Patient has sustained non-survivable injury or devastating illness, and family has decided to withdraw life sustaining treatment (WLST). Surgical recovery of organs after the pronouncement of death based on the cessation of cardiopulmonary function. All comfort care measures including declaration of death is completed by hospital care team.  

 

 

Items to be opened/brought into room on every case 

• Instrument Trays 

• Major General Set 

• Sternal saw, battery (and a spare), blade 

• Donor Alliance Retractors or approved retractors from DA staff 

• Garrett Dilators or Coronary Artery Dilators 

• Equipment 

• 3-4 back tables 

• Neptune (4 suction lines total) 

• 1-2 Slush machines 

• 2 IV poles at head of bed for draping 

• 1 IV pole at foot of bed 

• Body bag  

• Chloroprep 1-3 sticks and shaver  

 

Room Set Up 

• At least one OR circulator and one scrub tech is required for all cases. 

• A Donor Alliance Organ Procurement Specialist (OPS) or Organ Clinical Coordinator (OCC) will bring a two-part custom supply pack at least two hours prior to OR time. 

• Your OPS will stay with you from 2 hours before the case until the patient is either brought to the morgue or back to ICU (if they do not pass within time frames). 

• Your OPS will also provide all educational opportunities regarding layout of OR, timing, what to open, etc. 

• The Donor Alliance personnel will bring 2 instruments for reserialization- sternal & abdominal retractors. Ideally they will be brought night before or at least 5 hours before case start so your SPD department has time to turn over based on your hospital policy 

• Unless your hospital already owns approved DA retractors 

• Slush Preparation  

• Slush should be prepared at least 2 hours prior to scheduled OR time if hospital has a room available and a slusher available. 

• If no slush machine is available or at hospital- DA will provide all slush. 

• Follow your hospital policy regarding count of instruments and disposable items 

 

 

Patient Arrival Into Room 

• Patient will be moved from ICU bed onto hospital bed with Donor Alliance staff and hospital staff in room. 

• Patient ID will be verified with at least one Donor Alliance staff and one hospital staff member 

• One arm will be tucked at patient’s side 

• One arm will be placed on an arm board and rotated near head for family to hold 

• Noise cancelling headphones provided by Donor Alliance staff will be placed over patient's ear  

• All EKG leads will be moved lower laterally, upper shoulders (away from the chest and abdomen)  

• If appropriate- patient will be shaved from chin to pubis and table to table 

• Patient will be prepped with Chlora prep from chin to pubis and table to table 

• After three minute standoff of waiting on prep to dry, patient will be draped by hospital staff, Donor Alliance employees, or surgeons. 

• All necessary items needed for draping are provided in packs. 

• After draping, suction lines will be placed. No matter the case you will place 2 Yankuaer tips and 2 Poole tips on the field (also provided in packs). One on each side of the field in pockets of drape. 

• If DCD w/ NRP or BD you will run two bovies (also provided in packs). 

• Everything will need to be covered at this time with back table covers, etc. 

• Donor Alliance staff will then host a time out 

 

Family in OR 

• Extubation occurs in OR setting instead of ICU, family allowed to accompany their loved one in OR, just as they would in the ICU, and leave prior to incision. 

• All family educated about OR at multiple touchpoints throughout donation pathway 

• Chairs are placed at HOB, all instruments are covered, and surgical team leaves OR.  

• DA Donor Family Coordinator accompanies family entire time.  

 

Start of DCD or DCD w/ NRP process 

• A second area during this time will need to be utilized where surgical staff can remain sterile 

• All surgeons, OPS’, scrub techs, will exit OR at this time and go to second area. 

• Organ Clinical Coordinator (OCC), circulating nurse, family members of patient, a donor family coordinator (DFC), declaring physician or 2 RN’s (based on your hospital policy), and RT will stay in the operating room. 

• Heparin will be given, allowed to circulate for 3 minutes, and the RT or other trained hospital staff will then extubate the patient. This will start the wait time. 

• DA Team will monitor vitals of patient that are entered into a grid by the OCC 

• ICU nurses/appropriate hospital staff will provide comfort medication based on the needs of patient. DA IS NOT INVOLVED IN THE COMFORT CASE MEASURES OR ADMINISTRATION. 

