APPENDIX D: Donor Management Protocol used in CORE’s Designated Service Area
The critical care endpoints that CORE strives to achieve through the donor management order set include:
• Mean arterial pressure between 60 and 100 mm Hg
• Central venous pressure between 4 and 10 mm Hg
• Ejection fraction greater than 50%
• Arterial blood gas pH between 7.3 and 7.45
• PAO2:FIO2 >300 on PEEP = 5 cm H20
• Serum Sodium level between 135 and 160 mEq/L
• Blood glucose level less than 150 mg/dL
• Hemoglobin level greater than 10mg/dL
• Urine output between 1 and 3mL/kg/hr. for preceding 4 hrs.
In CORE’s designated service area, a potential organ donor is managed by the recovery team using the following protocol.
To maintain adequate organ perfusion and minimize ischemic injury to organs, systolic blood pressure is maintained above 100 mm of Hg. Alternatively, mean arterial pressure is maintained between 60 and 65 mm of Hg. Fluids including crystalloids, colloids and blood products are infused to maintain adequate blood volume. Pressor drugs including Dopamine, Neosynephrine (Phenylephrine), Levophed (Norepinephrine), Epinephrine, Dobutamine and Vasopressin are administered to induce vasoconstriction and maintain blood pressure.
Hormone Replacement Therapy
The brain dead organ donor undergoes a number of metabolic changes. Triiodothyronine (T3) & Thyroxine (T4) is limited resulting in decreased glucose metabolism. Anaerobic metabolism occurs leading to metabolic acidosis, decreased muscle contractility, and decreased cardiac output. This is also responsible for myocardial irritability, and responsiveness to inotropic drugs, leading to further vasodilation, and variations in heart rate and rhythm. Administration of T3 and T4 (converted to T3) reverses this process [48, 49]. Aerobic metabolism is once again established. T3 also replenishes myocardial energy stores, decreases serum lactate, and reduces inotropic support. This improves and stabilizes myocardial function. After 30 - 90 minutes, the donor will mostly likely become tachycardic, temperature and blood pressure will rise. Titration of other pressors can then begin. CORE has developed its own hormone replacement regime for donor management in its designated service area.
Fluid & Electrolyte Balance
All electrolytes (Na, K, Ca, Mg, PO4) are maintained at optimal level. Maintenance fluids are adjusted to balance for excess or depleted sodium and potassium. Central Venous Pressure is maintained between 6 to 8 mm of Hg. Urine output is maintained above 100 ml/hr.
Diabetes Insipidus occurs because Antidiuretic Hormone (vasopressin) is no longer being produces and secreted into the circulation. As a result, kidneys excrete excessive amount of urine. and is characterized by urine output that is greater than 7 ml/kg/hr or 300 ml/hr with specific gravity of urine less than 1.005 and rising sodium levels. Diabetes Insipidus can be managed by Desmopressin infusion and replacing all urine in excess of 250 ml/hr with 0.2 NaCl.
CORE uses following guidelines to ensure that the donor is adequately oxygenated:
• Pa(O2) > 100 mm Hg
• Aspiration Precautions: over-inflate cuff, kerlex
• Titrate Fi(O2) to maintain Sa(O2) > 98%
• Tidal Volume between 10 to 12 ml/kg
• Maintain PEEP at 5-8 cm H2O
• Rate adjusted to maintain normal pH (7.35-7.45)
• Suction airway as indicated
If the patient meets the criteria for lung donation, these additional requirements are followed:
• Recruit lungs to maximize functionality
• Ventilator settings: Tidal Volume 12ml/kg ideal body wt, rate 10, PEEP at 5 cm H2O, Fi(O¬2) 1.0 (02 Challenge)
• Mucomyst & Albuterol q3 hrs
• Solumedrol 15 mg/kg IV
• Chest physiotherapy
• P(O2) > 300 & PAP < 30 = Donor
• P(O2) < 300 & PAP > 30 = further evaluation with bronch
Warming and cooling blankets are used to maintain body temperature above 32oC.
Insulin and Hyperglycemia
In a brain dead donor, the body is no longer able to control insulin regulation. Blood sugar is closely monitored (every 2 hrs. or every hour if necessary). Insulin drip may be used after consulting with the OPC.
APPENDIX D: References
7- Partial pressure of oxygen in arterial blood.
8 - Fraction of inspired oxygen maintained in a mechanically ventilated patient.
9 - Arterial oxygen saturation as measured by pulse oxymetry. Measures tissue perfusion of oxygen.
10 - Positive End Expiratory Pressure. Positive pressure ventilation keeps the alveoli patent.