ORS033C
08-23-2010/Rev. 11
ORS
Organ Recovery Services
Clinical Procedure
Title: : Guidelines for Evaluation and Clinical Management of Pediatric Brain Dead Organ Donors (weight < 40 kg and/or < 10
years of age)
Associated Departments: Medical Director
Release Date: 08/23/2010
Approver: Alison Smith
Revision History
Revision Date
Revision
Description of Change
Author
08/23/2010
11
Update blood sample to be drawn
Michelle Mabry
03/15/2010
10
Updated General Evaluation Section and Kidney Specific Evaluation
Evelyn Schultz
12/15/08
4/10/2006
9
8
Update template
Add CMV status
Evelyn Schultz
Martin Mozes, M.D.
9/6/2005
7
Clarify antibiotics
Martin Mozes, M.D.
5/26/2004
6
Change approver
Martin Mozes, M.D.
11/21/2003
5
Change Weigh to Weight
Alison Smith
6/9/2003
4
Revision to content
Alison Smith
7/10/2002
3
Name Change
Alison Smith
3/20/2002
2
Conversion to ISO format
Alison Smith
10/1/1999
1
Document Created
Alison Smith
Definitions and Acronyms
ABG
ABO
ALB
ALK Phos
ALT
AST
BP
BUN
Ca+
Cl
CMV
CPK
CVP
CXR
DDAVP
EKG
FiO2
GGT
H&H
HLA
K+
KOH
MB%
MG
Na+
NG
PA
Arterial blood gas
Classification system for human blood that identifies four major blood types based on the presence or
absence of two antigens, A and B, on red blood cells.
A blood test that measures the amount of the enzyme ALP alkaline phosphatase. When it is present in
large amounts, it may signify bone or liver disease or a tumor.
alanine aminotransferase.
aspartate transaminase - an enzyme normally present in body tissues, especially in the heart and liver; it is
released into the serum as the result of tissue injury, hence the concentration in the serum (SGOT) may
be increased in disorders such as myocardial infarction or acute damage to hepatic cells.
Blood Pressure
Blood urea nitrogen - A waste product that is formed in the liver and collects in the bloodstream.
Calcium
Chlorine
Cytomegalovirus
A blood test that measures creatine phosphokinase (CPK), an enzyme found mainly in the heart, brain,
and skeletal muscle.
Central venous pressure
Chest x-ray
Desmopressin Acetate
Electrocardiogram (ECG / EKG) is an electrical recording of the heart
Fraction of Inspired Oxygen
Gammaglutamyltransferase
Hemoglobin & hematocrit
Human Leukocyte Antigen
Potassium
Potassium hydroxide preparation
myoglobin
Magnesium
Sodium
Nasal gastric
Pulmonary Artery
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Organ Recovery Services
Clinical Procedure
PAWP
PCN Allergy
pCO2
PEEP
PO4
PRBC
SaO2
SGPT
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08-23-2010/Rev. 11
ORS
pulmonary artery wedge pressure (PAWP), pulmonary capillary wedge pressure (PCWP) intravascular
pressure as measured by a catheter wedged into the distal pulmonary artery ; used to measure indirectly
the mean left atrial pressure
Penicillin Allergy
Partial Pressure of Carbon Dioxide
positive end-expiratory pressure a method of mechanical ventilation in which pressure is maintained to
increase the volume of gas left in the lungs at the end of exhalation, reducing shunting of blood through
the lungs and improving gas exchange.
Phosphorus
Packed Red Blood Cells
Saturation of Oxygen
Serum pyruvate aminotransferase; an enzyme in serum and body tissues that catalyzes the transfer of
amino acid groups from L-alanine to 2-ketoglutarate or the reverse, thus allowing nitrogen to be excreted
or incorporated into other compounds, used to measure liver function.
Required Documents and Tools - Criteria: The items listed in this section are required to be used or followed in executing this
procedure. Each item either captures or provides essential information to ensure the quality and consistency of the work being done.
Documents of external origin must include the revision status in the Title field.
Title
Control
Location
References and Optional Tools - Criteria: The items listed in this section are not required but may be used or followed in executing
this procedure. Each item assists or provides relevant information with regard to the work being done. Documents of external origin must
include the revision status in the Title field.
Title
Control
Location
Scope / Purpose
Gift of Hope establish guidelines for the consistent evaluation and clinical management of pediatric brain dead organ donors, thereby
maximizing the number of organs procured and transplanted. The following describe the guidelines for the evaluation and clinical
management of pediatric brain dead organ donors.
