OneLegacy - Organ Donation Alliance

OneLegacy
Clinical Practice Guidelines
Adult Brain Dead Donor
1
Table of Contents
ONELEGACY MANAGEMENT GOALS .......................................................................................................................................................... 4
DONOR MONITORING ................................................................................................................................................................................ 5
DONOR INTERVENTIONS ............................................................................................................................................................................ 6
Hypotension ............................................................................................................................................................................................ 6
Definition .......................................................................................................................................................................................................................... 6
Hypotension Management ............................................................................................................................................................................................... 6
Hypotension Pharmacological Management .................................................................................................................................................................... 7
Hypertension........................................................................................................................................................................................... 8
Definition .......................................................................................................................................................................................................................... 8
Hypertension Pharmacological Management ................................................................................................................................................................... 8
Fluid and Electrolytes .............................................................................................................................................................................. 9
General Table of Normal Values ....................................................................................................................................................................................... 9
Fluid-Reference ............................................................................................................................................................................................................... 10
Fluids .............................................................................................................................................................................................................................. 11
Electrolytes ..................................................................................................................................................................................................................... 11
Sodium ................................................................................................................................................................................................................................. 11
Potassium ............................................................................................................................................................................................................................. 12
Magnesium ........................................................................................................................................................................................................................... 12
Calcium ................................................................................................................................................................................................................................. 13
Phosphate............................................................................................................................................................................................................................. 13
Diabetes Insipidus (DI) Management ................................................................................................................................................... 14
Definition ........................................................................................................................................................................................................................ 14
Symptoms ....................................................................................................................................................................................................................... 14
Treatment....................................................................................................................................................................................................................... 14
Temperature ......................................................................................................................................................................................... 14
Blood Products ...................................................................................................................................................................................... 15
PRBCs ................................................................................................................................................................................................... 15
2
Disseminated Intravascular Coagulopathy (DIC) Management ........................................................................................................... 16
Definition ........................................................................................................................................................................................................................ 16
Symptoms ....................................................................................................................................................................................................................... 16
Test................................................................................................................................................................................................................................. 16
Treatment....................................................................................................................................................................................................................... 16
Lung Management ................................................................................................................................................................................ 17
ABG Reference Range ..................................................................................................................................................................................................... 17
Ventilation Goals ............................................................................................................................................................................................................ 17
Lung Therapies ............................................................................................................................................................................................................... 18
Oxygenation ......................................................................................................................................................................................................................... 18
Oxygenation Challenge......................................................................................................................................................................................................... 19
Manual CPT .......................................................................................................................................................................................................................... 19
Pulmonary Recruitment Maneuver ...................................................................................................................................................................................... 20
PEEP Maneuver .................................................................................................................................................................................................................... 20
Lung Conditions .............................................................................................................................................................................................................. 22
Respiratory Acidosis & Respiratory Alkalosis ....................................................................................................................................................................... 22
Atelectasis ............................................................................................................................................................................................................................ 22
Pulmonary Infiltrates ............................................................................................................................................................................................................ 22
Pleural Effusions ................................................................................................................................................................................................................... 23
Pulmonary Edema ................................................................................................................................................................................................................ 23
Liver Biopsy Management Guideline .................................................................................................................................................... 24
Indications and Preparation ........................................................................................................................................................................................... 24
Considerations ................................................................................................................................................................................................................ 24
Potential Complications .................................................................................................................................................................................................. 24
Post Biopsy Care ............................................................................................................................................................................................................. 24
Insulin Therapy...................................................................................................................................................................................... 25
Initial Insulin Guide ......................................................................................................................................................................................................... 25
Insulin Titration Guide .................................................................................................................................................................................................... 25
Insulin Titration Algorithm .............................................................................................................................................................................................. 26
References ................................................................................................................................................................................................ 27
3
OneLegacy
Clinical Practice Guidelines
Adult Brain Dead Donor
All treatments are to be documented. Treatments outside these guidelines require OneLegacy Team Lead (OTL) approval.
ONELEGACY MANAGEMENT GOALS1
Categories
Reference Ranges
Mean Arterial Pressure (MAP)
60 – 110 mmHg*
Central Venous Pressure (CVP)
4 – 12 mmHg
Ejection Fraction (EF)
≥ 50%
Arterial Blood Gas (ABG) – pH
7.3 – 7.5
P:F Ratio
≥ 300
Sodium
135 – 150 mEq/L**
Glucose
80 – 140 mg/dL**
Urine Output (UO)
≥ 0.5 ml/kg/hr balance over 4 hrs
Vasopressors
≤ 1 pressor
(Dopamine > 10 mcg/kg/min,
Neosynephrine > 60 mcg/min or
Levophed > 10 mcg/min)
Heart Rate (HR)
60 – 120 bpm
Lab values
Within Normal Limits (WNL)
Temperature (T)
96 – 99.5°F / 36 – 37.5°C
> 8.9 gm/dL /27 %
Hemoglobin / Hematocrit (H/H)
*If donor has a history of Hypertension (HTN), MAP goals are 70-110 mmHg
++
** Differs from Donor Management Goals (DMGs): Na ≤ 155 mEq/L , Gluc ≤ 150 mg/dL
NOTE: Unstable Donor = Hypotension or Normotensive and titrating pressors to maintain BP
1
(dePerrot et al., 2004; ; Powner, Darby, & Kellum, n. d; Shemie et al., 2006; Wood & McCartney, 2007)
4
DONOR MONITORING2
Q1H
Q2H
Q4H
• Vital Signs
• CVP
• Core temp
• Turn & Suction
• Peak Inspiratory
Pressure (PIP)
• Blood sugars
(unless on
drip, pg. 25)
• Terminal labs
(drawn no less
than 2 hrs
before set OR
time)
• Result all
cultures (no
less than 2 hrs
before set OR
time)
• CMP (Na, K, Cl, CO2, BUN,
Creatinine, Glucose, Ca,
AST, ALT, Alk Phos, T. Bili, D.
