Ventilator Management Orders
For Consented Organ Donors
______BiLevel Set Up

Initial FiO2 40%

Rate 8 - 20

PEEP Low 10 – 18 cm H2 : Adjust to maintain PaO2 > 100 mm Hg on FiO2 40%

PEEP High to obtain Vt 6 - 10 ml/kg ideal body weight

Adjust TH (time at PEEP high) to maintain an initial I:E 1:1

Monitor closely, maintaining PIPs < 38 cm H2O

Keep I:E ratio as close to 1:1 as possible while avoiding Auto peep
BiLevel Ventilation Changes – as indicated per ABG’s

To increase ventilation (ie decrease PaCO2) while maintaining MAP

Increase rate: Adjust TH (time at PEEP High) to maintain 1: 1 ratio

OR Increase PEEP High keeping Vt 6-10 ml/kg ideal body weight

To decrease ventilation (ie increase PaCO2) while maintaining MAP

Decrease rate: Adjust TH (time at PEEP High) to maintain 1:1 ratio

OR Reduce PEEP High keeping Vt 6-10 ml/kg ideal body weight

To increase oxygenation (ie increase PaO2) Keeping FiO2 at 40%

Raise Peep Low and raise the PEEP High by the same amount keep PIP’s < 38

OR Increase the I:E ratio (lengthen the TH)
DO NOT inverse I:E ratio without speaking to LifeShare Coordinator
______Pressure Control Set Up (for Transport Ventilators or when BiLevel is not available)

Initial FiO2 40%

Rate 8 – 20

PEEP 10 – 18 cm H20: Adjust to maintain PaO2>100 mm Hg on FiO2 40%

Inspiratory Pressure set to obtain Vt 6 - 10 ml/kg ideal body weight

Adjust Inspiratory time to maintain an initial I:E 1:1

Monitor closely, maintaining PIPs < 38 cm H2O

Keep I:E ratio as close to 1:1 as possible while avoiding Auto peep
Pressure Control Ventilation Changes as indicated per ABG’s

To increase ventilation (ie decrease PaCo2) while maintaining MAP

Increase rate: Adjust I time to maintain 1:1 ratio

OR Increase Inspiratory pressure keeping Vt 6 - 10 ml/kg ideal body weight

To decrease ventilation (ie increase PaCO2) while maintaining MAP

Decrease rate: Adjust I time to maintain 1:1 ratio

OR Decrease Inspiratory pressure keeping Vt 6-10 ml/kg ideal body weight

To increase oxygenation (ie increase PaO2) keeping FiO2 at 40%

Increase PEEP keeping the PIP’s<38
DO NOT inverse I:E ratio without speaking to LifeShare Coordinator
_______Respiratory Therapy Orders

Verbally report all ABG results, documenting MAP and Plateau Pressure, and ventilator changes to
LifeShare Coordinator

Use a heated circuit and DO NOT disconnect patient from ventilator without LifeShare notification

Place an end tidal CO2 or transcutaneous CO2 monitor and correlate with ABG’s

Transport ventilator to be used for all trips

In the event a transport ventilator is not available, manual ventilation with a PEEP valve is REQUIRED

Verify respiratory therapy orders on Adult Order Set and confirm chest PT
Oxygen Challenge (complete as ordered)

Obtain a baseline ABG prior to making ventilator changes for O2 challenge, documenting MAP and Plateau
Pressure

Maintain BiLevel or PCV mode during challenge

Increase FiO2 to 100%

Decrease PEEP Low to 5 cm H2O

BiLevel - decrease PEEP High to maintain Vt prior to O2 Challenge

Pressure Control - adjust inspiratory pressure to maintain Vt prior to O2 Challenge

Maintain setting for 15 minutes

Draw ABG, documenting MAP and Plateau Pressure, then immediately return to previous settings
 Verbally report to LifeShare Coordinator ABG’s and then make changes as indicated by previous ABG
Signature:_____________________________________________ per LifeShare Standing Orders/Protocol
LifeShare Organ Recovery Coordinator
Date:___________________ Time:__________________
Reviewed Date 02/22/2010
Lung Management Guidelines for LifeShare Coordinators – pg 1
Not part of order set

Upon consent and prior to ANY vent changes, consider a baseline ABG and O2 challenge

Initiate Ventilator Management Orders for ALL consented brain dead organ donors

In DCD, the attending physician has to sign the order for vent changes, but we do recommend it

Verify orders placed for:
1. Stat chest x-ray now and q 6 hours

Lung measurements of initial CXR and hard copy of terminal chest x-ray
2. ABG’s/O2Challenge

prn with initial changes and then q 2 hours

As directed by LifeShare

ALL ABG’s verbally reported to LifeShare Coordinator
3. Bronchoscopy for both anatomical and therapeutic evaluation

