS/ 20 mEq/KCl
D5W/0.45 NS, NS, LR, (can add KCl as needed)
15 and older
D5W, 0.45NS, (can add KCl as needed)
>148
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
100 mL/hr adjusted to patient status and condition
older)
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Hypovolemia: CVP < 6; PAWP <8
 Bleeding/Coagulopathy:
o Hematocrit < 30% or Hemoglobin <10 g/dL: Packed Red Blood Cells
o PT >15 or INR > 1.5: Fresh Frozen Plasma
o Platelets <100,000: Platelets
o Fibrinogen <2.9 : Cryoprecipitate
o 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 crossclamp 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:
o Adults: Fluid bolus
o 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
o Manage electrolyte imbalances
o Replace fluid loss as needed
o 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:
o Creatinine Clearance:
volume of urine

Urine Creatinine x min. of collection X 1.73

Serum Creatinine
BSA
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
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

If CVP <6: consider treatment for hypovolemia
Add pressors in the following order:
o Dopamine < 10 mcg/kg/min (consider tachycardia when starting)
o Levophed
o 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:
o Diltiazem or cardioversion
 Lethal arrhythmias:
o 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:
o If Sodium is less than 140: Sodium Bicarbonate
o If Sodium is greater than 140 and donor is making urine: Tromethamine
(THAM)
o If Sodium and Chloride are elevated and K is low or normal, consider
using Potassium Acetate.
Donor Management Goal #5: Final 100% FiO2 ABG= PO2 >300 or P/F
ratio >3
Ventilator Settings:
 Volume Ventilation
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o Tidal Volume 10-12 mL/kg of Ideal Body Weight
o Adjust rate for pH 7.35-7.45
o PEEP 5 cm H2O


Pressure Ventilation
o Consider if peak airway pressure is greater than 35 mm H2O
o Adjust rate for pH 7.35-7.45
o PEEP 5 cm H2O
Other setting changes to decrease peak pressure and minimize wasted
ventilation:
o Flow-decrease to 40-50 Liters/min
o 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
o Adults: 200-400 mL every 4 hours
o 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:
o D50 1 amp
o Regular Insulin 15 units
o Sodium Bicarbonate 1 amp
o 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.
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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
Low Phosphorus
Metabolic Acidosis/
Phosphorus
Hyperchloremia
Pediatric
KCl 0.5-1 mEq/kg
KPhos 0.1-0.3
Kacetate 1-4
over 2 hours
mmol/kg over 4-6
mEq/kg in 24
hours
hours
Adult
KCl 20-60 mEq at 20 KPhos 10-15 mmol K actetate 40 mEq
mEq an hour
over 4-6 hours
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
8 units IVP
10 units IVP
4-5 units/hr
5-6 units/hr
6-8 units/hr
Adjust According to Blood Glucose Levels every 1-2 hours
Current Infusion: Current Infusion: Current Infusion:
Glucose
1-5 units/hr
6-10 units/hr
11-16 units/hr
111-140
Increase by 0-1 Increase by 0-2 Increase by 0-3
unit/hr
unit/hr
unit/hr
141-180
Increase by 1-2 Increase by 1-3 Increase by 3-5
unit/hr
unit/hr
unit/hr
181-240
Increase by 1-2 Increase by 1-3 Increase by 4-6
unit/hr
unit/hr
unit/hr
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Current Infusion:
>16 units/hr
Call MM
Call MM
Call MM
240-300
301-360
>360
3 units IVP
Increase by 2-3
unit/hr
4 units IVP
Increase by 2-4
unit/hr
5 units IVP
Increase by 2-4
unit/hr
5 units IVP
Increase by 3-5
unit/hr
7 units IVP
Increase by 3-5
unit/hr
9 units IVP
Increase by 4-6
unit/hr
6 units IVP
Increase by 4-6
unit/hr
8 units IVP
Increase by 4-6
unit/hr
10 units IVP
Increase by 5-7
unit/hr
Call MM
Call MM
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.*
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Gift of Life Michigan Medication List
Medication
Albuterol
Adult Dose
Pediatric Dose <40kg or <16
years or
1.25-5 mg Q4 hours
2.5-5 mg Q4 hours
Nebulizer or unit dose
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
Argatroban
350 mcg/kg IV over 15 min
prior to cross-clamp
0.5 mg, typically given with
Albuterol
0.5-1 gram IV
0.5-1 gram IV
600 mg Q8 hours IV
50-100 mg/kg/day IV split into 3
doses every 8 hours
350 mcg/kg IV over 15 min prior
to cross-clamp
0.25, typically give with Albuterol
Atrovent
Nebulizer or unit dose
Calcium Chloride
Calcium Gluconate
Clindamycin
Desmopressin
(DDAVP)
Diltiazem
(Cardizem)
Dobutamine
*consult MM
Dopamine
Epinephrine
Furosemide (Lasix)
Glucose 25%
(D50)
Hydrocortisone
(Solu-Cortef)
Hydralazine
(Apresoline)
Insulin- regular
Lidocaine
Levothyroxine
4-8 mcg/day IV in 2 divided
doses
0.25 mg/kg IV bolus then 10-15
mg/hr
3-20 mcg/kg/min IV
10 mg/kg IV
100 mg/kg IV
25-50 mg/kg/day IV split into 4
doses every 6 hours
2-4 mcg/day IV in 2 divided
doses
0.25 mg/kg IV over 2 min then
5-15 mg/hr
3-20 mcg/kg/min IV
3-20 mcg/kg/min IV
1-4 mcg/min IV
20-120 mg IV
1 amp (25 grams)
3-20 mcg/kg/min IV
0.05-0.3 mcg/kg/min IV
0.5-1 mg/kg IV
1-2 mL/kg IV
15 mg/kg Q6 hours
6 mg/kg IV Q6 hours
5-10 mg IV q 10-15 min
(max of 10-15 mg Q4-6 hours
2-10 units/hr IV can be titrated
higher to maintain blood
glucose 70-200.
50-100 mg IV bolus; then 10-20
mcg/kg/min
20 mcg bolus; then 10-20
0.1-0.2 mg/kg/dose IV q 4-6
hours up to 1.7-3.5 mg/kg/day
0.05-0.2 unit/kg/hr IV, titrated for
blood glucose 70-200.
1 mg/kg bolus IV; repeat in 15
min x2 then 20-50 mcg/kg/min
Refer to Policy 5-09
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Magnesium Sulfate
mcg/hr
1-2 grams IV
Mannitol
50-200 gm/24 hours IV in
divided doses
Methylprednisolone 15 mg/kg Q6 hours
(Solu-Medrol)
Mucomyst
3-5 mL of 20% solution or
*Nebulizer only given
10 cc of 10% solution Q4 hours
when combined with
Albuterol
Mucomyst
*as needed to
25-50 mg/kg/dose IV diluted to
20% solution
0.25-0.5 g/kg IV every 4-6 hours
6 mg/kg Q6 hours
3-5 mL of 20% solution or
10 cc of 10% solution Q4 hours
600 mg PO pre-procedure
-------------------------------------------
minimize contrast
related renal toxicity
Narcan
*follow dose
8 mg IVP
Not commonly given
immediately with
Norcuron
Nicardipine
Nitroprusside
(Nipride)
Norcuron
(Vecuronium)
Norepinephrine
(Levophed)
Potassium Acetate
Potassium Chloride
Potassium
Phosphate
Primacor
(Milrinone)
*Consult MM
Saline 3%
Sodium
Bicarbonate
THAM
(Tromethamine
Vasopressin
5-15 mg/hr until desired BP
reached, then maintenance of
3 mg/hr
0.3-10 mcg/kg/min IV
10 mg IVP
-----------------------------------------0.5-8 mcg/kg/min IV
0.08-0.1 mg/kg IV; then 0.05-0.1
mcg/kg/min maintenance
0.05-0.3 mcg/kg/min IV
Initially 0.5-12 mcg/min
20-60 mEq
40 mEq/L IV
10-15 mmol IV
50 mcg/kg IV over 10 min
0.375-0.75 mcg/kg/min
Mixed with 0.45 or 0.9 NS
40 mL/hr for 3 hours
1 amp or 50 mEq IV
Base deficit x kg x 1.1= amount
in mL of 0.3 molar solution
0.008-0.67 units/min
1-4 mEq/kg in 24 hours
0.5-0.1 mEq/kg over 2 hours
0.08-0.36 mmol/kg/dose over 46 hours
50 mcg/kg IV over 10 min
0.375-0.75 mcg/kg/min
Mixed with 0.45 or 0.9 NS
5 mL/kg IV to raise Na by 4
mEq/L
1 mEq/kg/dose of 0.3 molar
solution over 20-30 minutes
1mL/kg for each pH unit below
7.4
0.5-10 miliunits/kg/hr
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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 0.150.2 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)
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