• If patient passes in the allotted time frame (typically 60-120 minutes): DFC will take family out of room during the FIRST pronouncement of death. 

• There will ALWAYS be a stand off time of 5 minutes from first to second declaration of death based on Donor Alliance policy, to ensure there is no autoresuscitation. 

• During the period between the first to second TOD- all staff can re-enter the room quietly, EXCEPT for the RECOVERING SURGEONS. During this time, the patient cannot be touched in any way. 

• After second TOD is called, AT THIS POINT THE RECOVERY SURGEONS CAN ENTER THE OPERATING ROOM and the procurement can commence. Prior to such, the death note should be signed and shown to the recovery surgeons. 

• If patient does not pass within the wait time, family will exit the room and be escorted back to ICU by DFC. 

• Patient will then be placed back on ICU bed, will NOT be re-intubated and taken back to ICU room to pass naturally 

• At this time the case is complete, no organs will be recovered, and Donor Alliance will step away from the case.  

 

Recovery Procedure DCD 

• An anesthesiologist should not be needed unless requested for special circumstances (lungs for transplant). 

• Incision will be made with a blade (from sternal notch to pubic symphysis) as quickly as possible by surgeons after the second TOD 

• The goal is to rapidly reach the aortic bifurcation and cannulate the aorta just proximal to this. In quick succession, afterward, the chest is opened, the aortic arch is clamped, and exsanguination then proceeds. The chest will always be opened regardless of organs being recovered to help with venting. Chest and abdominal retractors will also be placed during this time. 

• The OPS in the case will help the scrub tech ensure there is enough slush on the field to fill the entire body cavity  

• The OPS will also hang lines with preservation solution, so once the aorta is cannulated and the surgeon is ready to cross-clamp, flush can begin ASAP 

• This is the start of Cold Ischemic Time (CIT) for ALL organs 

• Following cross clamp, suction can fill very quickly, so please be ready to change canisters as needed.  We typically fill the larger (20 L) Neptune compartment first, followed by the smaller upper 4 L compartment 

• Depending on organs being recovered, organs will be assessed, and biopsies may be taken 

• If biopsies are taken, OR circulator will follow standard hospital policy and label the biopsy cup (if required by policy), and assist with taking the sample down to frozen pathology for reading 

• Donor Alliance will call pathologist in and will assist in communication 

• Donor Alliance has stickers to be placed on biopsy cups as well as a form for the pathologist to fill out for both liver and kidney biopsies. 

• The organs are then removed in the following order: Heart, lung(s), liver, pancreas, kidney(s), heart for valves, research organs 

• The iliac vessels (if liver or pancreas for transplant), spleen and mesenteric lymph nodes are also recovered. AFTER the thoracic and abdominal organs have been removed from the body. 

• Once all organs are recovered, a surgeon or an OPS will close the patient 

• If retractors are brought in by Donor Alliance staff, hospital policy will be followed, and retractors will be counted and taken off the field ASAP and sent down to SPD for clean cycle. 

• A final count of instruments and disposables, or your hospital policy, for count will occur. 

• OR circulator or available staff member will call security to transport patient down to the morgue. 

Patient has sustained non-survivable injury or devastating illness, and family has decided to WLST. Surgical recovery of organs after the pronouncement of death based on the cessation of cardiopulmonary function. All comfort care measures including declaration of death is completed by hospital care team.  

Addition of NRP (Normothermic Regional Perfusion): With the use of an Ex-situ pump that allows for postmortem normothermic regional perfusion (NRP) of organs intended for transplant, in-situ assessment of organs occurs prior to procurement. Only after declaration of death, and isolation and ligation of the cerebral vessels.  

 

Items to be opened/brought into room on every case 

• Instrument Trays 

• Major General Set 

• Minor vascular set or long vascular set 

• Sternal saw, battery (and a spare), blade 

• Donor Alliance Retractors or approved retractors from DA staff 

• Garrett Dilators or Coronary Artery Dilators 

• Tubing Clamps 

• Equipment 

• Two mayo stands  

• 3-4 back tables 

• 2 Bovie machines plus 2 grounding pads 

• Long Bovie extender 

• Neptune (4 suction lines total) 