Bili, Albumin, T. Protein),
Mg, PO4, iCa
• Cardiac enzymes (CPK/CK
MB, Troponin I)
• Amylase, Lipase
• Serum Osmolality
• Lactate
• CBC with manual
differential
• PT / PTT / INR
• Urinalysis with microscopy
exam
• ABG
• Intake & Output
(I&O)
• SaO2/ETCO2
Q6H
• CXR (lung
donor)
Other
• Continuous arterial pressure monitoring (left radial
preferred)
• Continuous EKG monitoring
• Measure height and record the earliest documented
hospital weight
• Hospital ABO/Rh (Subtype group A from at least one
source) from two separate draws (Note: Must have name
of facility on result)
• LDH/GGT
• Blood culture (aerobic/anaerobic) from all existing
central/arterial lines and at least 1 peripheral stick
• Urine Culture with Gram Stain
• Sputum Culture with Gram Stain
• 12-Lead EKG with cardiology interpretation on all donors
• Chest Percussion Therapy
(CPT)
• Bronchoscopy for all potential lung donors and as needed
• Pulmonary Recruitment Maneuver every 12 hrs and as
needed (pg. 20)
• Pulmonary Artery Wedge
Pressure (PAWP) as
applicable
• Before performing ECHO correct electrolytes, donor should
be on minimal pressors, normothermic, euvolemic and
cardiac enzymes trending downward
• 2D ECHO with 2 and 4 chamber view as well as short and
long axis views. Include wall thickness including septum
and posterior wall and EF
• Perform EKG within 2 hrs of ECHO
• Daily Weight
• Hemodynamics
(as applicable)
++
++
[Complete Metabolic Panel (CMP), Magnesium (Mg ), Phosphate (PO4 ), Ionized Calcium (iCa ), Complete Blood Count (CBC) with manual differential,
Prothrombin (PT) / Partial Thromboplastin Time (PTT) / International Normalized Ration (INR)]
Note: The above must be documented!
2
(dePerrot et al., 2004; Powner, Darby, & Kellum, n.d)
5
DONOR INTERVENTIONS
Hypotension
Definition
MAP < 60 mmHg or < 70 mmHg with history of HTN
Goal: Ensure adequate hydration
 CVP 4-12
 UO > 0.5 ml/kg/hr balance over 4 hrs
Hypotension Management3
HYPOTENSION
(causes)
Hypovolemia
(fluid loss)
CVP ≤ 4
Hypervolemia
(fluid overload)
CVP > 15
** pg. 11**
** pg. 23**
• Consider fluid
bolus, reassess
and repeat PRN
• Consider
diuretic or
vasodilator
Low H & H
(anemia)
Hgb < 8.9
mg/dL
Hct < 27 %
** pg. 15**
• Consider
transfusion for
Hgb < 10 mg/dL
and Hct < 30 %
Electrolyte
imbalance
** pg. 11-13**
• Replace as
indicated
• Do NOT use
hypotonic
solutions as
fluid boluses for
volume
resuscitation
3
Cardiac
arrhythmias
• Ensure
electrolyte
balance
(Ca, Mg, K)
• Cardiac consult
for
Antiarrhythmic
medication
(Shemie et al., 2006; Wood, Becker, McCartney, D’Alessandro, & Coursin, 2004)
6
Temperature
Acidosis
pH < 7.2
Hypotension &
euvolemia
Poor cardiac
function
** pg. 14**
** pg. 22**
** pg. 7**
** pg. 7**
• Medication
choices should
include options
A-E
• Medication
choices should
include options
A, C, D, F, & G
** pg. 7**
** pg. 7**
• Maintain
normothermia
(96-99.5°F /
36-37.5°C)
• Correct cause
Hypotension Pharmacological Management
Before initiation of “Hypotension Pharmacological Management” guidelines, the following should be considered first:
1. Administration of Solumedrol per standing orders
2. For renal graft function, Dopamine (1-4 mcg/kg/min) and Vasopressin (0.5 u/hr) as per standard orders
Use these guidelines4 after other causes are ruled out (pg. 6). For donors already on pressors, initiate T4 protocol and aggressively
wean pressors keeping MAP ≥ 60 or ≥ 70 mmHg with history of HTN.
Use of pressors in order of importance (A-E). Consult for use of inotropes (F&G) for poor cardiac function.
HYPOTENSION PHARMACOLOGICAL MANAGEMENT
T4 is the first pharmacological choice (prior to pressors or inotropes) for the treatment of the hypotensive donor.
