TEXAS ORGAN SHARING ALLIANCE (TOSA)
Pediatric Organ Donor Order Set
DONOR NAME ______
HEIGHT: ______cm WEIGHT ______kg
DONOR ALLERGIES: ______Date _____/_____/_____ Time ______:______(24 hour time)
GENERAL:
Contact admitting to discharge patient and create new patient account prior to other orders.
Notify TOSA coordinator immediately of any hemodynamic instability or critical lab values.
Monitor core temperature. Artificial warming as needed to keep core temp greater than or equal to 37 degrees Celsius (98.6 degrees Fahrenheit)
Record hourly vital signs to include systolic blood pressure (SBP), mean arterial pressure (MAP), HR, CVP, core temperature, urine output
RESPIRATORY:
Current ventilator settings: MODE: _____, TV/PC _____, Rate ____, PEEP ___, FiO2____
Portable chest x-ray STAT (after central line placement if not previously placed)
NG or OG tube to low intermittent wall suction
Inflate ETT cuff to maximum
Bronchoscopy
CARDIOVASCULAR:
12 Lead ECG (to be read by cardiologist)
Echocardiogram – 2D mode (TEE if Transcutaneous views not acceptable)
LABORATORY: All labs to be run STAT with results given to TOSA Coordinator
Type and Cross 2 units PRBC’s. Keep 2 units on hold at all times
Chemistry Panel: BMP, Calcium, Magnesium, Phosphorus
Liver /Pancreas Panel: AST, ALT, LDH, AlkPhos, Total & Direct Bili, PT/PTT (INR), Total Protein, Albumin, Lipase, Amylase
Heart Panel: Cardiac enzymes, MB fraction, Troponin
CBC with differential (automated or manual)
Urinalysis with micro
Cultures: Blood culture x 1, urine culture, sputum culture and gram stain (please report gram stain STAT).
ABG on current vent settings
LINE PLACEMENT:
Place arterial line and central line (triple or quadruple lumen), if not already placed, and transduce CVP
IV FLUIDS:
Maintenance IV fluid: ______with ______mEq KCL/Liter to run at ______mL /hour
Arterial Line: Normal saline + heparin 2 units/mL @ 1 mL/hr □ add Papaverine 12 mg/100 mL
Central venous line: Normal saline + heparin 2 units/mL @ 1 mL/hr
CONTINUOIUS INFUSIONS: (Titrate off all other vasoactive medications after Dopamine & Vasopressin have started and patient is stable)
Continue current infusion of ______at ______until titrated off.
Continue current infusion of ______at ______until titrated off.
Dopamine ______mcg/kg/min (not to exceed 20 mcg/kg/min). Titrate for age appropriate SBP or MAP.
Vasopressin (1 unit/mL) ______units/kg/MINfor blood pressure maintenance only (0.0003-0.002 units/kg/MIN)
Milrinone ______mcg/kg/min (0.3 – 0.7 mcg/kg/min) for inotropic effect
OTHER MEDICATIONS:
Methylprednisolone (SoluMedrol®) ______mg (1 mg/kg/dose) IV x1 dose
Vasopressin (0.1 unit/mL) ______units/kg/HOUR for diabetes insipidus (0.0005-0.01 units/kg/HOUR)
Cefazolin (Ancef®) ______mg (25 mg/kg/dose; Max: 1 gm/dose) IV every 6 hours
Continue current antibiotic/antifungal : ______
Contact ORC at this number for questions / clarifications: ______
TOSA ORC Name Printed: ______TOSA ORC Signature: ______
Page 1 of 2