Number: DP-OR25
STANDARD OPERATING PROCEDURES
Organ Recovery Services
Title: PEDIATRIC ORGAN DONOR MANAGEMENT
This document contains confidential and
proprietary information and is the property
of Donor Network of Arizona.
Revision #: 06
 Revision to Existing Document
 Annual Review
Implementation Date:
Effective Date:
1.
Purpose:
1.1.
2.
3.
Defines the expected management interventions for clinical organ donor
management.
Responsibilities:
2.1
Organ Recovery Coordinators (ORCs) are responsible for organ donor
management and for consulting with the Medical Director about organ donor
management.
2.2
The Organ Recovery Services Medical Director is responsible for giving clinical
guidance as needed to ORCs and for approving variances from established
guidelines on a case-by-case basis.
2.3
The Medical Executive Committee and the Medical Director are responsible for
reviewing and approving donor management guidelines on an annual basis as
part of the Medical Executive Committee meetings.
Definitions:
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
4.
 New
 Obsolete
STAT:
mg:
mcg:
mEq/L:
mmol:
mmhg:
hr:
IV:
Immediately
Milligrams
Micrograms
Milliequivalents per liter
Millimoles
Millimeters of mercury
Hour
Intravenous
References and/or Associated Documents:
4.1.
4.2.
4.3.
United Network for Organ Sharing (UNOS), Policies
4.1.1. Policy 2.0: Minimum Procurement Standards for an Organ Procurement
Organization.
Association of Organ Procurement Organizations (AOPO), Standards
4.2.1. Standard CL 4A: Guidelines for Evaluation and Management of Potential
Organ Donors
Centers for Medicare and Medicaid Services (CMS), 42CFR486, Subpart G:
Requirements for Certification and Designation and Conditions for Coverage:
Organ Procurement Organizations
DP-OR25.06 – PEDIATRIC ORGAN DONOR MANAGEMENT
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4.4.
4.5.
4.6.
4.7.
4.8.
5.
Materials and Equipment as Needed:
5.1
6.
4.3.1. § 486.344 Condition: Evaluation and Management of Potential Organ
Donors and Organ Placement and Recovery
Powner, DJ et. al. Proposed Treatment Guidelines for Donor Care. Progress in
Transplantation. 2004; 14:16-28
Lutz-Dettinger, N et. al. Care of the Potential Pediatric Organ Donor. Pediatric
Clinics of North America. 2001: 48(3): 715-49
Zuppa, A et. al. The effect of a thyroid hormone infusion on vasopressor support
in critically ill children with cessation of neurologic function. Critical Care
Medicine. 2004; 32:2318–2322
DP-OR25 - Attachment I – Pediatric Donor Management Orders Checklist
OP-CL01 – Hemodilution
None
Procedure:
6.1.
General considerations
6.1.1. Guidelines for pediatric organ donor management are reviewed and
approved annually by the Medical Executive Committee of Donor Network
of Arizona (DNA). These guidelines are not intended to supplant the
clinical decision-making of ORCs or physicians, including the Medical
Director, on a case-by-case basis.
6.1.2. ORCs are encouraged to consult the Medical Director (or other available
physician if the medical director is not available) for conditions not fully
addressed within these guidelines, or if further guidance is needed.
6.1.3. ORCs are encouraged to call upon the physicians, registered nurses,
respiratory care practitioners and other staff in the pediatric ICU setting
(local, regional and national) for suggestions and advice. These
individuals have vast experience caring for critically ill pediatric patients
and their suggestions and advice should be considered at all times.
6.2.
Guidelines for standard donor care
6.2.1. Upon assumption of donor care, the ORC will obtain a blood sample for
serological testing according to OP-CL01 – Hemodilution and send it for
STAT testing.
6.2.2. The ORC will order the following initial interventions, following established
order procedures at the donor hospital:
Note: The ORC may use DP-OR25 Attachment I – Pediatric Donor
Management Orders Checklist and share it with the hospital staff to
review plans for donor management.
6.2.2.1. Transfer care to DNA.
6.2.2.2. Monitor the following vital signs hourly:
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6.2.2.2.1.
Blood pressure (if arterial line no present, request
placement)
6.2.2.2.2.
Heart rate
6.2.2.2.3.