*** Do NOT wean T4 until other pressors have been weaned.***
Drug
Start
Max
Comments & Precautions
A
T4 (Levothyroxine)
10 mcg/hr
30 mcg/hr
B
Vasopressin
0.6 u/hr
5 u/hr
C
Dopamine
5 mcg/kg/min
30 mcg/kg/min
D
Levophed
5 mcg/min
30 mcg/min
E
Neosynephrine
10 mcg/min
300 mcg/min
F
Dobutamine
5 mcg/Kg/min
30 mcg/Kg/min
G
Milrinone
0.25 mcg/kg/min
1 mcg/kg/min
- Ensure K levels are corrected
- Monitor U/O if < 0.5ml/kg/hr consider
“D” or “E” for alpha support
Start “D” if:
- HR increases 30 bpm above baseline or
- >120 bpm for 1 hr or
- if drip exceeds 15 mcg/kg/min
Start “E” if:
- HR increases 20 bpm above baseline or
- >130 bpm for 1 hr or
- if drip exceeds 15 mcg/kg/min
- Start if HR > 130 bpm for 1 hr and
vasopressin contraindicated
- Consult with cardiology prior to use
- consider for CVP > 15 mmHg and poor
cardiac function
- may cause tachycardia and hypotension
4
(dePerrot et al., 2004; Institute for Healthcare Improvement [IHI], n.d.; Rostron et al., 2008; Shemie et al., 2006; Wood, Becker, McCartney, D’Alessandro, & Coursin, 2004; Wood & McCartney,
2007)
7
Hypertension
Definition
MAP > 110 mmHg
Hypertension Pharmacological Management5
HYPERTENSION PHARMACOLOGICAL MANAGEMENT
If the donor is hypertensive the following steps should be followed:
Ensure donor is not fluid overloaded (CVP > 15 mmHg, see Pulmonary Edema, pg. 23) then →
wean vasopressors → inotropes → T4 → treat BP.
If the donor’s HR > 120 bpm, consider option Ι & ΙΙ.
Drug
Start
Max
A
Morphine
10 mg IVP
10 mg/hr
B
Nicardipine
5 mg/hr
15 mg/hr
C
Nipride
0.25 mcg/kg/min
10 mcg/kg/min
D
Nitroglycerin
Bolus 12.5-25 mcg
IVP
500 mcg/min
- Central venous dilator
- may cause tachycardia
Labetalol
5 mg IV slow push
May repeat PRN
4 doses (20mg)
- May be considered as 1st line for HR > 120 bpm
- after 4th dose within 2 hrs start Esmolol drip
- may require extra fluid volume
Esmolol
Bolus 500 mcg/kg
over 1 min (Repeat
PRN for
tachycardia); Infuse
at 50 mcg/kg/min
Ι
ΙΙ
5
Comments & Precautions
200 mcg/kg/min
(Kutsogiannis, Pagliarello, Doig, Ross, & Shcmic, 2006; Shemie et al., 2006)
8
- Give IV bolus
- if effective repeat as needed or start a drip
- may cause tachycardia
- Calcium channel blocker causing central arterial
vasodilation
- may cause tachycardia
- Check cyanide levels for extended use or high
doses in renal compromised donors
- potent vasodilator
- may cause tachycardia
- May be used in conjunction with other classes of
antihypertensives and
- may require extra fluid volume
Fluid and Electrolytes
General Table of Normal Values6
6
7
Electrolytes
Normal Values
Sodium (Na+)
135 – 150 mEq/L (135-150 mmol/L) (pg. 11)
Potassium (K+)
3.5 – 4.5 mmoI/L (3.5-4.5 mEq/L) (pg. 12)
Corrected Serum Calcium (Ca++)
8.5-10.5 mg/dL (2.1-2.6 mmol/L) (pg. 13)
Ionized Calcium (ICa++)
4.5-5.6 mg/dL (1.1-1.4 mmol/L)7 (pg. 13)
Magnesium (Mg++)
1.8 – 2.3 mg/L (0.7-0.9mmol/L) (pg. 12)
Phosphate (PO4-)
2.3 – 4.7 mg/dL (0.7-1.5mmol/L) (pg. 13)
Blood Glucose
80 – 140 mg/dL (4.4-7.8mmol/L) (pg. 25)
(Shemie et al., 2006; Wood, Becker, McCartney, D’Alessandro, & Coursin, 2004)
http://www.globalrph.com/conv_si.htm ; http://en.wikipedia.org/wiki/Calcium_metabolism
9
Fluid-Reference
IV Fluid Composition per Liter8,9,10
Fluid
Glucose
(g)
Na
Cl
K
(mmol/L) (mmol/L) (mmol/L)
Ca
HCO3
mOsm/
(mmol/L) (mmol/L)
L
Kcal/L
Crystalloids
D5% (D5%W)
50
0
0
0
0
0
2502
170
D10% (D10%W)
100
0
0
0
0
0
556
340
D20% (D20%W)
200
0
0
0
0
0
1112
680
D50% (D50%W)
500
0
0
0
0
0
2777
1700
0.45% NaCl
0
77
77
0
0
0
154
0
3% NaCl
0
513
513
0
0
0
1025
0
0.9% NaCl
0
154
154
0
0
0
308
0
D5% in 0.225 NaCl
50
38
38
0
0
0
284
170
D5% in 0.45% NaCl
50
77
77
0
0
0
431
170
D5% in 0.9% NaCl
50
154
154
0
0
0
560
170
D5% in LR
50
130
110
4
3
27
575
180
0
130
110
4
1.5
27
273
<10
Lactated Ringers
(LR)
Colloids
Albumin 25%
(50ml)
-
130-160
130-160
<10
0
0
1500
-
Albumin 5%
(250ml)
-
130-160
130-160
<2
0
0
300
-
Hespan 6% (100ml)
-
154
154
0
0
0
310
-
8
http://www.efn.org/~nurses/IVF.html; http://en.wikipedia.org/wiki/Intravenous; http://www.talecris-pi.info/inserts/Plasbumin5.pdf
www.drugs.com
10
http://www.mybwmc.org//library/41/061100
9
10
Fluids
Goals: Urinary output of > 0.5 ml/kg/hr and CVP 4-12 mmHg
Fluid Management Recommendations
Precautions to Fluid Management
