Organ Recovery Services
Clinical Procedure
Title: : Guidelines for Evaluation and Clinical Management of Pediatric Brain Dead Organ Donors (weight < 40 kg and/or < 10 years of age)Associated Departments: Medical Director
Release Date: 08/23/2010 / Approver: Alison Smith
Revision History
Revision Date / Revision / Description of Change / Author
08/23/2010 / 11 / Update blood sample to be drawn / Michelle Mabry
03/15/2010 / 10 / Updated General Evaluation Section and Kidney Specific Evaluation / Evelyn Schultz
12/15/08 / 9 / Update template / Evelyn Schultz
4/10/2006 / 8 / Add CMV status / Martin Mozes, M.D.
9/6/2005 / 7 / Clarify antibiotics / Martin Mozes, M.D.
5/26/2004 / 6 / Change approver / Martin Mozes, M.D.
11/21/2003 / 5 / Change Weigh to Weight / Alison Smith
6/9/2003 / 4 / Revision to content / Alison Smith
7/10/2002 / 3 / Name Change / Alison Smith
3/20/2002 / 2 / Conversion to ISO format / Alison Smith
10/1/1999 / 1 / Document Created / Alison Smith
Definitions and Acronyms
ABG / Arterial blood gas
ABO / Classification system for human blood that identifies four major blood types based on the presence or absence of two antigens, A and B, on red blood cells.
ALB
ALK Phos / A blood test that measures the amount of the enzyme ALP alkaline phosphatase. When it is present in large amounts, it may signify bone or liver disease or a tumor.
ALT / alanine aminotransferase.
AST / aspartate transaminase - an enzyme normally present in body tissues, especially in the heart and liver; it is released into the serum as the result of tissue injury, hence the concentration in the serum (SGOT) may be increased in disorders such as myocardial infarction or acute damage to hepatic cells.
BP / Blood Pressure
BUN / Blood urea nitrogen - A waste product that is formed in the liver and collects in the bloodstream.
Ca+ / Calcium
Cl / Chlorine
CMV / Cytomegalovirus
CPK / A blood test that measures creatine phosphokinase (CPK), an enzyme found mainly in the heart, brain, and skeletal muscle.
CVP / Central venous pressure
CXR / Chest x-ray
DDAVP / Desmopressin Acetate
EKG / Electrocardiogram (ECG / EKG) is an electrical recording of the heart
FiO2 / Fraction of Inspired Oxygen
GGT / Gammaglutamyltransferase
H&H / Hemoglobin & hematocrit
HLA / Human Leukocyte Antigen
K+ / Potassium
KOH / Potassium hydroxide preparation
MB% / myoglobin
MG / Magnesium
Na+ / Sodium
NG / Nasal gastric
PA / Pulmonary Artery
PAWP / pulmonary artery wedge pressure (PAWP), pulmonary capillary wedge pressure (PCWP) intravascular pressure as measured by a catheter wedged into the distal pulmonary artery ; used to measure indirectly the mean left atrial pressure
PCN Allergy / Penicillin Allergy
pCO2 / Partial Pressure of Carbon Dioxide
PEEP / positive end-expiratory pressure a method of mechanical ventilation in which pressure is maintained to increase the volume of gas left in the lungs at the end of exhalation, reducing shunting of blood through the lungs and improving gas exchange.
PO4 / Phosphorus
PRBC / Packed Red Blood Cells
SaO2 / Saturation of Oxygen
SGPT / Serum pyruvate aminotransferase; an enzyme in serum and body tissues that catalyzes the transfer of amino acid groups from l-alanine to 2-ketoglutarate or the reverse, thus allowing nitrogen to be excreted or incorporated into other compounds, used to measure liver function.
Required Documents and Tools - Criteria: The items listed in this section are required to be used or followed in executing this procedure. Each item either captures or provides essential information to ensure the quality and consistency of the work being done. Documents of external origin must include the revision status in the Title field.
