PEDIATRIC DONOR MANAGEMENT ORDERS CHECKLIST
Organ Recovery Services
UNOS ID:
OPO ID#:
Donor name:
ORC name:
Phone/pager:
The following therapies or exams are requested to stabilize the potential donor and assess
organ function. If the patient has not yet been declared dead, the orders must be reviewed
and authorized by a physician. For any questions, please contact the DNA organ recovery
coordinator.
Vital signs:
 Monitor vital signs hourly  Monitor vital signs every 15 minutes
Vent settings:  __________________________________________________
 Oxygen challenge: increase FiO2 to 100% and draw ABG after 30 minutes,
then decrease FiO2 to 40% and draw repeat ABG after 30 minutes, then
return to original vent settings.
Labs:
 CMP  total bili  Amylase  Lipase
 Magnesium CBC with differential  UA  PT  PTT
 Troponin  CPK  CK/MB
Cultures:
 Blood (x2 from fresh sticks)  Urine  Sputum (with stat gram stain)
Medications:  Administer 8 mg/kg ciprofloxacin IV now and every 8 hours
 Alternate antibiotic therapy: ____________________________
 Solumedrol: 30 mg/kg (maximum dose 2 gm) IV now and every 12 hours
 Levothyroxine protocol: ______mcg/kg Levothyroxine IV bolus, then start
Levothyroxine IV drip at _______ mcg/kg/hr.
 Narcan 8mg IV bolus
 Albuterol via neb every four hours
 Titrate Dopamine drip for MAP >60 mmhg
 Administer 2 drops gentamycin opthalmic solution and 0.6cm Lacrilube (or
other corneal lubricant) to each eye, tape eyes shut
IVF:
 D5W  with 20 mEq KCl/Liter
 Alternate IVF: ______________________________________
 infusion rate: ________________________________________
Consults:
For the following items, consent must be completed prior to ordering
 Request arterial line placement
 Request central line placement  Request PA catheter placement
 Cardiology: request echocardiogram, indication: cardiac donor evaluation
 Pulmonology: request fiber-optic bronchoscopy, indication: lung donor
evaluation. Send bronchial washings from each lung for gram stain and
culture
Authorizing ORC: __________________________________________________
Revised October 2009
DP-OR25.06 – PEDIATRIC ORGAN DONOR MANAGEMENT
ATTACHMENT I REV. 10/2010
Page 1 of 1