 If the sodium is within the normal range and the blood
sugar is ≤ 200 mg/dL, use D5%0.45% NaCl for maintenance
IV fluid
 Follow electrolyte guidelines to add to or change IV fluids as
needed, considering K and Na levels and replacing other
electrolytes per guidelines
 Administer maintenance fluids at rate of 1.25 ml/kg/hr
 5% Dextrose should be added to ALL maintenance IV fluids
unless blood sugar is > 200 mg/dL
 Total hourly intake, should NOT exceed 150 ml/hr unless during
fluid resuscitation
 Do NOT use hypotonic solutions (e.g. D5%W, D5% 0.45% NaCl,
0.45% NaCl) as boluses
Electrolytes11
Sodium
Sodium12 135 – 150 mEq/L (135-150 mmol/L)
Hyponatremia
Na < 135 mEq/L (mmol/L)
Hypernatremia
Na > 150 mEq/L (mmol/L)
+
Serum Na+
Na 125-134 mEq/L
Na < 125 mEq/L
11
12
+
Treatment
Treatment
• Change IVFs to D5% 0.9%
NaCl or 0.9% NaCl
• Wean Vasopressin / DDAVP
Tap Water lavage
• Call OTL
• Consider 3% NaCl bolus 35ml/kg -> reassess
Check for
• 5 ml/kg via NG/OG clamp x 45 min low continuous suction
for 15 mindrain and repeat every 2 hrs and PRN
• Maintenance to IV D5%W
• Consider Vasopressin / DDAVP
• Diabetes Insipidus (DI protocol pg. 14)
- Without polyuria - Intensivist consult
• Glycosuria (Insulin Protocol pg. 25)
• Anemia / Hypoalbuminemia (pg. 15)
• Normothermia (96 – 99.5°F / 36 – 37.5°C) (pg. 14)
(Powner, Darby, & Kellum, n.d; .http://www.ohsu.edu/medicine/residency/handouts/pharmpearls/Nephrology/ElectrolyteReplacementProtocol.pdf;)
(dePerrot et al., 2004; Powner, Darby, & Kellum, n.d; Wood & McCartney, 2007)
11
Potassium
Potassium (K+) 3.5-4.5 mmoI/L (3.5-4.5 mEq/L) - Use caution with renal insufficiency (oliguria and/or creatinine ≥ 1.5 mg/dL)
Hypokalemia
Treat K < 4.0 mmol/L (mEq/L)
Hyperkalemia
Treat K > 5.0 mmol/L (mEq/L)
+
Serum K+
Add KCl/L
• 20 mEq/liter
3.5-3.9 mmoI/L
+
Serum K+
Treatment
• 20mEq IVPB over 1 hr
4.0-4.9 mmoI/L
Add KCl/L
Treatment
• Remove K from IV’s
• None
3.0-3.4 mmoI/L
• 40 mEq/liter
• 40 mEq IVPB over 1-2 hrs
5.0-6.0 mmoI/L
• None
2.5-2.9 mmoI/L
• 40 mEq/liter
• 60 mEq IVPB over 2-4 hrs
> 6.0 mmoI/L
• None
< 2.5 mmoI/L
• 40 mEq/liter
• 80 mEq IVPB over 4-5 hrs
• Kayexalate 15-60 gms
enema
• Consider Lasix 20 mg IVP
unless actively treating
volume deficit or
hypotension
• ½ amp D50%W IVP
• 20 units Insulin IVP, and
1 gm Calcium gluconate
IVPB
• repeat K level
• Consider Lasix 20 mg IVP
unless actively treating
volume deficit or
hypotension
Magnesium
Magnesium (Mg++) 1.8-2.3 mg/dL (0.7-0.9 mmol/L) - Use caution with renal insufficiency (oliguria and/or creatinine ≥ 1.5 mg/dL)
Hypomagnesemia
Treat Mg < 1.8 mg/dL (0.7 mmol/L)
Hypermagnesemia
Mg >2.3 mg/dL (0.9 mmol/L)
++
Serum Mg++
1.5-1.7 mg/dL
(0.6-0.7 mmol/L)
<1.5 mg/dL
(0.6 mmol/L)
++
Treatment
Treatment
• 2 gms MgSO4 IVPB in 25 ml NaCl over 2-3
hrs
Not independently treated in the organ donor
• 4 gms MgSO4 IVPB in 50 ml NaCl over 2-3
hrs
12
Calcium
Corrected calcium (Ca++) 8.5-10.5 mg/dL (2.1-2.6 mmol/L); ionized calcium (ICa++) 1.1-1.4 mmol/L (4.5-5.6 mg/dL)
Formula for corrected calcium: corrected calcium (mg/dL) = measured serum Ca++ (mg/dL) + [(4.0 - serum albumin g/dL) x 0.8]
Hypocalcemia
Treat Corrected Ca++ < 8.5 mg/dL (2.1 mmol/L) /
ICa++ < 4.5 mg/dL (1.1 mmol/L)
Serum Corrected
Ca++
Serum ICa++
Hypercalcemia
Corrected Ca > 10.5 mg/dL (2.6 mmol/L)
ICa++ > 1.4 mmol/L (4.5-5.6 mg/dL)
++
Treatment
Treatment
7.5 – 8.4 mg/dL
(1.9-2.1 mmol/L)
3.2-4.4 mg/dL
(0.8-1 mmol/L)
1 gm Calcium Chloride (CaCl)
or 3 gms Calcium Gluconate
IVPB over 15 min
< 7.5 mg/dL
(1.9 mmol/L)
< 3.2 mg/dL
(0.8 mmol/L)
2 gms CaCl or 6 gms Calcium
gluconate IVPB over 30 min
Not independently treated in the organ donor
Phosphate
Phosphorus (PO4-) 2.3-4.7 mg/dL (0.7-1.5 mmol/L)
Hypophosphatemia
Treat PO4- < 1.5 mg/dL (0.5 mmol/L)
Serum PO40.6-1.4 mg/dL
(0.2-0.5 mmol/L)
< 0.6 mg/dL
(0.2 mmol/L)
Treatment if
K < 4.0 mg/dL
• 0.16 mmol/kg
KPhos IV over 2-4
hrs
• 0.32 mmol/kg
KPhos IV over 2-4
hrs
PO4-
Treatment if
K > 4.0 mg/dL
• 0.16 mmol/kg NaPhos IV
over 2-4 hrs
• 0.32 mmol/kg NaPhos IV
over 2-4 hrs
13
Hyperphosphatemia
> 4.7 mg/dL (1.5 mmol/L)
Treatment
Not independently treated in the organ donor
Diabetes Insipidus (DI) Management
Definition
Endocrine dysfunction13 resulting from insufficient blood levels of ADH.