Temperature
6.2.2.2.4.
Oxygen saturation (SpO2)
6.2.2.2.5.
Urine output
6.2.2.2.6.
Central venous pressure (CVP) if a central line is
present
6.2.2.2.6.1.
6.2.2.2.7.
If a central line is not present, the
ORC should request placement of a
central line or (if patient is a potential
heart or lung donor) a pulmonary
artery catheter.
Pulmonary artery (PA) pressures, including
pulmonary artery occlusion pressures, if PA
catheter is present.
6.2.2.3. Ventilator settings should be adjusted to optimize oxygenation of
the organs. Recommended ventilator settings:
6.2.2.3.1.
Tidal volume: 8-10 cc/kg of donor ideal body
weight.
6.2.2.3.2.
Ventilation rate: 16 breaths per minute.
6.2.2.3.3.
Positive end-expiratory pressure (PEEP): 2.5
mmhg.
6.2.2.3.4.
Fraction of inspired oxygen (FiO2): 40% (may
adjust upwards or downwards to maintain PaO2
>100).
6.2.2.4. Elevate head of bed to 30 degrees.
6.2.2.5. Maintain temperature >36.5°C.
6.2.2.6. Continue routine pulmonary care including side-to-side
positioning.
6.2.2.6.1
The ORC should consider the use of the
intermittent mechanical pulmonary toilet devise
commonly know as the “Link Vest” for additional
pulmonary toilet maintenance.
6.2.2.7. Place nasogastric/orograstic tube, connect to low intermittent
suction.
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6.2.2.8. If consent for cornea donation is obtained, administer 2 drops
gentamycin ophthalmic solution and 0.6cm Lacrilube (or other
corneal lubricant) to each eye, and tape eyelids shut (to prevent
infection and corneal drying).
6.2.2.9. Continue vasoactive infusions at current settings.
6.2.2.9.1.
The ORC should direct the titration of vasoactive
infusions to maintain an age/size appropriate MAP
and SBP following direction of pediatric intensivist /
medical director should consider substituting
medications for optimal perfusion of the organs.
6.2.2.10. Start levothyroxine protocol.
6.2.2.10.1. Administer 30mg/kg Solu-Medrol IV, with maximum
dose of 2gms, every 12hrs.
6.2.2.10.2. Administer Levothyroxine bolus per age based
protocol in table I.
6.2.2.10.3. Administer Levothyroxine IV infusion using the age
appropriate rate per Table I.
Age
0–6 months
6–12 months
1–5 years
6–12 years
12–16 years
>16 years
Table I
Bolus
5 mcg/kg
4 mcg/kg
3 mcg/kg
2.5 mcg/kg
1.5 mcg/kg
0.8 mcg/kg
Infusion
1.4 mcg/kg/hr
1.3 mcg/kg/hr
1.2 mcg/kg/hr
1 mcg/kg/hr
0.8 mcg/kg/hr
0.8 mcg/kg/hr
6.2.2.10.4. In the event the donor becomes tachycardic and
hypovolemia is ruled out as the cause, discontinue
levothyroxine therapy and consult medical director.
6.2.2.11. IV fluid: 5% Dextrose in 0.45 sodium chloride (D5½NS) with 20
mEQ potassium chloride (KCl) per liter is the recommended IV
fluid. The ORC should choose fluids, rates and additives based
on electrolyte levels and hypo/hypervolemic state.
6.2.2.12. Administer 8 mg/kg ciprofloxacin IV now and every 8 hours to
prevent infection. If antibiotic therapy already in place, consult
medical director as to suitability. If known sensitivity, substitute
Vancomycin IV 10mg/kg every 6hrs, maximum dose 1gm/dose.
6.2.2.13. Order the following labs STAT (repeat PRN):
6.2.2.13.1. Comprehensive metabolic panel (CMP
6.2.2.13.2. Complete blood count (CBC) with differential
6.2.2.13.3. Prothrombin time (PT) and partial thromboplastin
time (PTT)
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6.2.2.13.4. Lipase
6.2.2.13.5. Amylase
6.2.2.13.6. Magnesium
6.2.2.13.7. Cardiac panel, to include Troponin-I, creatinine
phosphokinase (CPK), and creatine-kinase (CKMB)
6.2.2.13.8. Cultures
6.2.2.13.8.1. Blood from two fresh sticks; do not
draw from accesses >4 hours old
6.2.2.13.8.2. Sputum with stat gram stain
6.2.2.13.8.3. Urine
6.2.2.13.9. Urinalysis
6.2.2.14. Order a 12-lead electrocardiogram (EKG).
6.2.2.15. Order a portable chest x-ray (CXR)—indication: donor
evaluation.
