Standard monitoring |
- 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
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Laboratory investigations |
- 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
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Hemodynamic monitoring and therapy |
- 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%
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Agents for hemodynamic support |
- 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
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Glycemia and nutrition |
- 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
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Fluid and electrolyte targets |
- 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
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Diabetes insipidus |
- 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
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Hormonal therapy |
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
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Hematology |
- 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
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Microbiology |
- 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
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Heart-specific orders (to be initiated in potential heart donors) |
- 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
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Lung-specific orders |
- 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
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Intra-abdominal organs-specific orders |
- 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
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