• 1-2 Slush machines 

• 2 IV poles at head of bed for draping 

• 1 IV pole at foot of bed 

• 1 IV pole for NRP perfusionist team 

• Body bag  

• Chloroprep 1-3 sticks and shaver  

• GIA 55 or 75 w/ reloads 

• Ethicon-Echelon Flex Powered Plus Stapler w/ 2-3 reloads 

• Crash cart w/ internal paddles 

• Other miscellaneous supplies to have on standby in room 

• 2-0 silk pops SH  

• 4-0 Prolene RB-1 or SH 

• 8-20 bottles of saline for slusher + slush drape 

• Additional 10, 11 and 15 blades 

• Clip appliers (medium and large) 

 

Room Set Up 

• At least one OR circulator and one scrub tech is required for all cases. 

• A Donor Alliance Organ Procurement Specialist (OPS) or Organ Clinical Coordinator (OCC) will bring a two-part custom supply pack at least two hours prior to OR time. 

• Your OPS will stay with you from 2 hours before the case until the patient is brought to the morgue or back to ICU (if they do not pass within time frames). 

• Your OPS will also provide all educational opportunities regarding layout of OR, timing, what to open, etc. 

• The Donor Alliance personnel will bring 2 instruments for resterilization- sternal & abdominal retractors. Ideally, they will be brought night before, or at least 5 hours before case start so your SPD department has time to turn over based on your hospital policy 

• Unless your hospital already owns approved DA retractors 

• Slush Preparation  

• Slush should be prepared at least 2 hours prior to scheduled OR time if hospital has a room available and a slusher available. 

• If no slush machine is available or at hospital- DA will provide all slush. 

• Follow your hospital policy regarding count of instruments and disposable items 

 

Patient Arrival Into Room 

• The patient will be moved from the ICU bed onto the hospital bed with Donor Alliance staff and hospital staff in the room. 

• Patient ID will be verified with at least one Donor Alliance staff and one hospital staff member 

• One arm will be tucked at patient’s side 

• One arm will be placed on an arm board and rotated near head for family to hold 

• Noise cancelling headphones provided by Donor Alliance staff will be placed over patient's ear  

• All EKG leads will be moved lower laterally, upper shoulders (away from the chest and abdomen  

• If appropriate- patient will be shaved from chin to pubis and table to table 

• Patient will be prepped with Chlora prep from chin to pubis and table to table 

• After a three-minute standoff of waiting on prep to dry, the patient will be draped with hospital staff, Donor Alliance employees or surgeons. 

• All necessary items needed for draping are provided in packs. 

• After draping, suction lines will be placed. No matter the case you will place 2 Yankuaer tips and 2 Poole tips on the field (also provided in packs). One on each side of the field in pockets of drape. 

• We will run two bovies (also provided in packs). 

• Everything will need to be covered at this time with back table covers, etc. 

• Donor Alliance staff will then host a time out 

 

Family in OR 

• Extubation occurs in OR setting instead of ICU, family allowed to accompany their loved one in OR, just as they would in the ICU. Family will enter OR after extubation, and leave prior to incision 

• All family educated regarding OR at multiple touchpoints throughout donation pathway 

• Chairs are placed at HOB, all instruments are covered, and surgical team leaves OR 

• DA Donor Family Coordinator accompanies family entire time  

 

Start of DCD or DCD w/ NRP process 

• A second area during this time will need to be utilized where surgical staff can remain sterile 

• All surgeons, OPS’, scrub techs, NRP perfusionists will exit OR at this time and go to second area. 

• Organ Clinical Coordinator (OCC), circulating nurse, family members of patient, a donor family coordinator (DFC), declaring physician or 2 RN’s (based on your hospital policy), and RT will stay in the operating room. 

• Heparin will be given, allowed to circulate for 3 minutes, and the RT or other trained hospital staff will then extubate the patient. This will start the wait time. 

• DA Team will monitor vitals of patient that are entered into a grid by the OCC 

• ICU nurses/appropriate hospital staff will provide comfort medication based on the needs of the patient. DA IS NOT INVOLVED IN THE COMFORT CASE MEASURES OR ADMINISTRATION. 

• If patient passes in the allotted time frame (typically 60-120 minutes): DFC will take family out of room during the FIRST pronouncement of death. 

• There will ALWAYS be a standoff time of 5 minutes from first to second declaration of death based on Donor Alliance policy, to ensure there is no autoresuscitation had occurred. 