6.2.2.15.1. Consider delaying the CXR if central line placement
is planned within one hour; the single CXR can
then be used to check line placement as well.
6.2.2.16. If blood type (ABO) has not been determined, order ABO type
and screen, to include subtyping if ABO=A.
6.2.2.17. Type and cross for two units of packed red blood cells (PRBCs)
keep ahead two units throughout case.
6.2.2.18. Notify the ORC if any of the following situations occur:
6.2.2.18.1. Mean arterial pressure (MAP) or SBP drops below
age appropriate parameters, as directed by
pediatric intensivist/medical director.
6.2.2.18.2. Systolic blood pressure >170 mmhg
6.2.2.18.3. Heart rate <80 or >160 beats per minute
6.2.2.18.4. Temperature <36°C or >38°C
6.2.2.18.5. Urine output <1 cc/kg/hr
6.2.2.18.6. CVP or PAOP <6or >12 mmhg
6.2.2.19. Cardiac Donor Evaluation
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6.2.2.19.1. Once donor SBP or MAP maintains at guidelines
given in above with Dopamine <10mcg/kg/min
and/or phenylephrine <60mcg/min, request cardiac
consultation to include 2-dimensional
echocardiography.
6.2.2.20. Pulmonary Donor Evaluation
6.2.2.20.1. Oxygen Challenge
6.2.2.20.1.1. Increase FiO2 to 100%; draw ABG at
30 minutes.
6.2.2.20.1.2. Decrease FiO2to 40%; draw ABG at
30 minutes.
6.2.2.20.1.3. Return FiO2to previous settings
established in 6.2.2.3 of this SOP.
6.2.2.20.2. Bronchoscopy
6.2.2.20.2.1. If pO2 >300mmhg, request
pulmonary consult, including CXR
interpretation (including lung
measurements) and fiber optic
bronchoscopy.
6.2.2.20.2.2. Bronchoscopy should include
separate bronchial washings from
the right and left lung sent for
culture, STAT gram stain and fungal
smear.
6.2.2.20.3. Administer Albuterol nebulizer every 4 hours;
consider adding Mucomyst nebulizer every four
hours if secretions present.
6.2.2.20.4. Deep suction every two hours using one-time
suction kit (including red rubber catheter if
available, instead of in-line suction devise).
6.2.2.20.5. Give 30/kg Solu-Medrol (maximum dose 2 gm) IV
12hours after the dose given with the inception of
the levothyroxine protocol.
6.2.2.20.6. Give Narcan 8mg IV pushonce.
6.2.2.20.7. Repeat oxygen challenge two hours after
bronchoscopy and/or as requested by transplant
center.
6.3.
Guidelines for donors with hypertension
6.3.1. Because donor organs are at greater risk from hypotension than from
hypertension, a conservative management approach to hypertension is
DP-OR25.06 – PEDIATRIC ORGAN DONOR MANAGEMENT
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recommended. The goal for MAP should be less than 90 mmhg but
greater than 50 mmhg. Therapy should be started if the MAP is
sustained over 95 mmhg for a period of thirty minutes or longer.
6.3.2. Consider reducing vasoactive medications.
6.3.3. Consider a labetalol infusion at 0.4-1 mcg/kg/hr until a MAP of 65-70
mmhg is reached.
6.3.4. Consider a nitroprusside infusion at 0.1 mcg/kg/min; titrate slowly until a
MAP of 65-70 mmhg is reached.
Note: Consult medical director before using beta blockers in donors
with a history of pulmonary disease.
6.3.5
6.4.
If Nitroprusside fails to reduce the MAP, consult the Medical Director for
further guidance.
