Standing Orders for the Medical Management of Neurologically Deceased Organ Donors – Adults

• Arterial line continuous blood pressure monitoring
• Pulse oximetry, 3-lead ECG • Vital signs at least every hour
• Core temperature (rectal, bladder or esophageal) every 4 h
• Urine catheter to straight drainage, strict intake and output
• Nasogastric tube to straight drainage

• Arterial blood gases, lactate, electrolytes and glucose every 6 h, and as needed
• Complete blood counts every 12 h, and as needed
• Blood urea nitrogen, creatinine, AST, ALT, bilirubin (total and direct), INR (or PT) and PTT every 12 h and as needed
• Urine analysis

• General targets:
  • heart rate 60–120 bpm
  • mean arterial pressure ≥ 65 mmHg
  • systolic blood pressure (SBP) ≤ 180 mmHg and diastolic blood pressure (DBP) ≤ 120 mmHg
• In case of hypertension, SBP ≥ 180 mmHg or DBP ≥ 120 mmHg diastolic or if there is evidence of end organ damage:
  • Wean inotropes and vasopressors
  • Then if necessary, start short acting blood pressure lowering agents:
    • Esmolol: 100–500 µg/kg bolus followed by 100–300 µg/kg per min, OR
    • Labetalol 10 – 20 mg IV every 4 h, and as needed. If blood pressure not controlled start Labetalol IV infusion 0.5 – 2 mg per min, AND/OR
    • Nitroprusside: 0.5–5.0 µg/kg per min especially if HR < 60
• In case of hypotension MAP < 65 and/or shock:
  • Hold short acting blood pressure lowering agents
  • Fluid resuscitation to maintain normovolemia.
• Consider serum lactate and/or mixed venous/central venous oximetry; titrate therapy to MVO2 ≥ 60%

• First line: Vasopressin: 2 to 2.4 U per h (0.04 U per min)
• Second line: Norepinephrine up to 1 mcg/kg per min • Consider hydrocortisone 50mg IV every 6 h
• Additional vasopressors or inotropes depending on etiology (epinephrine, phenylephrine, dobutamine or milrinone)
• Avoid the use of dopamine at any dose

• Initiate enteral feeding (unless contra-indicated) or continue as tolerated, hold on call to the operating room
• If unable to tolerate enteral feeds, consider intravenous dextrose infusions
• Continue parenteral nutrition if already initiated prior to declaration
• Maintain serum glucose levels in the range of 6-10 mmol/L

• Urine output goal 0.5–3 mL/kg per h
• Serum Na target 135-155 mmol/L
• Maintain normal ranges for potassium, calcium, magnesium, phosphate

• Defined as:
  • Urine output > 4 mL/kg per h associated with
  • Rising serum sodium ≥ 145 mmol/L and/or
  • Rising serum osmolarity ≥ 300 mosM and/or
  • Decreasing urine osmolarity ≤200 mosM
• Therapy (to be titrated to urine output ≤ 3 mL/kg per h):
  • During hemodynamic stability:
    • Intermittent DDAVP, 1–4 µg IV then 1–2 µg IV every 6 h (there is no true upper limit for dose; should be titrated to desired urine output rate) and/or
    • Intravenous vasopressin infusion at ≤ 2.4 U per h
• During hemodynamic instability:
  • Intravenous vasopressin infusion at 2 to 2.4 U per h

Routine thyroid hormone therapy is not recommended, unless otherwise indicated or recommended. Thyroid hormone therapy can be considered in cases of cardiac dysfunction or hemodynamic instability (Tetraiodothyronine (T4): 20 μg IV bolus followed by 10 μg/h IV infusion (or 100 μg IV bolus followed by 50 μg IV every 12h)

• Routine high dose corticosteroid is not recommended.
• Routine infusion of combined solutions of glucose, insulin and potassium (GIK) is not recommended

• Transfuse packed red blood cells (PRBC) for target Hb >= 70 g/L
• Transfuse platelets to target above 10 x 109 /L or in cases of clinically relevant bleeding
• There are no predefined targets for INR, PTT; avoid transfusion of fresh frozen plasma unless in cases of clinically relevant bleeding.
• No other specific transfusion requirements

• Initial screening blood, urine, and endotracheal tube culture
• Repeat cultures as needed when clinically indicated
• Continue antibiotics started before neurological determination of death
• Administer antibiotics only for presumed or proven infection and not prophylactically

• 12-lead electrocardiogram
• 2-dimensional echocardiography
  • Consider repeat (serial) echocardiography as clinically indicated or recommended
  • Should only be performed after fluid and hemodynamic resuscitation
• Coronary angiography should only be performed in the presence of risk factors for coronary artery disease according to local criteria

• Mechanical ventilation (*):
  • Target tidal volumes: 6-8 mL/kg, and PEEP ≥ 8 cm H2O
  • Target pH: 7.35–7.45, PaCO2 : 35–45 mmHg, PaO2 : ≥ 80 mmHg, O2 saturation: ≥ 95%
• Recruitment maneuvers should be done upon ventilator disconnect (*):
  • preoxygenation with 100% FiO2
  • CPAP to 30 cm H2O of PEEP for 30 seconds
  • return FiO2 to previous FiO2
  • Use diuresis to target normovolemia
• Single routine chest radiograph should be done at baseline, additional chest imaging only as clinically indicated
• At least one-time bronchoscopy with gram stain and culture of bronchial wash

• If kidneys are considered, target goal core temperature between 34°C and 35°C • Can target normothermia if kidneys are excluded
• Test urine for albumin/creatinine ratio (ACR) only when investigating donor with type I or type II diabetes mellitus
• Consider abdominal imaging ultrasound or CT abdomen only if:
  • Age > 50
  • Comorbid conditions as determined, according to local criteria
  • High BMI
  • Clinical history for malignancy