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
o Do every 20 minutes x 3.
o May be done at a lower pressure if vent is not able, or if the patient doesn’t tolerate 40 cm H20.
o In order to RE-RECRUIT alveoli, perform once every time the circuit is broken, or patient is
suctioned.
o 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
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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
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Cardiac Donor
Management
Guidelines
Attachment B
Obtain urine drug screen test
if not previously done &
patient admitted less than 36
Hormonal Therapy
Regimen per
protocol
Place Pulmonary Artery Catheter
Patient with history of smoking, drug
abuse, HTN, cardiac disease, on more
than 1 inotrope or requested by TC
Goals: MAP > 60 mm Hg
PCWP 8-12 mm Hg
CVP 6-10 mm Hg
C.I. > 2.5-3.5L/min-m2
Dopamine
< 10 mcg/kg/min
as indicated
Hemodynamic
Management
Vasopressin
0.5-4 units/hr
Pressors should be weaned in this
order:
Primacor < 0.75 mcg/kg/min
Neosynephrine < 0.5 mcg/kg/min
Epinephrine < 0.05 mcg/kg/min
Levophed < 0.05 mcg/kg/min
Dopamine < 5 mcg/kg/min
Dobutamine < 5 mcg/kg/min
as indicated
Only Use Dobutamine w ith MM input
Minimum: Adults patients
Central line with CVP monitoring
(thoracic pref erred, f emoral f or
trends)
Obtain Initial Echo
r/o structural abnormalities
(substantial LVH, valvular
dysf unction, congenital lesions
Obtain echo at lowest doses of
inotropes and as long as time
permits.
LVEF > 45%
LVEF < 45%
Continue
Hemodynamic Management
Continue
Hemodynamic Management
Repeat echo warranted if
cardiovascular
improvement
If no improvement
contact RM/MM
Solumedrol
Adults: 15mg/kg
Peds: 6mg/kg
Using Dopamine/Nipride conjunctively and/or
to increase C.O. & decrease PAWP
Heart Catheterization
Considerations:
Males > 40, Females >45, Center Request,
Cocaine Usage, Smoking History. Always get
right & left sided catheterization & float
SWAN or maintain SWAN
May get approval from resource manager if pt
meets above and cardiologist is in hospital
ready to do cath ASAP.
Approval by RM/MM
Proceed with
Thoracic Offers
* NOTE: All Pressors/Ionotropes can cause significant hypotension or hypertension. Evaluate patient's
hematocrit, ionized calcium, & volume status prior to administering. Loading doses are not alw ays recommended.
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