**The patient is still in the care of the hospital team and all orders will be from the attending physician. Donor Alliance staff is on site in an advisory role.**

• The primary goal during management is maintaining hemodynamic stability and performing diagnostic testing prior to allocation of organs.
  • Maintain MAP >65 and <110, SBP ≥90-100
    • An arterial line will be requested if one is not already in place. -Maintain body temperature of >36 C° and <38 C°
  • Titrate FiO₂ to maintain SaO₂ of 93-97%
  • Maintain electrolyte levels with replacement protocols.
  • Maintain blood glucose levels <180 via ICU insulin protocols.
• Infection prevention
  • Current antibiotics will be maintained if already ordered. If not currently on antibiotics, will request Ancef 1 gm q 6 hrs for prophylactic coverage.
  • Sometimes, during allocation, transplant centers will request specific antibiotic coverage. This will be discussed with Donor Alliance’s medical director as well as the hospital healthcare team prior to approval.
• DVT prophylaxis
  • Unless contraindicated, 40 mg of Lovenox q daily will be requested.
• Diagnostic testing
  • Heart
    • If heart is eligible, a stat echocardiogram and 12-lead EKG will be requested
    • Based on patient history and/or echocardiogram results, a cardiac cath procedure may be requested as well.
  • Lungs
    • If lungs are eligible, a stat bronchoscopy will be requested followed by serial chest x-rays and ABGs.
    • Lung recruitment and procedures will also be ordered, please see the RT management section.
    • Maintain turning and suctioning q 2 hours and PRN for secretions.
  • Liver/kidneys
    • A chest and abdominal CT scan will be requested if one has not been done since admission for imaging of all organs.
• Labs
  • In addition to diagnostic testing, we will request a set of one time labs will be requested as well as serial labs to be drawn every 12 hours unless the clinical presentation requires more frequent monitoring.
  • One time labs
    • ABO Type and Screen, if one has not been done
    • CBC w/differential
    • Heart: CPK
    • Liver: LDH, GGT
    • Pancreas: A1C, amylase, lipase
    • Urine pregnancy test, if applicable
  • Serial labs (q 12 hours)
    • CBC without differential
    • Liver enzymes/hepatic function panel
    • Direct bilirubin may need to be requested as an individual order
    • Basic metabolic panel
    • Electrolytes (magnesium, phosphorus, ionized calcium)
    • Coags (PT/INR, PTT)
    • Urinalysis with micro
    • Troponin
    • Lactate

**After brain death has been declared, Donor Alliance will assume care for the donor and all orders will be placed through the on-site coordinator.** 

• As noted above, maintaining hemodynamic stability is paramount during the management phase of donation. 
  • Maintain MAP >65 and <110, SBP ≥90-100 
    • An arterial line will be requested if one is not already in place.  
    • During herniation and sometimes post-herniation, labile blood pressures can occur.  
  • Maintain body temperature of >36 C° and <38 C° 
    • The brain can no longer regulate temperature so it is common for brain dead donors to be hypothermic and will require continuous temperature regulation. 
  • Titrate FiO₂ to maintain SaO₂ of 93-97% 
  • Maintain electrolyte levels with replacement per the coordinator on-site.  
  • Maintain blood glucose levels <180 via IVP or continuous infusion of regular insulin.  
    • Brain dead donors tend to have high insulin resistance. When insulin is ordered, it will likely be in doses that seem higher than usual for this reason.  
  • Closely monitor fluid status.  
    • UOP documented hourly as diabetes insipidus (DI) is common in brain dead donors.  
    • Medications used to regulate DI: vasopressin and DDAVP/desmopressin 
    • Transduce a CVP, if able. 
    • We may bring a Cheetah on-site for non-invasive monitoring as well. 
    • If a Cheetah isn’t available, we may ask if your facility has a Flo Trac or similar device.  
• Medications 
  • In addition to the same medications as listed above for DCD donors, for brain death a large dose of SoluMedrol will be ordered once IV piggyback (2000 mg) followed by smaller doses IV piggyback (500 mg) q 8 hrs. 
    • This will often help to stabilize blood pressure as the catecholamine release from herniation disrupts normal regulation. 
• Diagnostic testing 
  • Heart 
    • If heart is eligible, a stat echocardiogram and 12-lead EKG will be requested if a Donor Alliance coordinator is unable to perform one. 
    • Based on patient history and/or echocardiogram results, a cardiac cath procedure may be requested as well.  
  • Lungs 
    • If lungs are eligible, a stat bronchoscopy will be requested, if a Donor Alliance coordinator is unable to perform one, followed by serial chest x-rays and ABGs.  
    • Lung recruitment and procedures will also be ordered please see the RT management section. 
      • Vent changes will be performed and determined by the coordinator on-site 
      • Recruitment maneuvers will be shared between the RT and the coordinator on-site. 
    • Maintain turning and suctioning q 2 hours and PRN for secretions. 
  • Liver/kidneys
    • A chest and abdominal CT scan will be requested if one has not been done since admission for imaging of all organs.  
• Labs 
  • In addition to diagnostic testing, we will request a set of one time labs will be requested as well as serial labs to be drawn every 12 hours unless the clinical presentation requires more frequent monitoring.  
    • One time labs 
      • ABO Type and Screen, if one has not been done 
      • CBC w/differential 
      • Heart: CPK 
      • Liver: LDH, GGT 
      • Pancreas: A1C, amylase, lipase  
      • Urine pregnancy test, if applicable  
    • Serial labs (q 12 hours) 
      • CBC without differential  
      • Liver enzymes/hepatic function panel  
      • Direct bilirubin may need to be requested as an individual order 
      • Basic metabolic panel 
      • Electrolytes (magnesium, phosphorus, ionized calcium) 
      • Coags (PT/INR, PTT) 
      • Urinalysis with micro 
      • Troponin 
      • Lactate 
• If able, Donor Alliance will likely transfer the donor to our recovery center for further management and allocation. 