Responsibilities
Organ Recovery Coordinators and
Organ and Tissue Surgical Technicians
Surgical Coordinator
Required Skills
Communication Skills
Assessment Skills
Documentation Skills
Blunt Dissection Skills
Identification of Laboratory and Hemodynamic abnormalities
Ability to treat Laboratory and Hemodynamic abnormalities
Flowchart
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Organ Recovery Services
Clinical Procedure
ORS033C
08-23-2010/Rev. 11
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Instructions
A.
GENERAL EVALUATION (minimum requirements)
1. History of current injury and medical treatment
2. Past medical and social history
3. Serology testing (pre-transfusion samples, if available)(1 red top tube, 1 lavender top tube)
4. ABO typing with sub-typing of ABO (A) donors
5. HLA cross-matching- obtain lymph nodes on donors >30 kg. Send 3 ACD yellow tops on all brain dead and DCD donors, If less
than 30 kg confer with the Gift of Hope laboratory supervisor to determine amount of blood needed.
6. Current physical examination
7. CXR on all donors, interpreted by a radiologist
8. Continuous arterial pressure monitoring (may not be available with infants)
9. CVP monitoring
10. HgB A1C to be obtained on all donors
11. ABG, H&H, serum electrolytes every six hours during management
12. Documentation of hourly intake and output, CVP pressures, SaO2, systolic and diastolic BP, and dosage of any vasoactive
medications, from the time of initiation of management
13. Documentation of core temperature every hour
14. Documentation of significant hypotension (for age), estimated frequency and length of episodes of cardiorespiratory arrest, any
episodes of defibrillation
15. Two blood cultures from different sites and urine culture
16. sputum cultures on all prospective lung donors
17. Ureter Tip Cultures to be obtained intra-operatively on any donor with documented bacteria in the urinalysis.
18. Organ specific information for kidney, liver, and small bowel on all donors with consent for these organs; heart and lung evaluation
on all donors, pancreas specific evaluation on all donors <90 lbs.
B.
KIDNEY SPECIFIC EVALUATION (minimum requirements)
1. Urinalysis with micro at time of admission if available, or at the initiation of management
2. Urinalysis within 24 hours of cross clamp
3. BUN and creatinine at time of admission if available, peak values, and last values obtained prior to organ recovery
C.
PANCREAS SPECIFIC EVALUATION (minimum requirements)
1. Amylase at time of admission and/or initiation of clinical management
2. Lipase at initiation of management
3. Admit blood glucose and check values every six hours after initiation of management
D.
LIVER SPECIFIC EVALUATION (minimum requirements)
1. AST (SGOT), ALT (SGPT), Alk Phos, Bilirubin (total and direct), GGT and Alb at time of admission if available, and initiation of
clinical management (within six hours of organ offer)
E.
HEART SPECIFIC EVALUATION
1. EKG within 12 hours of organ offer (interpreted by a cardiologist)
2. Echocardiogram within 12 hours of organ offer (interpreted by cardiologist)
3. CPK (total and MB%) within 12 hours of organ offer
4. ABG
F.
LUNG SPECIFIC EVALUATION (minimum requirements)
1. CXR within three hours of organ offer (interpreted)
2. Measurement of length of right lung, length of left lung, width of aortic knob, width at diaphragm (in centimeters)
3. ABG on 1.00 FiO2 and PEEP 5 cm H2O for fifteen minutes, then FiO2 decreased to 40% for fifteen minutes and repeat ABG, within
two hours of organ offer
4. Gram stain upon initiation of case.
G. INTESTINE EVALUATION
1. CMV status
2. Documentation of down time, acidosis and hypoxia
3. Documentation of prolonged vasopressor use
H.
OPTIONAL EVALUATIONS (pending specific circumstances of donor)
1. Bronchoscopy (therapeutic or diagnostic)
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Organ Recovery Services
Clinical Procedure
2.
3.
4.
5.
Transesophageal echocardiography
Organ specific evaluation of heart and lungs on all pediatric donors, pancreas on donors greater than 6 years old or > 25 kg.
Ultrasound for suspected pathologies (kidney stones, polycystic disease)
Hemodynamic monitoring by Swan Ganz or CVP
CLINICAL MANAGEMENT
A.
ORGAN PERFUSION
1.