Symptoms
 Polyuria- Urine Output > 4 ml/kg/hr for 2 hrs
 Serum sodium > 150 mEq/L
 Serum Osmolality > 310 mmol/L
 Urine Osmolality < 300 mmol/kg
 Urine Specific gravity < 1.005
Treatment
 Vasopressin drip 0.2 – 5 units/hr
 DDAVP 1-4 mcg IVP every 8 – 12 hrs
 Call OTL for continued polyuria or instability
Temperature
Goals: Core temperature14 of 36 – 37.5°C / 96 – 99.5°F
Hypothermia
•
•
•
•
•
13
14
Reassess labs with significant temperature changes
Apply external warming blankets, or heating devices and
ensure head is covered
Warm donors slowly, goal for 0.5-1°C / 1-2°F per hour
Perform warmed NG lavage if temperature is less than
34°C / 93.2°F
Use warming devices for infusions
Hyperthermia
•
•
•
•
•
•
•
(Shah & Bhosale, 2003, Wood & McCartney, 2007)
(Powner, Darby, & Kellum, n.d.)
14
Reassess labs with significant temperature changes
Remove excessive blankets / clothing
Acetaminophen 650 mg suppository every 4 hrs
Apply external cooling blanket and / or ice packs
If temp remains > 39°C / 102°F after 3 hrs of cooling,
contact OTL
Obtain cultures and review antibiotics and hematology
Consider Infectious Diseases consult
Blood Products
PRBCs15






15
Do not transfuse PRBC’s with a Hgb > 12 without consult
Use leukocyte depletion filter or leukocyte-depleted blood for all transfusions of PRBC’s until CMV status is known
(obtain serology and HLA lab samples prior to infusion when possible); if CMV negative, give CMV negative blood
Use warming unit if available (critical in pediatrics, hypothermia, DIC and multiple transfusions)
Unless contraindicated, transfuse Hgb < 9 and/or Hct < 27%
After every 2 units of PRBCs, check serum Ca and ionized Ca; if hypocalcemic follow treatment table on pg. 13
For severe bleeding consult Intensivist
(Wood, Becker, McCartney, D’Alessandro, & Coursin, 2004; Powner, Darby, & Kellum, n.d.)
15
Disseminated Intravascular Coagulopathy (DIC) Management
Definition
DIC16 is a serious disorder in which the proteins that control blood clotting become abnormally active.
Symptoms
 Bleeding, possibly from multiple sites in the body
 Thrombus/emboli
 Drop in blood pressure
 Sudden bruising/petechia
Test
 Fibrin degradation products (FDP) - high
 Partial thromboplastin time (PTT) - high
 Platelet count (Plt) - low
 INR - high
 Serum fibrinogen - low
Treatment
• Identify and treat underlying cause
• Administer blood products as needed (Blood Products pg. 15)
• Call OTL for continued bleeding with instability
16
(Shah & Bhosale, 2003; Wood & McCartney, 2007)
16
Lung Management17
ABG Reference Range
ABG
Normal Values
pH
7.3 - 7.5
PaO2
> 120 mmHg on FiO2 40 %
PaCO2
35 – 45 mmHg
HCO3
22-26 mEq/L
Measures
Goals & Treatment
Tidal volume (Vt)
8-10 ml / PBW*, +5 cmH2O PEEP
• Men: PBW(kg) = 50 + 2.3 (height [inches] – 60)
• Women: PBW(kg) = 45.5 + 2.3 (height [inches] – 60)
Adjust rate accordingly
Peak inspiratory pressures (PIP)
< 35 cmH2O
Plateau Pressure
< 30 cmH2O
Rate
Adjust to maintain PaCO2 35-45 mmHg and pH 7.3 - 7.5
PEEP
Maintain PEEP of 5 cmH2O when making offers
Peak Flow
To achieve an I:E ratio of 1:1 – 1:2
P/F Ratio
> 300 on FiO2 40 % and 100 %
SpO2
> 97 %
Ventilation Goals
* PBW – Predicted Body Weight
17
(dePerrot et al., 2004; Rostron et al., 2008; Baumann, Augibert, McDonnell, & Mertes, 2007)
17
Lung Therapies
Oxygenation
1. Verify:
a.
b.
c.
d.