• During the period between the first to second TOD (time of death)- all staff can re-enter the room quietly, EXCEPT for the RECOVERING SURGEONS. During this time, the patients cannot be touched in any way. 

• After the second TOD is called, AT THIS POINT THE RECOVERY SURGEONS CAN ENTER THE OPERATING ROOM and the procurement can commence. Prior to such, the death note should be signed and shown to the recovery surgeons. 

• If a patient does not pass within the wait time, the family will exit the room and be escorted back to ICU by DFC. 

• Patient will then be placed back on ICU bed, will NOT be re-intubated and taken back to ICU room to pass naturally 

• At this time the case is complete, no organs will be recovered, and Donor Alliance will step away from the case.  

 

Recovery Procedure DCD w/ NRP 

• An anesthesiologist will be needed if lungs are being taken for transplant or special circumstances 

• The anesthesiologist will be needed to stay through the lungs being recovered 

• Blood (PRBC’s) will be requested from hospital blood bank for this type of case (order placed prior to OR, by Hospital Attending overseeing pt care) 

• An incision will be made with a blade immediately after second TOD 

• Incision will always be from sternal notch to pubis, regardless of organs being recovered 

• The chest will be opened using a sternal saw and the surgeons will cannulate the aorta and right atrium in a TA-NRP (thoracic NRP) or the distal aorta and IVC in a A-NRP (abdominal NRP) 

• Head vessels will be clamped so no blood flow to the brain or brain stem will occur 

• This will allow for re-circulation of oxygenated blood to be re-established in the patient 

• NRP is an in-situ perfusion of a portion of the patient’s body with the help of an extracorporeal organ support (ECOS) 

• This begins our “on pump” time frame. 

• This can last anywhere from 60-120 minutes based on patient factors, recipient factors, biopsy’s, trends in lab results, etc. 

• During this time, we can start utilizing bovies  

• Depending on organs being recovered, organs will be assessed, and biopsies may be taken 

• If biopsies are taken, OR circulator will follow standard hospital policy and label the biopsy cup (if required by policy), and assist with taking the sample down to frozen pathology for reading 

• Donor Alliance will call pathologist in and will assist in communication 

• Donor Alliance has stickers to be placed on biopsy cups as well as a form for the pathologist to fill out for both liver and kidney biopsies. 

• Once all organ function is assessed and organs are accepted/declined, and the “on pump” time is complete, the surgeons will then cannulate and get ready for cross clamp 

• The NRP perfusionists will pull the patient off pump before cross clamp occurs 

• During cross clamp, the entire body cavity will be filled with slush, OPS will hang lines and flush all organs for transplant with perfusion solution (that DA provides) 

• This will start Cold Ischemic Time (CIT) for all organs 

• The organs are then removed in the following order: Heart, lung(s), liver, pancreas, kidney(s), heart for valves, research organs 

• The iliac vessels (if liver or pancreas for transplant), spleen and mesenteric lymph nodes are also recovered. AFTER the thoracic and abdominal organs have been removed from the body. 

• Once all organs are recovered, a surgeon or an OPS will close the patient 

• If retractors are brought in by Donor Alliance staff, hospital policy will be followed, and retractors will be counted and taken off the field ASAP and sent down to SPD for a clean cycle. 

• A final count of instruments and disposable, or your hospital policy for count will occur. 

• OR circulator or available staff member will call security to transport patient down to the morgue 

Brain death is complete and permanent cessation of all functions of the brain including the brain stem. 

Time of declaration of brain death is legal time of death. This declaration is determined by hospital care team and abides by hospital policy.  

Cardiopulmonary function is maintained. 

 

Items to be opened/brought into room on every case 

• Instrument Trays 

• Major General Set 

• Minor vascular set or long vascular set 

• Sternal saw, battery (and a spare), blade 

• Donor Alliance Retractors or approved retractors from DA staff 

• Garrett Dilators or Coronary Artery Dilators 

• Tubing Clamps 

• Equipment 

• Two mayo stands  

• 3-4 back tables 

• 2 Bovie machines plus 2 grounding pads 

• Long Bovie extender 

• Neptune (4 suction lines total) 

• 1-2 Slush machines 

• Fluid warmer with 2 bottles of saline 

• 2 IV poles at head of bed for draping 

• 1 IV pole at foot of bed 

• Body bag  

• Chloroprep 1-3 sticks and shaver  

• Crash cart w/ internal paddles 

• Other miscellaneous supplies to have on standby in room 

• 2-0 silk pops SH  

• 4-0 Prolene RB-1 or SH 

• 8-20 bottles of saline for slusher + slush drape 

• Additional 10, 11 and 15 blades 

• Clip appliers (medium and large) 

 

Room Set Up 

• At least one OR circulator and one scrub tech is required for all cases. 