Guidelines for donors with hypotension
6.4.1. Hypotension in the brain-dead organ donor can be due to ongoing or
preexisting conditions leading to hemorrhagic, cardiogenic, distributive,
obstructive or other types of shock, but is more commonly due to the loss
of vasomotor centers in the brain causing vasodilation, decreased
contractility of the heart, or hypovolemia due to ongoing fluid loss due to
diabetes insipidus. Hypotension in pediatric organ donors is defined as a
MAP <50 mmhg.
6.4.2. Ensure that any signs of hemorrhage have been evaluated and treated.
6.4.3. Discontinue any anti-hypertensive medications.
6.4.4. Administer additional fluid such as 0.45% sodium chloride or Ringer’s
lactate. Colloid solutions (5% albumin) may be added.
6.4.4.1. For CVP <5 mmhg, consider a 20 cc/kg fluid challenge.
6.4.4.2. For CVP 5-12 mmhg, consider a 15 cc/kg fluid challenge.
6.4.4.3. For CVP >12, no fluid challenge is indicated.
6.4.5. If a fluid challenge does not resolve the hypotension, consider the use of
vasoactive medications.
6.4.5.1. Titrate dopamine to achieve MAP endpoints; maximum dose 20
mcg/kg/min, but consider use of other pressors if dopamine
dose is >10mcg/kg/min or if donor becomes tachycardic.
6.4.5.2. Consider the use of vasopressin IV 0.00002-0.0003 U/kg/min
especially if the patient is in diabetes insipidus. Monitor pt’s urine
output closely and discontinue if the urine output is <1cc/kg/hr.
6.4.5.3. If dopamine is ineffective, add phenylephrine at 0.1-0.5
mcg/kg/min, Titrate to a maximum dose of 200 mcg/min.
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Maximum dose may be exceeded with medical director
approval.
6.4.5.3.1.
Alternately, the ORC may consider the use of
epinephrine 0.05mcg/kg/min, titrate up to 1
mcg/kg/min.
6.4.6. If PA monitoring is available, obtain a cardiac/hemodynamic profile.
6.4.6.1. If the systemic vascular resistance index (SVRI) is <1400,
consider the immediate use of a vasopressor such as
phenylephrine, norepinephrine, or epinephrine.
6.4.6.2. If the left ventricular stroke work index is low (<35 g m/m2)
consider the use of a positive inotropic agent such as dopamine
or dobutamine.
6.4.7. Continue to monitor hemodynamic status and titrate all vasoactive drips
to minimum levels.
6.5.
Guidelines for glucose management
6.5.1. Monitor glucose level every 2 hours either by normal labs or by
fingerstick.
6.5.2. Hypoglycemia
6.5.2.1. For hypoglycemia (glucose <75 mg/dL), administer 50 ml of 25%
dextrose IV (in donors under 1 year of age, use a 10% dextrose
solution).
6.5.2.2. Check glucose via fingerstick in 30 minutes and repeat 25%
dextrose if the donor glucose level <75 mg/dL (in donors under 1
year of age, use a 10% dextrose solution).
6.5.2.3. If the glucose remains <75 mg/dL after the second 25%
dextrose administration, consult the Medical Director.
6.5.3. Hyperglycemia
6.5.3.1. For hyperglycemia (glucose >300 mg/dL), ensure that all
glucose is removed from fluids and infusions unless required by
pharmacy.
6.5.3.2. Administer insulin 0.1 unit/kg IV and recheck glucose level 30
minutes after administration.
6.5.3.3. If glucose remains >300 mg/dl, repeat dose.
6.5.3.4. If glucose remains > 300 mg/dl after repeat dose, start insulin
infusion 0.05-0.1 units/kg/hr; titrate based on hourly glucose
levels.
6.5.3.5. When treating hyperglycemia with insulin, monitor serum
glucose hourly via fingerstick.
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6.6.
Guidelines for temperature management
6.6.1. Temperature should be monitored from a core site, such as a PA
catheter, bladder catheter, or rectal temperature. Axillary and oral
temperatures should not be used.
6.6.2. Hypothermia (donor temperature <36°C).
6.6.2.1. If the donor temperature is <36°C, use active surface warming,
such as warm blankets, or hot air warming blanket with
insulating thermal blankets.
6.6.2.2. Cover the donor’s head and other exposed body surfaces to
minimize exposure to room temperature.