Goals
a. Optimum Hemodynamic parameters as indicated below
b. Urinary output: < 2 years – 2 cc/kg/hr
> 2 years – 1 cc/kg/hr
c. CVP 4-8 mmHg
d. PAWP (if already available) 5-15 mmHg
AGE
Newborn – 1 year
1 year – 10 years
> 10 years
SYSTOLIC (mmHg)
65-110
80-120
manage as small adult
HEART RATE
120-180
80-140
RESP RATE
30-40
20-30
2.
Assessment
a. Continuous arterial pressure monitoring
b. Continuous EKG monitoring
c. Hourly CVP recordings (or PA recordings if available, with PAWP readings every two hours)
d. Hourly urine output measurements
e. Urine specific gravity evaluation upon initiation of donor management and every four hours as needed
3.
Intervention
a. Hypotension (Systolic BP <60 mmHg in newborn – 1year, <70 mmHg 1 year – 10 years)
i.
ii.
iii.
iv.
Initial treatment: depending on serum sodium level, administer normal saline boluses of 20-30 cc/kg over 15 minutes,
may repeat once. If remains hypotensive, administer vasoactive medications (see below)
After second fluid bolus above, for SBP <60, initiate Dopamine infusion. Start infusion at 3-5 mcgs/kg/min and titrate to
clinical effect or maximum of 20 mcgs/kg/min.
If Hypotension persists with CVP > 5 after fluids and Dopamine infusion at 20 mcgs/kg/min, administer Neo-synephrine
infusion at 0.1 mcg/kg/min and titrate as needed to 0.5 mcg/kg/min. Alternatively, Epinephrine may be used at an
infusion rate of 0.05 mcg/kg/min with titration up to 1.0 mcg/kg/min.
In cases of suspected or known impaired cardiac output, initiate Dobutamine infusion if SBP continues below parameters
after maximum Dopamine infusion. Begin infusion at 2-2.5 mcg/kg/min and titrate for clinical effect to maximum of 20
mcgs/kg/min. (Clinical effects may not be fully seen until 30 minutes, initial drop in BP is normal.) Terminate infusion if
clinically significant tachycardias occur. When administering Dobutamine in conjunction with Dopamine wean the
Dopamine infusion FIRST. Begin weaning of Dobutamine when Dopamine dosage is less than 5 mcgs/kg/min.
CLINICAL CONDITION
Anemia/Acute Hemorrhage
Coagulopathy/Acute Hemorrhage
Hypotension without acute
hemorrhage
Hypotension
b.
PREFERRED COLLOID
PRBC’s
(CMV negative blood will be
administered if pt’s CMV status is
negative or unknown)
FFP
Hespan
(Do not use for < 6 years old)
5% Albumin
COMMENTS
10-15 cc/kg
10 – 15 cc/kg
Max total dose of 20 cc/kg
20 cc/kg bolus
Supraventricular Tachycardia
i. Adenosine 0.1 mg/kg (max 6mg) as iv fast bolus within 2 seconds, if no effect in two minutes, a second bolus dose of 0.2
mg/kg (max 12 mg) can be administered. If no effect, contact Managing Physician or Medical Director for further
direction.
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Organ Recovery Services
Clinical Procedure
c.
B.
Other Cardiac Arrhythmias
i. Treat cardiac arrhythmias per American Heart Association PALS protocol (excluding Atropine for bradycardia)
FLUID BALANCE AND ELECTROLYTES
1.
Goals
a. Serum Na+, K+, Cl-, will be within normal values
b. Urinary output of 1-2 cc/kg/hr
c. Blood glucose level 60-120 mg/dl
d. Serum Ca+, Mg and PO4 will be within normal values
2.
Assessment
a. Blood electrolyte panels every six hours (or as indicated)
b. Strict hourly intake and output
c. Serum Ca+, Mg and PO4 at initiation of clinical management
3.
Interventions
a. IV fluids
i. Administer maintenance fluids to maintain urinary output of 1-2 cc/kg/hr. (Use the table below to select fluid type.)
SERUM SODIUM
Less than 130
131-140
141-160
161 or greater
FLUID TYPE
consult managing surgeon
D5% ½ NS
D5% ¼ NS
D5% W
Maintenance Rate:
<10 kg – 4cc/kg/hr
10-20 kg – 4cc/kg/hr +2cc/kg/hr for every kg over 10kgs (e.g. 15kg = 40cc+(2x5) = 50cc/kg/hr)
>20kg – 60cc + 1 cc/kg/hr (e.g. 30kg = 60 +10 = 70cc/kg/hr)
b.
