
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
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 H
2
O 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
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
10-20 kg
----
----
D5/ 0.2 NS/ 20 mEq/L KCl
D5/ 0.3 NS/ 20 mEq/L KCl
>20 kg to age 15
15 and older
----
<148
D5/ 0.45 NS/ 20 mEq/KCl
D5W/0.45 NS, NS, LR, (can add KCl as needed)
D5W, 0.45NS, (can add KCl as needed) 15 and older >148
Hourly Maintenance Amounts:
Adjust rate on a case by case basis based on fluid balance status
Size: Calculation:
<10 kg
10-20 kg
>20 kg
100 mL/kg/24hours
(1000 mL + 50 mL/kg for each kg >10)/24 hours
(1500 mL + 20 mL/kg for each kg >20)/24 hours
Adults (15 and 100 mL/hr adjusted to patient status and condition
Page 1
Rev. 7/11/11

older)
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
Age:
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
PRBC’s
FFP Platelets Cryo
Pediatric 10-15 mL/kg 10-15mL/kg 10-20 mL/kg 5-10 mL/kg
Adult

Dehydration:
1-2 units o Adults: Fluid bolus
4 units 5 units 6 units 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
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
Page 2
Rev. 7/11/11

Hypotension: MAP <60, CVP >6

Initiate T4 therapy

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.
Baseline ABG and repeat every 4-6 hours
Always treat pH, not CO
2

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.
Page 3
Rev. 7/11/11

2
2
Ventilator Settings:

Volume Ventilation o Tidal Volume 10-12 mL/kg of Ideal Body Weight o Adjust rate for pH 7.35-7.45 o PEEP 5 cm H
2
O

Pressure Ventilation o Consider if peak airway pressure is greater than 35 mm H
2
O o Adjust rate for pH 7.35-7.45 o PEEP 5 cm H
2
O

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 FiO
2
and PEEP (maximum 10 cm H
2
O)

Diuretics, avoid Colloids

Consider proning
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.
Page 4
Rev. 7/11/11

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
Adult
KCl 0.5-1 mEq/kg over 2 hours
KCl 20-60 mEq at 20 mEq an hour
KPhos 0.1-0.3 mmol/kg over 4-6 hours
KPhos 10-15 mmol over 4-6 hours
Kacetate 1-4 mEq/kg in 24 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
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
10 units IVP
6-8 units/hr
Current Infusion:
>16 units/hr
111-140 Call MM
141-180
181-240
240-300
301-360
>360
Increase by 0-1 unit/hr
Increase by 1-2 unit/hr
Increase by 1-2 unit/hr
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
Increase by 0-2 unit/hr
Increase by 1-3 unit/hr
Increase by 1-3 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
Increase by 0-3 unit/hr
Increase by 3-5 unit/hr
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
Call MM
Call MM
Call MM
Call MM
Call MM
Page 5
Rev. 7/11/11

unit/hr
If blood glucose is below desired range: unit/hr
80-110 No change unit/hr
70-79
60-69
Decrease rate by 50% and recheck in 1 hour
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.
Page 6
Rev. 7/11/11

Medication
Adult Dose Pediatric Dose <40kg or <16 years or
1.25-5 mg Q4 hours Albuterol
Nebulizer or unit dose
Amiodarone
Ancef
2.5-5 mg Q4 hours
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.
1 gm Q 8 hours IV
Argatroban
Atrovent
Nebulizer or unit dose
350 mcg/kg IV over 15 min prior to cross-clamp
0.5 mg, typically given with
Albuterol
Calcium Chloride 0.5-1 gram IV
Calcium Gluconate 0.5-1 gram IV
Clindamycin 600 mg Q8 hours IV
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
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
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
Desmopressin
(DDAVP)
Diltiazem
(Cardizem)
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 Dobutamine
*consult MM
Dopamine
Epinephrine
3-20 mcg/kg/min IV
1-4 mcg/min IV
Furosemide (Lasix) 20-120 mg IV
1 amp (25 grams) Glucose 25%
(D50)
Hydrocortisone
(Solu-Cortef)
Hydralazine
(Apresoline)
Insulin- regular
Lidocaine
15 mg/kg 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
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
6 mg/kg IV Q6 hours
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
Page 7
Rev. 7/11/11

Levothyroxine 20 mcg bolus; then 10-20 mcg/hr
Magnesium Sulfate 1-2 grams IV
Sodium
Bicarbonate
THAM
(Tromethamine
Vasopressin
Refer to Policy 5-09
Mannitol
Methylprednisolone
(Solu-Medrol)
Mucomyst
*Nebulizer only given when combined with
Albuterol
Mucomyst
* as needed to minimize contrast related renal toxicity
Narcan
* follow dose immediately with
Norcuron
Nicardipine
50-200 gm/24 hours IV in divided doses
15 mg/kg Q6 hours
3-5 mL of 20% solution or
10 cc of 10% solution Q4 hours
600 mg PO pre-procedure
8 mg IVP
5-15 mg/hr until desired BP reached, then maintenance of
3 mg/hr
Nitroprusside
(Nipride)
Norcuron
(Vecuronium)
0.3-10 mcg/kg/min IV
10 mg IVP
Norepinephrine
(Levophed)
Initially 0.5-12 mcg/min
Potassium Acetate 20-60 mEq
Potassium Chloride 40 mEq/L IV
10-15 mmol IV Potassium
Phosphate
Primacor
(Milrinone)
*Consult MM
Saline 3%
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
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
-------------------------------------------
Not commonly given
------------------------------------------
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
1-4 mEq/kg in 24 hours
0.5-0.1 mEq/kg over 2 hours
0.08-0.36 mmol/kg/dose over 4-
6 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
Page 8
Rev. 7/11/11

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.
Page 9
Rev. 7/11/11


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 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 :
Page
10 Rev. 7/11/11


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
11 Rev. 7/11/11

Page
12 Rev. 7/11/11

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
Hemodynamic
Management
Hormonal Therapy
Regimen per protocol
Dopamine
< 10 mcg/kg/min as indicated
Vasopressin
0.5-4 units/hr as indicated
Solumedrol
Adults: 15mg/kg
Peds: 6mg/kg
Obtain urine drug screen test if not previously done & patient admitted less than 36
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
Only Use Dobutamine w ith MM input
Minimum: Adults patients
Central line with CVP monitoring
(thoracic pref erred, f emoral f or trends)
LVEF < 45%
Continue
Hemodynamic Management
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%
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
Continue
Hemodynamic Management
Repeat echo warranted if cardiovascular improvement
If no improvement contact RM/MM
Proceed with
Thoracic Offers
* NOTE: All Pressors/Ionotropes can cause significant hypotension or hypertension. Evaluate patient's
Page
13 Rev. 7/11/11

Page
14 Rev. 7/11/11