6.6.2.3. If the temperature remains <36°C after three hours of active
rewarming, consult the Medical Director.
6.6.3. Hyperthermia (donor temperature >38°C)
6.6.3.1. Hyperthermia is rare in organ donors.
6.6.3.2. Remove additional blankets.
6.6.3.3. Administer 10 mg/kg acetaminophen per suppository every
three hours.
6.6.3.4. Use cooling blanket.
6.6.3.5. If temperature remains >38°C after three hours of cooling,
consult the Medical Director.
6.7.
Guidelines for anemia (donor hematocrit <28%)
6.7.1. Review the medical record for evidence of bleeding sites, previous
transfusion requirements, or other information about blood loss and/or
hemolysis.
6.7.2. Observe for signs of bleeding from external wounds, IV sites,
gastrointestinal (GI) tract (via gastric tube or bowel movements), and
urinary tract.
6.7.3. Observe for abdominal distension and changes in abdominal firmness
over time.
6.7.4. Refer to section 6.8 of this policy for coagulopathy treatment guidelines
and obtain PT, PTT, fibrinogen and platelet count. Treat as indicated.
6.7.5. If hematocrit is < 28%, transfuse 5 cc/kg PRBC rapidly. Please give CMV
negative blood if available.
6.7.6. Reassess the hematocrit level 30 minutes after the end of the transfusion
and repeat the transfusion if the hematocrit remains <28%.
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6.7.7. If the hematocrit remains <28% after a total of 20 cc/kg of PRBCs, consult
the medical director.
6.7.8. Administer 20mg/kg/dose of calcium chloride for every four pediatric
RBC’s transfused.
6.8.
Guidelines for treating coagulopathy and thrombocytopenia
6.8.1. Review the donor medical record for any anticoagulant medications that
have been given. Consult with medical director if any anticoagulants
have been administered within the past 48 hours, or if the patient has
been on outpatient anticoagulant therapy.
6.8.2. Send PT, PTT, fibrinogen, d-dimer, and platelet count.
6.8.3. Platelets
6.8.3.1. If platelet count < 80,000/mL3, administer 30 cc/kg of pooled
platelets rapidly.
6.8.3.1.1.
If using single donor platelets, administer in doses
of 10 cc/kg due to higher concentrations.
6.8.3.2. Recheck platelet count 30 minutes after infusion ends and
repeat infusion if platelet count remains <80,000/ mL3.
6.8.3.3. If platelet count remains <80,000/ mL3after the second platelet
infusion, consult medical director.
6.8.4. Coagulopathy with PT >15 seconds and/or PTT >38 seconds
6.8.4.1. If patient had been receiving IV heparin and PTT >75 seconds,
consider protamine administration. Consult with the Medical
Director.
6.8.4.2. Rapidly infuse 10-15 cc/kg fresh frozen plasma (FFP) and
repeat PT/PTT 30 minutes after the end of the infusion.
6.8.4.3. Repeat the infusion if PT/PTT remain above the treatment
ranges.
6.8.4.4. If PT/PTT remain elevated after second dose of FFP, consult the
Medical Director.
6.8.5. Coagulopathy with fibrinogen <100 mg/dL.
6.8.5.1. Infuse 5 cc/kg cryoprecipitate rapidly.
6.8.5.2. Repeat fibrinogen 30 minutes after infusion ends; repeat
infusion if fibrinogen level remains <100 mg/dL.
6.8.5.3. If fibrinogen level remains <100 mg/dL after the second infusion,
consult the Medical Director.
6.9.
Mechanical ventilation of donors
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6.9.1. Volume-controlled ventilator settings
6.9.1.1. Tidal Volume (Vt): 8-10 cc/kg ideal body weight
6.9.1.1.1.
If peak airway pressures >30 cm H20, reduce Vt to
6-8 cc/kg.
6.9.1.2. Adjust rate to maintain minute ventilation of approximately 8-10
L/minute or to maintain PaCO2 between 16-50 mmhg.
6.9.1.3. Adjust positive end-expiratory pressure (PEEP) to a minimum of
5 cm H20, titrate to maintain PaO2 > 100 mmhg.