Hypokalemia
i. Administer KCL (adjust in cases of oliguria or polyuria)
SERUM POTASSIUM
Greater than 5.0
4.0 – 5.0
3.0 – 4.0
Less than 3.0
Less than 2.5
ADD KCL PER LITRE
None
20 mEq/liter
40 mEq/liter
60 mEq/liter
Consult with Peds ICU Staff
KCL BOLUS
None
None
0.5 mEq/kg dose over 1-2 hours*
0.5 mEq/kg dose over 1 hr x 2 doses*
*Serum Potassium needs to be rechecked after each bolus dose.
c.
Fluid Balance
i. Administer DDAVP if urinary output greater than 6 cc/kg/hr X 2 hours, and urinary specific gravity is 1.005 or less.
Administer 0.05 – 0.1 mcgs/kg IV push. (May repeat dose at 0.2 mcgs/kg after 2 hours if inadequate response). Do not
administer within 4 hours of OR.
ii. If DDAVP not effective after 1 –2 hours, use Vasopressin as IV infusion of 0.5 miliunits/kg/hr. Double the dose every 30
minutes to max at 10 miliunits (0.01 units)/kg/hr.
iii. Administer Lasix 1 mg/kg IV push if urinary output less than 1 cc/kg/hr provided SBP >80 and CVP >5 (PAOP > 15).
Repeat at 2mg/kg after 1 hour if response inadequate. Repeat as necessary dependent on urine output. If no response
to a dose of 2mm/kg consult Managing Physician. Maximum daily dose = 6mg/kg/day.
iv. Lasix may be combined with 25% Mannitol IV infusion 1-2 cc/kg, provided CVP is >10 mmHg.
d.
Glucose
i. Administer regular insulin 0.1 unit/kg IV or 0.2 units/kg SQ for glucose > 300 mg/dl. Remove all dextrose containing
solutions from IVF administered. Repeat glucose level 30 minutes after insulin. Repeat same dose if glucose remains >
300 mg/dl. If after second dose glucose remains > 300 mg/dl, initiate insulin infusions at 0.05 – 0.1 units/kg/hr and titrate
based on hourly glucose levels.
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Organ Recovery Services
Clinical Procedure
C.
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08-23-2010/Rev. 11
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e.
Hypocalcemia
i. Administer Calcium Chloride 10mg/kg (0.2 cc/kg of 10% solution) IV slowly, no faster than 100 mg/min to avoid
bradycardia, if ionized calcium < 1.0 or total calcium < 8.5 mEq/liter. Evaluate serum calcium at initiation of management,
and if greater than 4 units of PRBCs (approximately 25 ml/kg) have been infused.
f.
Hypomagnemia
i. Consult Managing Physician or Medical Director. Consider administration of magsulfate 25-50 mg/kg.
HEMATOLOGY
1. Goals
a.
b.
c.
Hgb greater than 10 GMs/dl and Hct greater than 20%
Platelet count between 20,000 and 400,000
PT less than 1.5 times control value
2. Assessment
a.
b.
CBC with platelet count at initiation of management
PT/PTT at initiation of management
3. Interventions
a.
Administer PRBCs (obtain serology and HLA lab samples prior to infusion and request CMV negative blood if CMV status in
unknown or negative). Use warming unit if available (blood warmer is critical in pediatrics, hypothermia, and multiple
transfusions)
HEMATOCRIT
Greater than 25%
20-25%
Less than 20%
b.
c.
d.
e.
D.
NUMBER OF UNITS INFUSED
None
As needed to keep Hct>25%
Consult with Medical Director
Type and crossmatch two pediatric units PRBCs (keep 2 units on hold)
PRBCs 10 cc/kg will raise Hct 5%. May use “Pedi Paks” or “Quad Packs.” These are approximately ¼ of adult unit—be sure
to document cc’s administered.
Administer FFP 10-15 cc/kg infused as a single dose, only in cases of active hemorrhage, when the PT is greater than 2 times
the control value, and when the platelet count has decreased by 50% (consider acidosis and hypothermia)
Administer Platelets 1 unit/kg (will raise count by 50,000) for platelet count less than 20,000 (consult with Medical Director, if
available)
OXYGENATION AND VENTILATION
1.
Goals
a. Continuous SaO2 greater than 95%
b. PaO2 90-110 torr
c. pH 7.35-7.45
d. pCO2 35-45 torr
2.