HOB 30-40°
turn and suction every 2 hrs
CPT / bronchodilators every 4 hrs
Solu-Medrol 500 mg IV every 8 hrs
2. Early therapeutic bronchoscopy for all potential lung donors and donors with
a. suspected mucous plugs
b. bronchial wash for culture
c. Bronchoalveolar lavage (BAL)- Consult with OTL prior to performing
3. Hypoxemia (P/F Ratio <300)
a. Consider Pulmonary Recruitment Maneuver (pg. 20)
b. Consider PEEP Maneuver (pg. 20)
c. Consider repeat bronchoscopy
d. Consider Narcan 8 mg IVP for evidence of pulmonary edema
i. Give with Neuromuscular blocker (i.e Norcuron) to prevent hyperreflexia of spinal nerves
4. Refractory hypoxemia (unresponsive to treatments prescribed for hypoxemia)
a. Increase and maintain PEEP in increments of 2 cmH2O to maximum of 15 cmH2O (on non-lung donors)
i. Ensure PIP <40 cmH2O and hemodynamic stability
b. If interventions are ineffective consult OTL and/or Intensivist for consideration of alternative modalities
5. Adjust FiO2 to LOWEST possible percentage to achieve PaO2 of > 120 mmHg on FiO2 40 %
18
Oxygenation Challenge
(for potential lung donors)
1. Method for oxygenation challenge
a. Normalize ABG’s
b. Increase FiO2 to 100 % and PEEP 5 cmH2O
c. Obtain ABG 30 mins after change
d. Decrease FiO2 to 40 % on the same ventilator settings
e. Obtain ABG 30 mins after change
2. Use in conjunction with Pulmonary Recruitment Maneuver when applicable (pg. 20)
3. Maintain PEEP of 5 cmH2O after lung offers initiated unless Pulmonary Recruitment Maneuver or PEEP Maneuver (pg. 20) is
being performed
a. All challenge gases should be performed on PEEP of 5 cmH2O for > 30min unless otherwise requested by recovering
center
4. Perform Oxygenation Challenge at least once prior to making lung offers
a. After lung offers have been made repeat every 4 hrs or per request of recovering center
b. Ensure Oxygen Challenge and PCXR are performed within 2 hrs prior to scheduled Operating Room (OR) time
5. DO NOT perform if patient requires a baseline PEEP > 5 cmH2O for oxygenation
Manual CPT
1. Method
a. Ensure gastric contents have been removed
b. Increase FiO2 to 100%
c. Place patient in recombinant (side lying) Trendelenburg position (head down) for postural drainage
d. Perform manual/vest CPT on raised side
e. Suction
f. Repeat on other side
g. Suction
h. Resume prior position (HOB 30-40°) and vent settings (unless using with Pulmonary Recruitment Maneuver [pg. 20])
2. Ensure patency of all supportive devices while changing positions
3. Contraindications include: Thoracic / abdominal trauma, rib fractures, and hemodynamic instability
a. Abort if donor becomes unstable
19
Pulmonary Recruitment Maneuver
1. Pulmonary Recruitment Maneuver - Used to expand sections of atelectasis and to improve oxygenation and compliance.
a. Ensure hemodynamic stability and monitor vital signs at bedside during either procedure.
b. Ensure euvolemia and do not use with donors on more than one of the following pressors and doses:
i. Dopamine > 10mcg/kg/min; Neosynephrine > 60mcg/min; Levophed > 10mcg/kg/min
c. Stop for hemodynamic instability and/or a decrease in SpO2.
d. Use caution in donors with pneumothorax/pneumomediastinum or with airleak in chest-tube:
1) Normalize pH/PaCO2 and oxygenate with FiO2 100% for 30 mins.
2) Draw baseline ABG.
3) Perform manual CPT and suction (pg. 19).
4) Change mode to CPAP with PEEP at 30 cmH2O and hold for 30 seconds.
5) Providing donor still stable, resume ventilation on prior settings with FiO2 100% and change to PEEP 10
cmH2O for 2 mins.
6) Change mode to CPAP with PEEP 30 cmH2O and hold for 30 seconds as in ‘step 4’.
7) Providing donor still stable, resume ventilation on prior settings with FiO 2 100% and change to PEEP 10
cmH2O for 1 hr.
8) Decrease PEEP to 5 cmH2O and obtain ABG 30 mins after change.
9) Decrease FiO2 to 40% and obtain ABG 30 mins after change.
10) Repeat Pulmonary Recruitment Maneuver every 12 hrs and PRN.
(algorithm on page 22)
PEEP Maneuver
PEEP Maneuver – Place on PEEP 10 cmH2O for 1 hr, if Pulmonary Recruitment Maneuver contraindicated.
20
21
Lung Conditions
Respiratory Acidosis & Respiratory Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
pH <7.3 with PaCO2 >45 mmHg
For continued acidosis after ventilator adjustments,
contact OTL
pH >7.5 with PaCO2 <35 mmHg
For continued alkalosis after ventilator adjustments,
contact OTL
Adjust minute volume ventilation to maintain PaCO2 35-45 mmHg
→ Adjust rate
→ Ensure Vt 8 – 10 ml/kg/PBW and PIP <35 cmH2O and Plateau Pressure <30 cmH2O
Atelectasis
Atelectasis18 is the collapse of the airspaces which also results in the visual impression of increased soft tissue density. This makes it
impossible to distinguish infiltrates from atelectasis on the basis of visual density alone. Considering other factors is therefore
required. Atelectasis must have volume loss by definition (collapse of airspaces must reduce lung volume), whereas infiltrate does
not.