6.9.1.4. Adjust FiO2 to maintain PaO2>100 mmhg.
6.9.2. Pressure-limited ventilator settings
6.9.2.1. Peak inspiratory pressure of 35-40 cm H20; consult with
respiratory care practitioner for recommendations based on the
specific ventilator model.
6.9.2.2. Adjust rate to maintain minute ventilation of approximately 4-6
L/minute or to maintain PaCO2 between 16-50 mmhg.
6.9.2.3. Adjust PEEP to a minimum of 5 cm H20, titrate to maintain PaO2
> 100 mmhg.
6.9.2.3.1.
PEEP adjustments may change delivered Vt and
minute volume during pressure-limited ventilation.
6.9.2.4. Adjust FiO2 to maintain PaO2 >100 mmhg.
6.9.3. General therapy
6.9.3.1. Ensure adequate suctioning/pulmonary toilet.
6.9.3.2. Consider use of Link Vest system.
6.9.4. Ventilator adjustments
6.9.4.1. Consult with pediatric intensivist and/or pediatric respiratory care
practitioner for optimal ventilator management.
6.9.4.2. Goals for ventilatory management of pediatric organ donors:
6.9.4.2.1.
SpO2 >95%
6.9.4.2.2.
PaO2 90-110 mmhg
6.9.4.2.3.
pH 7.35-7.45
6.9.4.2.4.
pCO2 35-45 mmhg
6.9.4.3. Check ABG 30 minutes after each ventilator change.
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6.9.4.4. Maintain peak inspiratory pressures <35 cm H20.
6.9.4.5. Adjust tidal volume to 8-10 cc/kg.
6.9.4.6. Apply PEEP at 5 cm H20. Increase to maximum of 10 cm H20
for refractory hypoxemia.
6.9.4.7. Turn and bag suction every two hours.
6.9.5. Guideline for management of fluids and electrolytes
6.9.5.1. Hypernatremia (sodium >150 mmol/l)
6.9.5.1.1.
In the presence of polyuria (>250ml urine output
above intake per hour) see polyuria guideline in
section 6.9.6 of this Standard Operating Procedure
(SOP).
6.9.5.1.2.
Without polyuria:
6.9.5.1.2.1.
Give 10 cc/kg 0.2% sodium chloride
with 20mEq KCL/L solution as rapid
infusion.
6.9.5.1.2.2.
Replace urine output mL/mL per
hour with 0.2% sodium chloride
solution with 20 mEq KCL/L or D5W.
6.9.5.1.2.3.
Ensure that all medications are
mixed in 0.45% sodium chloride
solution or 0.2% sodium chloride
solution if pharmaceutically possible,
and that any maintenance IV fluid is
changed to 5% dextrose in water
(D5W) or 5% dextrose in 0.2%
sodium chloride solution.
6.9.5.1.2.4.
Avoid the use of diuretics.
6.9.5.2. Hyponatremia (sodium < 133 mmol/L)
6.9.5.2.1.
Ensure that all medications are mixed in 0.9%
sodium chloride solution if pharmaceutically
possible, and that any maintenance IV fluid is
changed to 5% dextrose 0.9% sodium chloride
solution.
6.9.5.2.2.
Correct hyperglycemia before addressing
hyponatremia (see section 6.5.3 of this SOP).
6.9.5.2.3.
If the sodium level remains <133 mmol/L after three
hours, consult the Medical Director.
6.9.5.3. Hyperkalemia (potassium > 5.8 mmol/L)
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6.9.5.3.1.
Do not treat hyperkalemia if the lab reports the
specimen as hemolyzed. Send a new specimen.
6.9.5.3.2.
Ensure that all potassium is removed from
infusions.
6.9.5.3.3.
If hyperkalemia persists:
6.9.5.3.4.
6.9.5.3.3.1.
Give 1 mL/cc 25% dextrose IV.
6.9.5.3.3.2.
Give 0.1 units/kg regular human
insulin IV.
6.9.5.3.3.3.
Give 1 mEq/kg sodium bicarbonate
(1 ampoule) IV.
6.9.5.3.3.4.
Measure potassium level one hour
after medication administration.
If hyperkalemia persists, consult the Medical
Director.
6.9.5.4. Hypokalemia
6.9.5.4.1.
Delay diuretic administration.
6.9.5.4.2.