Assessment
a. Continuous SO2 oxymetry monitoring
b. ABG every six hours (every four hours if possible lung donor) and 30 minutes after each ventilator adjustment
c. Peak inspiratory pressures with ABG if possible lung donor
d. CXR on initiation of management (and every four hours if possible lung donor)
3.
Interventions
a. Ventilation – In general, pressure limited time cycled ventilation (30/5 peak pr/peep) is used for infants and children < 10 kg in
weight and volume cycled ventilation is used for children weighting > 10 kg.
i. Adjust tidal volume to 6-12 cc/kg. Tidal volumes should be set at the highest possible range while maintaining peak
inspiratory pressures less than 30-35 cm.
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Organ Recovery Services
Clinical Procedure
ii.
iii.
E.
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08-23-2010/Rev. 11
ORS
Adjust rate to achieve minute ventilation to keep pCO2 35-45 torr.
Adjust peak flow rates between 30-70 liter/minute to achieve an I:E ratio of 1:2 – 1:4
b.
Oxygenation
i. Administer 2.5 cm PEEP. Increase in increments of 2 cm to maximum of 10 cm in cases of refractory hypoxemia as
needed.
ii. Adjust FiO2 to LOWEST possible percentage to achieve PaO2 of 90-110 torr
iii. TURN BAG AND SUCTION A MINIMUM OF EVERY TWO HOURS
iv. Administer Dexamethasone (Decadron) 3 mg 1 kg IV over 30 minutes (after HLA lab samples are obtained, if possible).
Administer drug as soon as possible after lab samples have been collected.
v. Where indicated for bronchial toilet, consider therapeutic bronchoscopy of donors with an O 2 challenge PaO2 > than 200300 toss with recent (less than 24 hours) evidence of aspiration
vi. If possible, obtain re-intubation with larger tube if ETT is less than optimal size (check with ICU attending)
vii. Uncuffed ETT is used in children < 8 years since a narrow pediatric cricoid cartilage acts as a functional cuff.
c.
Acidosis
i. Adjust tidal volume and ventilation rate (see previous section) to maintain pCO2 between 35-45 torr. After adjusting
minute ventilation, administer NaHCO3 1 mEq/kg over 15 minutes for pH less than 7.25 or BE less than 6.0. Repeat
ABGs within 30 minutes and reevaluate.
d.
Alkalosis
i. Adjust minute ventilation to keep pCO2 35-45 torr.
TEMPERATURE
1.
Goals
a. Core temperature of 36-37.5 degrees C (REMEMBER, the brain death declaration requires a minimum temp of 32.2 degrees C)
2.
Assessment
a. Monitor core temp every two hours
3.
Interventions
a. Hypothermia
i. Apply external warming blankets, or heating devices
ii. Adjust inspired air temperatures on ventilator circuit between 32-36 degrees
iii. Administer all fluids and/or blood products via warming device
iv. Cover infants heads to avoid ambient heat loss
v. Perform warmed NG lavage if temperature is less than 34 degrees C
A. INFECTION
1.
Goals
a. Treatment of existing infections
b. Prevention and treatment of common nosocomial infections
2.
Assessment
a. Blood, urine and sputum cultures obtained at initiation of clinical management (if donor has been hospitalized greater than 72
hours)
b. Sputum gram stain and KOH (on all possible lung donors)
3.
Interventions
a. Antibiotics (dose based on weight for pediatric donors)
i. All donors – Cefazolin 50mg/kg IV every 8 hours.
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ORS033C
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Organ Recovery Services
Clinical Procedure
ii.
iii.
All potential lung donors: Clindamycin 15-40 mg/kg IV every 6 hours. IV and Ceftazidime* 30-50 mg/kg IV every 8 hrs*
after sputum culture is obtained. Administer Aztreonam IV every 6 hours in cases with PCN allergy. Maximum dose is
120 mg/kg/day.
* Ceftazidime is excreted by the kidneys and dosage needs to be lowered with renal failure to 10 mg/kg every 8 hours.
Non-thoracic organ donors—Cefazolin 50 mg/kg IV every 8 hours.
* Ceftazidime is excreted by the kidneys and dosage needs to be lowered with renal failure to 10 mg/kg every 8 hours.
This policy was reviewed by the Advisory Council- November 2009
Key Metrics
Records
Record Title
Record Holder
Retention Requirement
Record Location
Standards
Standard
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