Kidney Specific Evaluation

4

1.     Urinalysis with micro at time of admission if available, and 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 every 4-6 hours starting at the initiation of case.

4.     Ureter tips to be cultured when most current UA show bacteria

Pancreas Evaluation

3

1.     Amylase, Lipase at initiation of management and repeated every 4-6 hours

2.     Documentation of Blood Glucose levels and insulin administration throughout hospital stay

3.     Hgb A1C to be obtained on all donors

Intestine Specific Evaluation

3

1.     Obtain CMV status of donor

2.     Documentation of downtime, acidosis, and hypoxia

3.     Documentation of prolonged pressor usage

Liver Evaluation

4

1.     AST (SGOT), ALT (SGPT), Alk Phos, Bilirubin (total and direct), GGT, Alb and LDH at time of admission if available, and q4-6 hrs throughout case.

2.     PT/PTT at time of initiation of clinical management and  q4-6 hrs as indicated

3.     Fibrinogen/FSP or D-dimer at time of initiation of clinical management and q4-6 hrs as indicated

4.     Bedside liver biopsy when requested by transplant center or at AOC discretion when possible

Heart Specific Evaluation

a-f

a.     12 lead EKG

b.     Troponin, CPK, CPK-MB measured every 4-6 hours

c.     Echocardiogram (and repeat later in case when indicated)

d.     TEE if unable to obtain echo or if poor window visualized

e.     Cardiac Catheterization (refer to policy).

f.      Continuous cardiac output monitoring when available

Lung Evaluation

1-7

1.     CXR upon initiation of case (interpreted by a physician) repeated q4 hours

2.     Measurement of  L of right lung, L of left lung, and W at diaphragm (in cm)

3.     O2 challenge every 4 hours-ABG on 1.00 FiO₂ and PEEP 5 cm H₂O for 30 minutes, then FiO₂ decreased to the donor's initial ventilator setting for fifteen minutes and repeat ABG.  The O₂ challenge test must be performed within two hours of starting organ offer.

4.     Gram stain at initiation of case

5.     Bronchoscopy (refer to policy)

6.     Continuous cardiac output monitoring when available

7.       IPV treatments when available.  GOH coordinator to determine settings based on donor tolerance

Optional Evaluations

1-6

1.     A cardiac catheterization is necessary if the donor meets established criteria or has significant risk factors—this will be done before organ offers at the discretion of the AOC(refer to policy)

2.     Pulmonary Artery Catheter monitoring to be done when requested by the transplant center. 

3.     KUB to be done when there is a known history of kidney stones

4.     CT of abdomen and or chest for investigation of trauma or pathology to be done at medical director discretion or request of transplant center.

5.     Continuous cardiac output monitoring

6.       IPV treatments

Arterial blood pressure

!!!GOAL/END points!!!

MAP > 60

SBP > 90

SV goal

What is SV?

>50

I dont know

1-3 ml/kg

Or

>60-100ml/hr

Donor specific interventions:

Steroids?

A.     Solumedrol 1gm q 12hr - to be given on every donor as early in case as possible. 

       Give Decadron 200 mg IVPB over 20 min at initiation of case and repeat dose within 1 hour of OR when solumedrol is not available.

Donor Specific Interventions:

Hypotension (basic)

3

1.     MAP to be maintained at ≥ 65 when off vasopressors

2.    Maintain MAP between 60-65mm/Hg when on vasopressors

3.     If MAP is ≥65 active weaning of vasopressors should be ongoing as tolerated by Donor.

Clinical Situation: What do you do? What do you do!?!

Active hemorrhaging and or Hypovolemia (SVV>18%or CVP<8) and hypotensive

First Line:       Blood and blood products

Second Line:  Fluid bolus if no blood products are required

Third Line:      Move to vasopressors until donor can be

                       fluid resuscitated

Clinical Situation: What do you do? What do you do!?!

Normovolemic (SVV 13-18% or CVP 4-8) and Hypotensive

First line:        Treat cause (hypoxemia, acidosis, electrolyte 

                        imbalance, etc.)

Second Line:  Move to vasopressors while the above are being

                        treated

Clinical Situation: What do you do? What do you do!?!

Hypervolemic (SVV<13% orCVP>10) and Hypotensive

First Line:      Diurese with Lasix

Second Line:  Move to vasopressors while diuresing

Guidlines to choosing vasoprssors: When to use/not use?

Neosynephrine

First line drug in most cases

Switch to this drug if other vasopressors are being utilized and then wean others as tolerated

In most cases, this is the LAST vasopressor to wean off

Dosage:  Up to 400 mcg/kg/min

Guidlines to choosing vasoprssors: When to use/not use?

Levophed

Second line drug to be used when Neosynephrine is maxed at 400mcg/min

Use as second line drug

Dosage:  Up to 40 mcg/min

Guidlines to choosing vasoprssors: When to use/not use?