1. In cases with persistent atelectasis by CXR consider Pulmonary Recruitment Maneuver (pg. 20 ).
2. Prevent interruptions in the ventilator circuit when possible.
a. Pulmonary Recruitment Maneuver contraindicated perform PEEP Maneuver (pg. 20)
3. Consider repeat bronchoscopy in cases of segmental atelectasis.
4. Ensure Vt 8-10 ml/kg PBW.
Pulmonary Infiltrates
An infiltrate19 is the filling of airspaces with fluid (pulmonary edema), inflammatory exudates (white cells or pus, protein and
immunological substances), or cells (malignant cells, red cells or hemorrhage) that fill a region of lung and increase the visual
impression of increased soft tissue density.
1.
2.
3.
4.
5.
6.
7.
8.
18
19
Ensure early bronchoscopy.
Ensure heated humidification of vent circuit.
Ensure ETT cuff inflated to 30 cmH2O.
Perform Manual CPT every 2 hrs (pg. 19).
Consider aggressive pharmacologic interventions for CVP >15 mmHg to treat pulmonary edema (pg. 23).
Review culture & sensitivities, antibiotics, and drug regimes.
Ensure HOB 30-40°.
Position “good” lung down.
a. Consider lateral decubitus
(Powner, Darby, & Kellum, n.d.; Wood & McCartney, 2007; http://www.aic.cuhk.edu.hk/web8/Very%20BASIC%20CXR%20lungs.htm )
(Powner, Darby, & Kellum, n.d.; Wood & McCartney, 2007; http://www.aic.cuhk.edu.hk/web8/Very%20BASIC%20CXR%20lungs.htm )
22
Pleural Effusions
A pleural effusion20 is an accumulation of fluid between the layers of tissue that line the lungs and chest cavity.
1. Diagnostic portable ultrasound of chest.
2. Obtain Intensivist consult.
a. If moderate to large, request placement of chest tube as needed.
Pulmonary Edema
Pulmonary edema21 is transudate fluid collecting in the lung tissue. Three mechanisms lead to pulmonary edema including:
1. Increased hydrostatic gradient
2. Decreased intravascular oncotic pressure
3. Increased capillary permeability due to endothelial injury secondary to herniation process and cytokine release
PULMONARY EDEMA MANAGEMENT

Treat the noncardiogenic pulmonary edemic donor that is fluid overloaded (CVP >15) as indicated below

Ensure maintenance IV-fluids are per management guidelines (pg. 11)

If donor is not fluid overloaded and maintenance IV-fluids are per guidelines, then request Cardiac consult for cardiogenic pulmonary
edema as evidenced by portable CXR, refractory hypoxemia, frothy sputum and EF <30%.
Medications to Consider for Pulmonary Edema Caused by Non-Cardiogenic Factors
Cause
Drug
Dose
Route
Frequency & Other
Fluid overload
(CVP >15 mmHg)
Lasix
20-60 mg
IV
May repeat as necessary
Mannitol
25-50 gms
IV
May repeat as necessary
Narcan
8 mg
IV
Every 12 hrs as needed
Morphine
10 mg
Bolus 12.5-25 mcg IVP;
Titrate 5-10 mcg/min q 5-10 min
25% in 50 ml
IV
May repeat as necessary
Titrate to MAP >60 or >70 mmHg with history
of HTN; Max dose = 500 mcg/min
May repeat every 4 hrs as needed.
Follow Albumin dose with Lasix (as above)
Nitroglycerin
Decreased oncotic
pressure
Albumin
(& Lasix as above)
20
IV drip
IVPB
(http://www.umm.edu/ency/article/000086.htm)
(Baumann, Augibert, McDonnell, & Mertes, 2007; Rostron et al., 2008; http://www.mayoclinic.com/health/pulmonary-edema/DS00412/DSECTION=treatments-and-drugs;
http://emedicine.medscape.com/article/300813-treatment; http://www.rxmed.com/b.main/b2.pharmaceutical/b2.1.monographs/CPS-%20Monographs/CPS-%20(General%20Monographs%20D)/DOBUTREX.html)
21
23
Liver Biopsy Management Guideline
Indications and Preparation
• The need for a liver biopsy22 will be determined by the OTL
• Evaluate pathologist availability
• Review CXR, INR and/or other requested labs with performing physician
• If biopsy is being done always place sample in 0.9% NaCl
Considerations
• Coagulation support
o Plt infusion if
• Plt count is < 100,000, or
• there was a history of ASA, NSAIDs, Plavix or other anticoagulants within 5 days of biopsy
o FFP infusion if INR > 1.4
Potential Complications
• Bleeding
• Hypotension
• Pneumothorax
• Injury to surrounding organs
Post Biopsy Care
• STAT CXR & liver ultrasound with readings
• Monitoring vital signs every 15 min for 1 hr and every 30 mins for 1 hr
• Position on right side
• Check H&H 30 mins after, then every 1 hr for 2 hrs
22
(California Pacific Medical Center [CPMC], 2003)
24
Insulin Therapy
If patient has BG > 140 mg/dL address potassium imbalances as needed, and start insulin drip.
