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:
- Adhere to age-related norms for pulse and blood pressure
- In case of age-related hypotension 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 0.05 to 0.1 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 o
- 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: 0.25–1 μg IV every 6 h (there is no true upper limit for dose; should be titrated to desired urine output rate)
- Intravenous vasopressin infusion 0.0003–0.0007 U/kg per minute (0.3– 0.7 mU/kg/minute) to a maximum dose of 2.4 U/h
- During hemodynamic instability: Intravenous vasopressin infusion 0.0003– 0.0007 U/kg per minute (0.3–0.7 mU/kg/minute) to a maximum dose of 2.4 U/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 50–100 μg IV bolus followed by 25–50 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 PRN 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
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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 |
- 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 according to local criteria
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