Vasopressin

Third Line Drug when Neosynephrine and Levophed are maxed. First line drug when SVR<600  

DO NOT USE when donor is showing signs of renal insufficiency and or has UO <100cc/hr,

DO NOT USE STRICTLY FOR DI- f pt is NOT hypotensive treat DI with DDAVP

Dosage:  Up to .17 U/min

Guidlines to choosing vasoprssors: When to use/not use?

Dopamine

Consider starting when the above drugs are maxed outAvoid drug if HR is elevated >120 bpm

Do Not use to increase UO - Use lasix/fluid for UO

Dosage: Up to 20mcgs/kg/min

Guidlines to choosing vasoprssors: When to use/not use?

Epinephrine

Last vasopressor to be added

Do not use if not maxed on all the above

Must be weaned prior to Echocardiogram

Dosage: up to 10mcgs/min

Guidlines to choosing vasoprssors: When to use/not use?

Dobutamine/

Milrinone

Use with known Heart Failure, when LVF is severely depressed, or if none of the above drugs are maintaining organ perfusion *consult with Managing surgeon

These drugs MUST BE WEANED OFF AT LEAST 1HOUR PRIOR TO OBTAINING ECHO

Clinical situation: What do you do? What do you do!?!

Hypertension

HR 60-100 AND DBP>100 FOR 1 HR

a.     May consider Lopressor 5-10mg IVP q1 hour for SPB>170 or DBP>90

NIPRIDE INFUSION:

Mix 50mg in 250 D5W

Begin infusion at .3mcg/kg/min and titrate to max of 5mcg/kg/min for clinical effect

Clinical situation: What do you do? What do you do!?!

Hypertension

HR > 100 AND DBP> 100 FOR 1HR

a.     May consider Lopressor 5-10mg IVP q1 hour for SPB>170 or DBP>90

ESMOLOL INFUSION:

Mix 20mg in 100cc NS

Loading dose of 500mcg/kg/min over 1 min

Maintenance dose starts at 50mcg/kg/min and titrated to max of 200mcg/kg/min for clinical effects

*If Esmolol decreases HR but fails to decrease DBP add Nipride drip as indicated above

Clinical situation: What do you do? What do you do!?!

Cardiac Arrhythmias (SVT, Bigemeny, VT, etc)

a.             Obtain stat 12 lead EKG w stat interpretation by a physician

b.             Send stat electrolyte panel including Mg, Ca, and Phos

c.             Initiate tx of abnormal lytes stat (refer to fluid/electrolyte section)

d.             Initiate current ACLS protocols

e.             Contact transplant surgeon accepting heart, or if not placed, contact managing surgeon for further management suggestions.

Clinical situation: What do you do? What do you do!?!

What is choice of IVF based on?

Clinical situation:

LR

Clinical situation:

.9NS

Clinical situation:

 .45NS

Clinical Situation:

D5W

Na level >165  (try to avoid using if pt will be pancreas donor or if glucose levels are elevated) Manage glucose levels

Clinical Situation:

3% 100ml bolus

Na level < 130

contact managing surgeon/AOC before infusing

Clinical Situation:

fluid balance - infusion rate?

Infusion rates chosen to maintain CVP 4-8 and SVV 13-18%b                

Administer 20-40 mg lasix as required to maintain CVP 4-8 and SVV 13-18%

Bumex 1-5mg IVP given when lasix fails to produce UO 1-3cc/kg

Clinical Situation:

fluid balance - Bolus, Mannitol and DDAVP?

Administer Fluid boluses as required to maintain CVP 4-8 and SVV 13-15%

Administer 25% mannitol 12.5-25g IVPB for NPE as needed

Administer 2-4mcg of DDAVP Q1-2 hours for UO >300-400cc/hr and urine specific gravity of 1.005 or less

Administer vasopressin for DI when DDAVP is ineffective

Clinical situation:

Hyponatremia

Maintain sodium level of 135-145

Hyponatremia caused by overdose of free H2O or overuse of D5W

Check phosphate levels when sodium is low

Clinical Situation:

Hypernatremia

Maintain sodium level of 135-145

Hypernatremia is caused b severe dehydration or an overdose of .9NS

It is corrected by hydrating with dilute saline solutions and/or use of loop diuretics

Large volumes of D5W should be avoided in potential pancreas donors

Clinical Situation:

Hypokalemia

Potassium range?

Maintain K level 4.0-5.5 mEq/L

Give in 40 mEq in100 cc NS Infuse at 20 mEq/hr. 