BD and DCD donors 

• based on current lung compliance, adjust Vt to 8ml/kg IBW and increase peep to +10 

• Initiate Q4 duo nebs, Q4 CPT, and Q2 recruitment maneuvers 

• Recruitment to be done using Peep ladder or PV tool while being mindful of patient's compliance with the ventilator.  

• Peep Ladder: Start on set peep and go up +2-+3 of peep. Allow pt to breath at higher set peep for approximately 5 breaths. If patient can tolerate a 10 sec inspiratory hold please do so, if not just measure Plat pressure. If Plat pressure remains <30, go up +2-+3 off peep again. Again, allow patient to breath approximately 5 breaths at higher set peep. Do 10 sec inspiratory hold if pt tolerates. Continue this ladder until Plat pressures of 30 are reached. Once 30 is reached, now drop peep slowly by +2-+3 allowing pt to breath approximately 5 breaths. Continue this until baseline peep is reached. 

• PV tool only to be used on BD DONORS ONLY!! DA coordinator will instruct hospital staff  

Pre OR into OR  

DCD  

• DA coordinator to work with hospital OR team to set OR time 

• Coordinate pronouncing provider (MD or 2 RNs per hospital policy) 

• MD to place DCD orders for DA team which includes: DNR/DNI, Heparin 30000-50000 units, extubation, and comfort care medications (per hospital policy). Additional orders like blood products may be used for organ recovery. 

• Honor walk: DA will coordinate with hospital staff  

• *** Anesthesia will be needed for OR if lungs will be recovered 

RN roles/ responsibilities for DCD OR 

• Continue to manage patient stability until extubation 

• If declaring patient, will huddle with DA staff to go over expectations in OR for declaration 

• Administer heparin in OR  

• Maintain comfort care measures per hospital policy 

RT roles/responsibilities for DCD OR 

• Will be expected to transport patient to OR. Expect to be in OR for 40 mins prior to extubation 

• Extubate patient in OR 

BD OR 

• Anesthesia will be needed for recovery 

• RN will transfer care over to anesthesia 

• If lungs are being recovered, RT to place pt on transport vent and transport to OR

• Optimizing organ function – adequate blood pressure, lung recruitment, appropriate fluid status   

• Providing data to transplant centers based on UNOS policy – UNOS requires certain information to be available prior to running lists for organs (echo for heart, bronchoscopy for lungs, etc.).  (UNOS – United Network of Organ Sharing) 

• Hospital labs: UNOS policy requires labs to be drawn on a regular schedule for ongoing assessment of organ function. These will be ordered through the EMR and processed through the hospital lab.  

• Serologies and tissue typing: Additionally, Donor Alliance must draw enough blood for extensive tissue typing and serology testing on every donor before organ allocation can be started. These are specific blood tubes that will be provided to you and will be returned to the coordinator as they are processed outside of the hospital.  

• During organ allocation, transplant centers may request additional blood samples to be shipped for cross matching. This tests the potential recipient’s serum against the donor’s to ensure the risk of organ rejection is low.  As with serology and tissue typing, these tubes will be provided to you and returned to the coordinator.  

• High dose steroids: During the brain death process, the body releases catecholamines in an attempt to perfuse the brain. Brain dead donors require high dose steroids to replace what they can no longer organically produce. 

• High dose insulin: Brain dead patients are extremely insulin resistant. It is important to maintain appropriate blood glucose levels during the donor management period, and large doses of IV insulin will be required to achieve that either through IV push doses or via a continuous infusion.  

• T4: While not as commonly used as often in donor management, T4 is still built into some hospital order sets. Once thought to work at a metabolic level to move the body from anaerobic to aerobic metabolism and achieve normal hemodynamics without vasopressors, it is now believed that restoration of hemodynamic status after T4 administration is more from fluid resuscitation.  

Donor Alliance covers all potential donors with broad spectrum antibiotics as a preventative measure. If the donor is already on targeted antibiotics for a known infection, the broad spectrum may not be necessary. 

• Any labs, imaging, and testing related to a donor case is paid for by Donor Alliance.  There is no cost to the donor family for organ or tissue donation. 

• Donor Alliance utilizes imaging and labs to assess for organ function and viability at the beginning of a case and may include CT imaging, echocardiogram, bronchoscopy, and cardiac catheter imaging in some cases.  

• UNOS policy requires labs and imaging be done at regular intervals and this information be provided to transplant centers.  

Donor Alliance will evaluate all organs for possible transplantation and allow individual transplant centers to make the final determination on appropriateness for transplant. Not all donors with a history of alcohol, tobacco or drug use will have long-term evidence of such during organ evaluation, and many of these organs go on to be successfully transplanted.

If a DCD patient does not pass within the time frame required for donation, the cost of treatment after that point will return to the patient/insurance/estate.  They are informed of this during the authorization process. 

Donor Alliance must seek coroner authorization for donation in all cases. 

Most of the time, recipients are waiting at home to be notified that an organ is available.  If the recipient is very sick, they may be currently admitted to the transplant center for close monitoring 

Organ Clinical Coordinator: Come from a wide variety of backgrounds including Registered Nurse, Paramedic/EMT, Respiratory Therapist, or having obtained a Transplantation and Donation Sciences Master’s Degree