TEXAS ORGAN SHARING ALLIANCE (TOSA)
Pediatric Organ Donor Order Set
DONOR NAME ______________________________
HEIGHT: ________ cm
WEIGHT ________ kg
DONOR ALLERGIES: ________________________
DONOR ID LABEL OR ADDRESSOGRAPH
Date _____/_____/_____ Time ______:______ (24 hour time)
GENERAL:
 Contact admitting to discharge patient and create new patient account prior to other orders.
 Notify TOSA coordinator immediately of any hemodynamic instability or critical lab values.
 Monitor core temperature. Artificial warming as needed to keep core temp greater than or equal to 37 degrees Celsius (98.6
degrees Fahrenheit)
 Record hourly vital signs to include systolic blood pressure (SBP), mean arterial pressure (MAP), HR, CVP, core temperature,
urine output
RESPIRATORY:
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Current ventilator settings: MODE: _____, TV/PC _____, Rate ____, PEEP ___, FiO2____
Portable chest x-ray STAT (after central line placement if not previously placed)
NG or OG tube to low intermittent wall suction
Inflate ETT cuff to maximum
Bronchoscopy
CARDIOVASCULAR:
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12 Lead ECG (to be read by cardiologist)
Echocardiogram – 2D mode (TEE if Transcutaneous views not acceptable)
LABORATORY: All labs to be run STAT with results given to TOSA Coordinator
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Type and Cross 2 units PRBC’s. Keep 2 units on hold at all times
Chemistry Panel: BMP, Calcium, Magnesium, Phosphorus
Liver /Pancreas Panel: AST, ALT, LDH, Alk Phos, Total & Direct Bili, PT/PTT (INR), Total Protein, Albumin, Lipase,
Amylase
Heart Panel: Cardiac enzymes, MB fraction, Troponin
CBC with differential (automated or manual)
Urinalysis with micro
Cultures: Blood culture x 1, urine culture, sputum culture and gram stain (please report gram stain STAT).
ABG on current vent settings
LINE PLACEMENT:
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Place arterial line and central line (triple or quadruple lumen), if not already placed, and transduce CVP
TOSA ORC Name Printed: _____________________________ TOSA ORC Signature: ______________________________
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IV FLUIDS:
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Maintenance IV fluid: _______________ with ________ mEq KCL/Liter to run at ________ mL /hour
Arterial Line: Normal saline + heparin 2 units/mL @ 1 mL/hr
□ add Papaverine 12 mg/100 mL
Central venous line: Normal saline + heparin 2 units/mL @ 1 mL/hr
CONTINUOIUS INFUSIONS: (Titrate off all other vasoactive medications after Dopamine & Vasopressin have started and patient
is stable)
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Continue current infusion of ______________ at ___________________________________________ until titrated off.
Continue current infusion of ______________ at ___________________________________________ until titrated off.
Dopamine _______ mcg/kg/min (not to exceed 20 mcg/kg/min). Titrate for age appropriate SBP or MAP.
Vasopressin (1 unit/mL) ________ units/kg/MIN for blood pressure maintenance only (0.0003-0.002 units/kg/MIN)
Milrinone ________ mcg/kg/min (0.3 – 0.7 mcg/kg/min) for inotropic effect
OTHER MEDICATIONS:
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Methylprednisolone (SoluMedrol®) ____________ mg (1 mg/kg/dose) IV x1 dose
Vasopressin (0.1 unit/mL) __________ units/kg/HOUR for diabetes insipidus (0.0005-0.01 units/kg/HOUR)
Cefazolin (Ancef®) ____________ mg (25 mg/kg/dose; Max: 1 gm/dose) IV every 6 hours
Continue current antibiotic/antifungal : ______________________________________________________
Contact ORC at this number for questions / clarifications: ________________________________
TOSA ORC Name Printed: _____________________________ TOSA ORC Signature: ______________________________
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