If the hospital has a protocol you may use the hospital’s otherwise use the following drip protocol.
Target BG levels: 80 – 110 mg/dL
The insulin drip should be maintained through organ allocation as necessary in order to treat
hyperglycemia. All blood glucose measurements should be performed with arterial blood samples.
Initial Insulin Guide
Baseline BG
Bolus
Initial Infusion Rate
141-160
--
5 units/hr
161-180
2 units and
6 units/hr
181-200
3 units and
8 units/hr
201-250
5 units and
10 units/hr
251-300
5 units and
15 units/hr
>300
10 units and
15 units/hr
Check BG 30 minutes after beginning insulin drip and follow titration guidelines.
Insulin Titration Guide




BG
Bolus
Titration
<60
Give ½ amp D50.
Stop infusion. Recheck BG in 15 min.
60-80
--
Stop infusion. Check BG in 15 min.
80-110
--
 by 1 unit/hr if > 50mg/dL lower
than last test
 by 2 units/hr if > 100mg/dL lower
than last test
111-120
--
No intervention
121-140
--
 by 1 units/hr
141-160
--
 by 2 units/hr
161-180
2 units
 by 2 units/hr
181-200
2 units
 by 4 units/hr
201-250
4 units
 by 5 units/hr
251-300
5 units
 by 5 units/hr
>300
5 units
 by 5 units/hr
Check BG 30 minutes after insulin titration.
If BG >140 mEq/L repeat above titration steps.
If BG within goal maintain rate, then check BG every hour. If three consecutive values within
target range, then check BG every 2 hrs.
After BG level is > 120 following ‘stop infusion’ restart insulin drip at ½ the previous rate
25
Insulin Titration Algorithm
26
References
Angel, L. F., Levine, D. J., Restrepo, M. I., Johnson, S., Sako, E., & Carpenter, A. et al. (2006). Impact
of a lung transplantation donor-management protocol on lung donation and recipient outcomes.
American Journal of Respiratory Critical Care Medicine, 174, 710-716.
Avlonitis, V. S., Fisher, A. J., Kirby, J. A., & Dark, J. H. (2003). Pulmonary transplantation: The role
of brain death in donor lung injury. Transplantation, 75, 1928-1933.
Baumann, A., Augibert, G., McDonnell, J., & Mertes, P. M. (2007). Neurogenic pulmonary edema.
Acta Anaesthesiol Scand, 51, 447-455.
California Pacific Medical Center (2003). Liver biopsy management guideline protocol. Retrieved
November 17, 2009, from http://www.cpmc.org/advanced/liver/physicians/guideline-liverbx.pdf
DePerrot, M., Snell, G. I., Babcock, W. D., Meyers, B. F., Patterson, G., & Hodges, T. N. et al. (2004).
Strategies to optimize the use of currently available long donors. The Journal of Heart and
Lung Transplantation, 23, 1127-1134.
Institute for Healthcare Improvement (n.d.). Implement the sepsis resuscitation bundle: Apply
vasopressors for ongoing hypotension. Retrieved November 2, 2009, from
http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes/IndividualChanges/ApplyVasopres
sorsforOngoingHypotension.htm
Kutsogiannis, D. J., Pagliarello, G., Doig, C., Ross, H., & Shcmic, S. D. (2006). Medical management
to optimize donor organ potential: review of the literature. Canadian Journal of Anesthesia,
53, 820-830.
Phongsamran, P. V. (2004). Critical care pharmacy in donor management. Progress in
Transplantation, 14, 105-113.
27
Powner, D. J., Darby, J. M., & Kellum, J. A. (n.d.). Proposed treatment guidelines for donor care.
Retrieved November 10, 2009, from
http://www.natco1.org/prof_development/files/ProposedTreatmentGuidelines.pdf
Rostron, A. J., Avlonitis, V. S., Cork, D. M., Grenade, D. S., Kirby, J. A., & Dark, J. H. et al. (2008).
Hemodynamic resuscitation with arginine vasopressin reduces lung injury after brain death in
the transplant donor. Transplantation, 85(4), 597-606.
Selck, F. W., Deb, P., & Grossman, E. B. (2008). Deceased organ donor characteristics and clinical
interventions associated with organ yield. American Journal of Transplantation, 8, 965-974.
Shah, V., & Bhosale, G. (2003). Organ donor problems and their management. Indian Journal of
Critical Care Medicine, 10(1), 29-34.
Shemie, S. D., Ross, H., Pagliarello, J., Baker, A. J., Greig, P. D., & Trand, T. et al. (2006). Organ
donor management in Canada: Recommendation of the forum on medical management to
optimize donor organ potential. Canadian Medical Association Journal, 174(6), S13-S30.
Snell, G. I., & Westall, G. P. (2009). Donor selection and management. Current Opinion in Organ
Transplantation, 14, 471-476.
Sopko, N., Shea, K. J., Ludrosky, K., Smedira, N., Taylor, D. O., & Starling, R. C. et al. (2007).
Survival is not compromised in donor hearts with echocardiographic abnormalities. Journal of
Surgical Research, 143(1), 141-144.
Wood, K. E., & McCartney, J. (2007). Management of the potential organ donor. Transplantation
Reviews, 21, 204-218.
Wood, K. E., Becker, B. N., McCartney, J. G., D’Alessandro, A. M., & Coursin, D. B. (2004). Care of
the Potential Organ Donor. The New England Journal of Medicine, 351, 2730-2739.
28