Title / Control / Location
References and Optional Tools - Criteria: The items listed in this section are not required but may be used or followed in executing this procedure. Each item assists or provides relevant information with regard to the work being done. Documents of external origin must include the revision status in the Title field.
Title / Control / Location
Scope / Purpose
Gift of Hope establish guidelines for the consistent evaluation and clinical management of pediatric brain dead organ donors, thereby maximizing the number of organs procured and transplanted. The following describe the guidelines for the evaluation and clinical management of pediatric brain dead organ donors.
ResponsibilitiesOrgan Recovery Coordinators and
Organ and Tissue Surgical Technicians
Surgical Coordinator
Required SkillsCommunication Skills
Assessment Skills
Documentation Skills
Blunt Dissection Skills
Identification of Laboratory and Hemodynamic abnormalities
Ability to treat Laboratory and Hemodynamic abnormalities
FlowchartInstructions
A. General Evaluation (minimum requirements)
1. History of current injury and medical treatment
2. Past medical and social history
3. Serology testing (pre-transfusion samples, if available)(1 red top tube, 1 lavender top tube)
4. ABO typing with sub-typing of ABO (A) donors
5. HLA cross-matching- obtain lymph nodes on donors >30 kg. Send 3 ACD yellow tops on all brain dead and DCD donors, If less than 30 kg confer with the Gift of Hope laboratory supervisor to determine amount of blood needed.
6. Current physical examination
7. CXR on all donors, interpreted by a radiologist
8. Continuous arterial pressure monitoring (may not be available with infants)
9. CVP monitoring
10. HgB A1C to be obtained on all donors
11. ABG, H&H, serum electrolytes every six hours during management
12. Documentation of hourly intake and output, CVP pressures, SaO2, systolic and diastolic BP, and dosage of any vasoactive medications, from the time of initiation of management
13. Documentation of core temperature every hour
14. Documentation of significant hypotension (for age), estimated frequency and length of episodes of cardiorespiratory arrest, any episodes of defibrillation
15. Two blood cultures from different sites and urine culture
16. sputum cultures on all prospective lung donors
17. Ureter Tip Cultures to be obtained intra-operatively on any donor with documented bacteria in the urinalysis.
18. Organ specific information for kidney, liver, and small bowel on all donors with consent for these organs; heart and lung evaluation on all donors, pancreas specific evaluation on all donors <90 lbs.
B. Kidney Specific Evaluation (minimum requirements)
1. Urinalysis with micro at time of admission if available, or at the initiation of management
2. Urinalysis within 24 hours of cross clamp
3. BUN and creatinine at time of admission if available, peak values, and last values obtained prior to organ recovery
C. Pancreas Specific Evaluation (minimum requirements)
1. Amylase at time of admission and/or initiation of clinical management
2. Lipase at initiation of management
3. Admit blood glucose and check values every six hours after initiation of management
D. Liver Specific Evaluation (minimum requirements)
1. AST (SGOT), ALT (SGPT), Alk Phos, Bilirubin (total and direct), GGT and Alb at time of admission if available, and initiation of clinical management (within six hours of organ offer)
E. Heart Specific Evaluation
1. EKG within 12 hours of organ offer (interpreted by a cardiologist)
2. Echocardiogram within 12 hours of organ offer (interpreted by cardiologist)
3. CPK (total and MB%) within 12 hours of organ offer
4. ABG
F. Lung Specific Evaluation (minimum requirements)
1. CXR within three hours of organ offer (interpreted)
2. Measurement of length of right lung, length of left lung, width of aortic knob, width at diaphragm (in centimeters)
3. ABG on 1.00 FiO2 and PEEP 5 cm H2O for fifteen minutes, then FiO2 decreased to 40% for fifteen minutes and repeat ABG, within two hours of organ offer
4. Gram stain upon initiation of case.
G. INTESTINE EVALUATION
1. CMV status
2. Documentation of down time, acidosis and hypoxia
3. Documentation of prolonged vasopressor use
H. Optional Evaluations (pending specific circumstances of donor)
1. Bronchoscopy (therapeutic or diagnostic)
2. Transesophageal echocardiography
3. Organ specific evaluation of heart and lungs on all pediatric donors, pancreas on donors greater than 6 years old or > 25 kg.