• A Donor Alliance Organ Procurement Specialist (OPS) or Organ Clinical Coordinator (OCC) will bring a two-part custom supply pack at least two hours prior to OR time. 

• Your OPS will stay with you from 2 hours prior to the case until the patient is brought to the morgue  

• Your OPS will also provide all educational opportunities regarding layout of OR, timing, what to open, etc. 

• The Donor Alliance personnel will bring 2 instruments for reserialization- sternal & abdominal retractors. Ideally, they will be brought the night before, or at least 5 hours prior to case start so SPD department has time to turn over based on your hospital policy 

• Unless your hospital already owns approved DA retractors 

• Slush Preparation  

• Slush should be prepared at least 2 hours prior to scheduled OR time if hospital has a room available and a slusher available. 

• If no slush machine is available or at hospital- DA will provide all slush. 

• Follow your hospital policy regarding count of instruments and disposable items 

 

Patient Arrival Into Room 

• Patient will be moved from ICU bed onto hospital bed with Donor Alliance staff and hospital staff in room. 

• Patient ID will be verified with at least one Donor Alliance staff and one hospital staff member 

• All EKG leads will be moved lower laterally, upper shoulders (away from the chest and abdomen)  

• If appropriate- patient will be shaved from chin to pubis and table to table 

• Patient will be prepped with Chlora prep from chin to pubis and table to table 

• After three minute stand off of waiting on prep to dry, patient will be draped with hospital staff, Donor Alliance employees or surgeons. 

• All necessary items needed for draping are provided in packs. 

• Donor Alliance staff will then host a time out 

 

Recovery Procedure BD 

• An anesthesiologist/CRNA is needed to monitor the patient and give medications and fluids.  

• A printed guideline sheet will be provided to them as well to fill out  

• The anesthesiologist will be needed to stay through cross clamp or until the lungs are recovered, if lungs are being taken for transplant 

• Incision is made with a bovie from sternal notch to pubis 

• Chest is opened with a sternal saw 

• Both abdominal and chest retractors are placed. 

• Depending on organs being recovered, organs will be assessed, and biopsies may be taken 

• If biopsies are taken, OR circulator will follow standard hospital policy and label the biopsy cup (if required by policy), and assist with taking the sample down to frozen pathology for reading 

• Donor Alliance will call pathologist in and will assist in communication 

• Donor Alliance has stickers to be placed on biopsy cups as well as a form for the pathologist to fill out for both liver and kidney biopsies. 

• Once all organs are accepted or declined and surgeons are ready, heparin will be given, cannulas will be placed, the aorta will be clamped and the patient will be exsanguinated of blood. 

• This is called cross clamp. Blood flow will stop, the body cavity will be filled with slush and a preservation solution will perfuse where the cannulas are placed. 

• The solution will be provided by Donor Alliance staff. The flush will be monitored by our staff. 

• This is the start of Cold Ischemic Time (CIT) for ALL organs. 

• During cross clamp, your suction can fill very quickly so please be ready to change canisters as needed  

• The organs are then removed in the following order: Heart, lung(s), liver, pancreas, kidney(s), small bowel, heart for valves, research organs 

• The iliac vessels (if liver or pancreas for transplant), spleen and mesenteric lymph nodes are also recovered, AFTER the thoracic and abdominal organs have been removed from the body. 

• Once all organs are recovered, a surgeon or an OPS will close the patient 

• If retractors are brought in by Donor Alliance staff, hospital policy will be followed, and retractors will be counted and taken off the field ASAP and sent down to SPD for clean cycle. 

• A final count of instruments and disposables, or your hospital policy for count, will occur. 

• OR circulator or available staff member will call security to transport patient down to the morgue