Draw Phos level before administering K. Phosphate has to be given with Na+ or K+

Clinical Situation:

Hyperkalemia

• Maintain Potassium level 4.0 to 5.5 mEq/L
• Contact the managing surgeon with extremely high potassium levels
• It is common for high potassium levels to be a result of hemolyzed sample.
• ALWAYS re-run level with FRESH sample immediately
• Dialysis is an option but confer with AOC/medical director prior to initiating

Clinical Situation:

K+ levels > 6.0 mg/dl

10 units Humalog insulin + one ampule of D50 + one ampule of NaHCO3 IV push may be given but not prior to discussion with Medical Director/AOC and/or Managing Surgeon,  If this form of therapy is utilized, re-check glucose 2 hours and potassium 4 hours after therapy,

After any therapy, potassium levels should be re-checked every 4 hours,

Clinical Situation:

Hyperkalemia txs?

Clinical Situation:

Calcium level goal?

Clinical Situation:

Treating Hypocalcemia

Maintain Calcium level 8.5 to 10.5 mg/dL

Give calcium chloride slow IVP or IVPB over 10-15min,

*May need to increase doses if giving PRBCs

Clinical Situation:

Hypomagnesium?

Maintain Magnesium level 2.0 to 3.0 mg/dL

Mix in a bag of 100 cc NS infuse over 20-30 min

Maintain Phosphorus level 2.4 to 4.7 mg/dL

Always check K+/NA+ levels before administering, as Phos can be given only with KCL or NA

IF POTASSIUM LEVELS ARE GREATER THAN 4.5 AND NA LEVELS ARE <135

Loss of brain stem reflexes

Prior to planned DC of support

Pupils

corneals

cough/gag

response to pain

breathing

1. Dispatch ORC, DS, DC
2. Review medical record
3. PCC
4. Approach

Attending

Nurses

...

1. FPC
2. DBD
3. DCD

Illinois - All organs and tissue but not research

Indiana - Only organs - no tissue or research

1. Manage donor
2. Obtain nodes, serologies and cultures
3. Creates donor chart

ID testing -

ABO w subtype

Serology testing

Histocompatibility HLA

Hep B

Hep C

HIV

RPR - syphilis

CMV

EBV

Placement Perfusion Coordinator - place HILL

Heart and Lung - HLA

Intestine 

Liver - MELD/PELD

• ICU nurse/charge
• Attending physician
• Support staff
• Pharm
• Lab
• Cards
• Pulm
• Path
• OR staff - Scrub, circ, anesth/CRNA

1. GoH does not manage the donor
2. Extubation and comfort care is donse by the hospital
3. ORC does not perform lymph node dissection
4. No invasive procedures are performed with Hosp obtained consent from the family
5. Off the vent testing -- hospital physicians order required
6. Declaration of death is done by the hosp phys
7. Organs are recovered in the OR by transplant surgeons

1. Verify ABO
2. Pronouncement of death
3. Consent
4. OPO donor chart and Med/Soc Hx
5. Serology results
6. Plasma dilution

APO w subtype

death note

consent

OPO chart w med/soc hx

Seroloy results

Plasma dilution

***blood/tissue sample***

Time out

Entered the OR time (I entered)

Incision time

Cross clamp

Each organ out of body

Slush ready

anesthesia has correct heparin dose

flush set up

continuous suction ready (circulator)

OR table path to bach table 

1. Start flush - free flowing
2. Note time of Cross Clamp
3. Be sure flush is flowing full and be ready for switch
4. Notify of each L of flush infused (4L usual total)

Have flush solution ready

Kidney anatomy documentation

biopsies - conical with Redstuff

Labels are ready before hand

Cardioplege, UW, or Celsior solution arrests the heart (1-2L)

Cross clamp - Slush into cavity

Max cold time 4-6hrs

Pulmoplege used to perfuse (1-4L)

Cold saline/slush in cavity

MAX Cold time - 4-6hrs

Prostaglandin e

SPS (GOH) to perfuse (2-6L)

Slush in cavity

MAX cold time - 12-18hrs

Be prepared with back table flush - 500ml in kidney cups/1L Liver

SPS 2-6L

Dissection and flush at back table

MAX cold time 36hr+

OR documentation

PAPER

POAP

Paper--

Anesthesia worksheet

Op Note

Kidney anatomy form

BD checklist (signed prior to start)

Waivers- ???

Organ Release Trip Sheet

POAP-- 

Cross clamp time

Names of OR Staff/team members

Solution, additives, volume, characteristics of flush

Solution volume

HEART - anatomical abnormalities, surg damage

LUNGS

LIVER

KIDNEY -

PANC

Vessel

Standardized internal lable distributed by the OPTN contractor

The label must contain:

• Recovery date
• ABO
• all serology results
• container contents
• UNOS Donor ID
• "High risk" status

Box- label same color

     (Bag

          (rigid container cooler - Donor doc (ABCD(POAP chart???),PD,Serology)

               (bag

                    (bag-label same color))))

EXTERNAL ORGAN LABEL

MUST HAVES

1. UNOS ID
2. DONOR ABO
3. CROSS CLAMP DATE AND TIME
4. CONTENTS OF BOX
5. Doc ice
6. ILIP - 1800-545-4438
7. Destination Info

PUT LABEL ON OUTSIDE OF BOX