Minimal lavage

Separate culture and smears from each lung, if possible

Repeat O2 Challenge 1 hour after bronchoscopy
4. Echocardiogram

Consider reducing the low PEEP to 8 for ECHO and returning to previous settings when complete

Question if a poor echo is due to increased intrathoracic pressures if Peep >10

Verify medications ordered on Routine Deceased Donor Orders:
1. Narcan 8 mg IVP – USE EARLY/USE ALWAYS
2. SoluMedrol 2 gm and repeat 1 gm q 12 hours
3. Zosyn 4.5 gms IV STAT and repeat q 6 hours

Consider use of these additional medications as indicated:
1. Bronchodilators - Combivent MDI or Albuterol MDI 10-12 puffs every 2-4 hours

Avoid nebulizers, they place a break in the circuit
2. Vasopressin infusion titrated to desired urine output

Wean Levophed off first, titrating Neosynephrine and Dopamine down as tolerated

Consider d/c if hemodynamically stable 1-2 hrs prior to OR to allow natural diuresis
3. Dopamine – recommended/”acceptable” dose 3 mcg/kg/min

If pt requires pressor support, this is first line preference of transplant surgeons in general
4. Mannitol 25-50 gm bolus, then consider infusion of 3-6 gm/hr

Mechanism allows for “third space” fluid to be diuresed and protection of lungs

Closely
1.
2.
3.

Verify orders and review with RN and respiratory therapy for aggressive pulmonary toileting, which may include any or all of
the following:
1. Module bed with rotation and percussion
Notes on Chest PT

Percussion 15 min q 1 hours (minimum)
-Evaluate chest Xray prior to initiating

Manually Rotate pt > 45 degrees q 1 hour
percussion to evaluate for rib fxs, etc

Module bed rotation q 15 minutes
-Maintain pt in high lateral position
2. Manual percussion/pulmonary therapy (consider if module not available)
-If module or rotation bed used, manually

Percussion q 2 hrs – consider LINK vest
rotate the patient to > 45% angles hourly

Manually rotate hourly
-Rotation should always be right to left, left
3. Suction with gentle quad cough
to right, NEVER flat on the back

If you auscultate sounds after percussion, suction
-Percuss only one side at a time to minimize
time in trendelenburg

If no sounds or secretions, suction q 4 hrs
4. Auscultate q 2 hours
5. HOB elevated @ 30° (except during manual CPT and suctioning  trendelenburg)

Adjust vent setting per ABG’s, as indicated

Correlate ABG’s with end tidal CO2 device

Expect a 7 point variation, anything greater is indicative of how sick your patient may be
monitor/achieve/maintain hourly:
CVP 4-8 mmHg
I and O status
Adjust fluids as necessary to maintain CVP and clear lung fields

Avoid albumin

Remain conscious of vasopressin dosing
Reviewed Date 02/22/2010
Lung Management Guidelines for LifeShare Coordinators – pg 2
Not part of order set

After evaluating social/medical history, ABG’s, chest x-rays and bronchoscopy, consider chest CT

ONLY after discussion with AOC and Intensivist consult

Verify pt has not already had one done upon admission

Allocation decision:
1. If Pa02 >350 and CXR clear or improving

Begin placement
2. If Pa02 <350 and/or CXR not clear, worsening:

Reconsider:
a. Bronchodilators every 1 hour X 2
b. Mannitol bolus/gtt
c. Aggressive pulmonary toilet
d. Ventilator manipulation and/or other recruitment maneuvers
e. Repeat therapeutic bronchoscopy

Discuss with AOC and Intensivist stopping pursuit of lungs

If lung allocation stopped:

D/C serial CXR’s and ABG’s except as needed for overall management
IMPORTANT/FYI:
Sputum Gram Stain
Characteristics
Clinical Interpretation
Large number of squamous cells, few to moderate PMN’s
Saliva, possibly mixed with purulent
(polymorphonuclear cells), mixed flora
bronchial secretions
Large number of PMNs; gram positive diplococci
Pneumococcal infection
Large number of PMNs; gram negative organisms
Haemophilis infection
Large number of PMNs; gram positive cocci in clusters
Staphylococcal infection
Large number of PMNs; no organisms seen

Transport ventilators are necessary for all “trips” and settings should be discussed with
intensivist, respiratory therapist, anesthesia and LifeShare Coordinator if BiLevel is not
available

Avoid disconnecting patient from ventilator or any interruptions in the circuit

The Ventilator Management Orders is acceptable in pediatrics. You may need to
reevaluate the Rate, PEEP and PIP. The acceptable parameters will be established on a
case by case basis.
Reviewed Date 02/22/2010