Give 0.5-1 mEq/kg potassium chloride over 60-90
minutes (preferably via central catheter).
6.9.5.4.2.1.
Alternately, consider the use of
potassium acetate. Consult with
pharmacist for dosing.
6.9.5.4.3.
Repeat up to four doses if serum potassium
remains <2.9 mmol/L.
6.9.5.4.4.
If hypokalemia persists, consult the Medical
Director.
6.9.5.5. Hypomagnesaemia (serum magnesium <1.5 mg/dL)
6.9.5.5.1.
Consult the Medical Advisor.
6.9.5.6. Hypophosphatemia (serum phosphate <2.2 mg/L)
6.9.5.6.1.
Consult the Medical Director.
6.9.5.7. Hypoionized calcemia (ionized calcium < 1.1 mmol/L or <4.4
mg/dL)
6.9.5.7.1.
Consult the Medical Advisor.
6.9.6. Guidelines for treating polyuria
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6.9.6.1. Evaluate for hyperglycemia and treat according to section 6.5.3
of this SOP.
6.9.6.2. Stop any prescribed diuretic therapy.
6.9.6.3. Calculate current intake and output for pt and consider boluses
for deficit >250cc.Monitor serum sodium and glucose levels
every two hours.
6.9.6.4. If the serum sodium level is between 135-147 mEq/L, continue
to observe urine output and continue to monitor sodium and
glucose.
6.9.6.5. If the serum sodium level >148 mEq/L:
6.9.6.5.1.
If urine output >5 cc/kg/hr above IV intake over two
hours, start IV vasopressin at 0.0005
unit/kg/minute.
6.9.6.5.2.
Vasopressin may be titrated to a maximum dose of
0.01 units/kg/hr. Observe the donor for signs of
hypertension.
6.9.6.5.3.
If the urine output does not decrease below 3
cc/kg/hr after two hours at the maximum
vasopressin dose, consult the Medical Director.
6.9.6.5.3.1.
Alternatively, the ORC may consider
the use of 0.05-0.1 mcg
desmopressin IV if the patient is
hypertensive.
6.9.6.5.3.2.
The desmopressin dose may be
repeated once if the urine output
does not decrease over two hours.
6.9.6.5.3.3.
If the urine output does not decrease
after two doses, consult the Medical
Director.
6.9.7. Guideline for acid-base management
6.9.7.1. Metabolic acidosis
6.9.7.1.1.
If the arterial pH remains < 7.32 after the changes
recommended in section 6.9.4 of this SOP,
administer 1 mEq/kg sodium bicarbonate slow IV
bolus. Recheck the ABG in 30 minutes.
6.9.7.1.1.1.
If the serum sodium > 150 mEq/L at
any time, consult the medical
director before administering any
sodium bicarbonate.
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6.9.7.1.2.
If the arterial pH remains < 7.32 30 minutes after
the first dose, administer a second dose of sodium
bicarbonate.
6.9.7.1.3.
If the arterial pH remains < 7.32 after two doses,
consult the Medical Director.
6.9.7.2. Metabolic alkalosis
6.9.7.2.1.
If the arterial pH remains >7.45 after the treatment
changes recommended in section 6.9.4 of this
SOP, consult the Medical Director.
6.9.8. Guidelines for infection
6.9.8.1. If the donor has bacterimia confirmed by culture, consult with the
Medical Director and/or hospital pharmacist for an organismspecific antibiotic.
6.9.8.2. If the donor has a depressed white blood cell (WBC) count and
an elevated band count on differential, consult with the Medical
Director for specific therapy.
6.9.8.3. If the donor is showing signs of systemic infection
(hypoperfusion, elevated temperature, decreased SVRI) consult
with the Medical Director for specific therapy.
Changes since last revision:
Changes originated by: PJ Geraghty
Removed direct/indirect bilirubin and GGT requirements (no longer required by UNOS). Added
references to CMS, AOPO and UNOS policies.
Approval Signatures:
Associate Director, Organ Recovery Services
Date
Director, Organ Recovery Services
Date
Director, Quality and Regulatory Affairs
Date
Medical Director, Organ Recovery Services
Date
DP-OR25.06 – PEDIATRIC ORGAN DONOR MANAGEMENT
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