4. Ultrasound for suspected pathologies (kidney stones, polycystic disease)
5. Hemodynamic monitoring by Swan Ganz or CVP
CLINICAL MANAGEMENT
A. Organ Perfusion
1. Goals
a. Optimum Hemodynamic parameters as indicated below
b. Urinary output: < 2 years – 2 cc/kg/hr
> 2 years – 1 cc/kg/hr
c. CVP 4-8 mmHg
d. PAWP (if already available) 5-15 mmHg
AGE / SYSTOLIC (mmHg) / HEART RATE / RESP RATENewborn – 1 year / 65-110 / 120-180 / 30-40
1 year – 10 years / 80-120 / 80-140 / 20-30
> 10 years / manage as small adult
2. Assessment
a. Continuous arterial pressure monitoring
b. Continuous EKG monitoring
c. Hourly CVP recordings (or PA recordings if available, with PAWP readings every two hours)
d. Hourly urine output measurements
e. Urine specific gravity evaluation upon initiation of donor management and every four hours as needed
3. Intervention
a. Hypotension (Systolic BP <60 mmHg in newborn – 1year, <70 mmHg 1 year – 10 years)
i. Initial treatment: depending on serum sodium level, administer normal saline boluses of 20-30 cc/kg over 15 minutes, may repeat once. If remains hypotensive, administer vasoactive medications (see below)
ii. After second fluid bolus above, for SBP <60, initiate Dopamine infusion. Start infusion at 3-5 mcgs/kg/min and titrate to clinical effect or maximum of 20 mcgs/kg/min.
iii. If Hypotension persists with CVP 5 after fluids and Dopamine infusion at 20 mcgs/kg/min, administer Neo-synephrine infusion at 0.1 mcg/kg/min and titrate as needed to 0.5 mcg/kg/min. Alternatively, Epinephrine may be used at an infusion rate of 0.05 mcg/kg/min with titration up to 1.0 mcg/kg/min.
iv. In cases of suspected or known impaired cardiac output, initiate Dobutamine infusion if SBP continues below parameters after maximum Dopamine infusion. Begin infusion at 2-2.5 mcg/kg/min and titrate for clinical effect to maximum of 20 mcgs/kg/min. (Clinical effects may not be fully seen until 30 minutes, initial drop in BP is normal.) Terminate infusion if clinically significant tachycardias occur. When administering Dobutamine in conjunction with Dopamine wean the Dopamine infusion FIRST. Begin weaning of Dobutamine when Dopamine dosage is less than 5 mcgs/kg/min.
CLINICAL CONDITION / PREFERRED COLLOID / COMMENTSAnemia/Acute Hemorrhage / PRBC’s
(CMV negative blood will be administered if pt’s CMV status is negative or unknown) / 10-15 cc/kg
Coagulopathy/Acute Hemorrhage / FFP / 10 – 15 cc/kg
Hypotension without acute hemorrhage / Hespan
(Do not use for < 6 years old) / Max total dose of 20 cc/kg
Hypotension / 5% Albumin / 20 cc/kg bolus
b. Supraventricular Tachycardia
i. Adenosine 0.1 mg/kg (max 6mg) as iv fast bolus within 2 seconds, if no effect in two minutes, a second bolus dose of 0.2 mg/kg (max 12 mg) can be administered. If no effect, contact Managing Physician or Medical Director for further direction.
c. Other Cardiac Arrhythmias
i. Treat cardiac arrhythmias per American Heart Association PALS protocol (excluding Atropine for bradycardia)
B. Fluid Balance and Electrolytes
1. Goals
a. Serum Na+, K+, Cl-, will be within normal values
b. Urinary output of 1-2 cc/kg/hr
c. Blood glucose level 60-120 mg/dl
d. Serum Ca+, Mg and PO4 will be within normal values
2. Assessment
a. Blood electrolyte panels every six hours (or as indicated)
b. Strict hourly intake and output
c. Serum Ca+, Mg and PO4 at initiation of clinical management
3. Interventions
a. IV fluids
i. Administer maintenance fluids to maintain urinary output of 1-2 cc/kg/hr. (Use the table below to select fluid type.)
SERUM SODIUM / FLUID TYPELess than 130 / consult managing surgeon
131-140 / D5% ½ NS
141-160 / D5% ¼ NS
161 or greater / D5% W
Maintenance Rate:
<10 kg – 4cc/kg/hr
10-20 kg – 4cc/kg/hr +2cc/kg/hr for every kg over 10kgs (e.g. 15kg = 40cc+(2x5) = 50cc/kg/hr)
>20kg – 60cc + 1 cc/kg/hr (e.g. 30kg = 60 +10 = 70cc/kg/hr)
b. Hypokalemia
i. Administer KCL (adjust in cases of oliguria or polyuria)
SERUM POTASSIUM / ADD KCL PER LITRE / KCL BOLUSGreater than 5.0 / None / None
4.0 – 5.0 / 20 mEq/liter / None
3.0 – 4.0 / 40 mEq/liter / 0.5 mEq/kg dose over 1-2 hours*
Less than 3.0 / 60 mEq/liter / 0.5 mEq/kg dose over 1 hr x 2 doses*
Less than 2.5 / Consult with Peds ICU Staff
*Serum Potassium needs to be rechecked after each bolus dose.
c. Fluid Balance
i. Administer DDAVP if urinary output greater than 6 cc/kg/hr X 2 hours, and urinary specific gravity is 1.005 or less. Administer 0.05 – 0.1 mcgs/kg IV push. (May repeat dose at 0.2 mcgs/kg after 2 hours if inadequate response). Do not administer within 4 hours of OR.
ii. If DDAVP not effective after 1 –2 hours, use Vasopressin as IV infusion of 0.5 miliunits/kg/hr. Double the dose every 30 minutes to max at 10 miliunits (0.01 units)/kg/hr.
iii. Administer Lasix 1 mg/kg IV push if urinary output less than 1 cc/kg/hr provided SBP >80 and CVP >5 (PAOP > 15). Repeat at 2mg/kg after 1 hour if response inadequate. Repeat as necessary dependent on urine output. If no response to a dose of 2mm/kg consult Managing Physician. Maximum daily dose = 6mg/kg/day.
iv. Lasix may be combined with 25% Mannitol IV infusion 1-2 cc/kg, provided CVP is >10 mmHg.
d. Glucose
i. Administer regular insulin 0.1 unit/kg IV or 0.2 units/kg SQ for glucose > 300 mg/dl. Remove all dextrose containing solutions from IVF administered. Repeat glucose level 30 minutes after insulin. Repeat same dose if glucose remains > 300 mg/dl. If after second dose glucose remains > 300 mg/dl, initiate insulin infusions at 0.05 – 0.1 units/kg/hr and titrate based on hourly glucose levels.
e. Hypocalcemia
i. Administer Calcium Chloride 10mg/kg (0.2 cc/kg of 10% solution) IV slowly, no faster than 100 mg/min to avoid bradycardia, if ionized calcium < 1.0 or total calcium < 8.5 mEq/liter. Evaluate serum calcium at initiation of management, and if greater than 4 units of PRBCs (approximately 25 ml/kg) have been infused.
f. Hypomagnemia
i. Consult Managing Physician or Medical Director. Consider administration of magsulfate 25-50 mg/kg.
C. Hematology
1. Goals
a. Hgb greater than 10 GMs/dl and Hct greater than 20%