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Pediatric Donor Management
Guidelines for Clinical Management of Organ Donors: Weight < 40 kg Organ Perfusion & Hormonal Replacement Guidelines:
• Normal HR, SBP: (see chart below) • Urinary output of 1-3 cc/kg/hr • CVP 6-10 mmHg Normal Heart
Normal Resp.
Fluid Challenge
Systolic BP
(20 mL/kg)
Premature

Assessment:

• Continuous arterial pressure monitoring • Continuous ECG monitoring • Hourly urine output
• Urine specific gravity at initiation of donor management and consider with the suspicion of DI

Interventions:

• Consult pediatric intensivist/medical director OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 1 of 7 Hypotension:
• Assess for excessive fluid losses above intake: o Output > intake and urine output < 1 mL/kg/hr o If polyuria present, refer to DI Prevention/Treatment Guideline • Evaluate for evidence of recent blood loss: o Confirm that the most recent Hct is > 30% o Reaffirm w/ an immediate repeat Hct and treat per Hematology Guidelines • Initiate intervention for signs of continued hemorrhage (i.e., external, GI, urinary, abdominal): consult intensivist • Assess recent CVP • Assess for ECG changes: o Repeat ECG and maintain at bedside o Consult MD for interpretation • Assess for evidence of ongoing severe infection, drug or other allergic reactions (i.e., due to blood transfusion), pericardial effusion, or hemo/pneumothorax: o Obtain a chest radiograph o Consult MD for interpretation • Discontinue medications that may contribute to hypotension (i.e., anti-hypertensives, beta-blockers)
• Correct intravascular volume (pre-load) = CVP > 6. Note: Take into account fluid and electrolyte
status, refer to Fluid Balance and Electrolytes Guideline o Start a fluid bolus of LR or 0.9% NS at 20 mL/kg, reassess, repeat x 2 if needed: consult
intensivist/medical director
o Colloid solutions may be preferred for repeated fluid challenges (5% albumin: 20 mL/kg) o Maintain CVP = 6-10 • Levophed (Norepinephrine) Infusion: 0.05-2 mcg/kg/min (do not exceed 2 mcg/kg/min) if so then add: o Phenylephrine infusion start at 0.1-0.5 mcg/kg/min and titrate up to maintain minimum acceptable blood pressure, maximum dose of 0.5 mcg/kg/min o Solumedrol 15 mg/kg IV over 30-60 minutes (consider repeat every 12 hrs if already given) o Consider Dopamine 2-20 mcg/kg/min o Consider Epinephrine Infusion: dose 0.1-1 mcg/kg/min o Consider Vasopressin Infusion: 0.3-2 milliunits/kg/min if urine output > 1 ml/kg/hr ƒ Consult pediatric intensivist, medical director, or transplant surgeon if higher doses
of vasoactive agents are required
o For a low EF (<45%), a positive inotropic agent (i.e., milrinone) should be used: consult
intensivist/medical director
ƒ Milrinone: dose 0.25-0.75 mcg/kg/min (no bolus, watch for vasodilation, may need alpha ƒ Dopamine: dose 2-20 mcg/kg/min ƒ Dobutamine: dose 2-20 mcg/kg/min • Reassess: Hct, Electrolytes, and pH for correctable causes of hypotension (acidosis, anemia, and • Consider Hormone Replacement Therapy, refer to section Hormone Replacement Therapy
Hormone Replacement Therapy:
• Improvement in cardiovascular lability • Reduction in electrocardiographic abnormalities • Reduction in acid-base disturbances • Improvement in the suitability of organs for transplantation OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 2 of 7 Assessment:
• Reserve hormone replacement therapy for: o Unstable donors requiring dopamine at a dose of more than 10 mcg/kg/min or multiple pressors o An ejection fraction < 45% (serial echocardiograms after hormone replacement – recommended) Intervention:
• Correct K+ > 3.5 • Correct CVP > 6 o Dextrose 200 mg/kg for infant/neonate or 1 gm/kg for child o 0.1 unit/kg Regular Insulin o 30 mg/kg Solumedrol over 30-60 minutes o T4 bolus then start infusion according to tables below: T4 (levothyroxine) bolus T4 (levothyroxine) infusion
• Wean vasoactive agents as able • Wean T4 or DC for persistent tachycardia outside acceptable normal, or hemodynamic instability Dysrhythmia:
• Send STAT electrolytes including Ca, Mg, and Phos • Supraventricular Tachycardia: o Administer Adenosine 100 mcg/kg rapid IV push for clinically significant (symptomatic BP or HR >
200. Consider fluid status and oxygenation. If no effect within 2 minutes, repeat at 200 mcg/kg (max single dose = 12 mg) o If no response within 2 minutes, consider Amiodarone 5 mg/kg infused over 5-60 minutes, may
repeat dose of 5 mg/kg, then infusion at 5-15 mcg/kg/min. Monitor for hypotension: consult w/
pediatric intensivist/cardiac transplant physician/medical director prior to administering
Amiodarone

o Consult with pediatric intensivist/medical director for treatment recommendations Fluid Balance, Glucose & Electrolyte Guidelines:
• Serum Na+, K+, Cl-, Mg, Ca, and Phos within normal values Assessment:
• Serum electrolyte panels every 6 hrs (if patient on an insulin drip, check blood glucose every 1 hr and serum K+ every 2 hrs) • Serum K+, Ca+, Mg and Phos at initiation of management and following replacement (ideally correct to within normal limits prior to echocardiogram) • Consider eliminating dextrose if there are current or potential concerns about hyperglycemia OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 3 of 7 • Hypoglycemia:
For serum glucose < 60 mg/dL give 2 ml/kg of D10; repeat glucose check in 1 hr • Consult pediatric intensivist/medical director
IV Fluids:
• Administer maintenance IV fluids at a rate of:
o 4 mL/kg for 1st 10 kg, then
o 2 mL/kg for 2nd 10 kg, then
o 1 mL/kg for every kg in weight thereafter
• Goal: to achieve output of 1-3 cc/kg/hr and CVP 6-8 mmHg after initial fluid resuscitation Oliguria/Polyuria:
• Check urine specific gravity if urine output increases or color is pale
• Administer DDAVP if urinary output > 5 cc/kg/hr and specific gravity is 1.005 or less AND/OR serum
sodium is rising:
o Infuse 0.5 mcg/hr IV
o Titrate to decrease UO to 3-4 mL/kg/hr
o Do not give within 4 hours of the OR
• Consider Vasopressin Drip: give 0.5-1 milli-units/kg/hr IV and titrate to decrease UO to 3-4 mL/kg/hr Treatment of diabetes insipidus should consist of pharmacologic management to decrease but not completely stop urine output. Replacement of urine output with ¼ or ½ normal saline should be used in conjunction with pharmacologic agent to maintain serum sodium levels between 130-150 mEq/L.
• Administer Lasix 1 mg/kg IV push (max dose 20 mg) if urinary output < 1cc/kg/hr and SBP > minimum
Hypernatremia:

Serum Sodium
Fluid Type
Hypernatremia Protocol:
ƒ Current Na-Desired Na/Current Na x 1000mL/L x 0.6L/kg of body weight = mL/kg ƒ Desired Na is usually 145 unless otherwise directed by pediatric intensivist/medical director o Replace 1/2 of fluid volume deficit with 0.25% NS over 2-3 hrs (or more rapidly if the donor is hypotensive), then reassess serum sodium. If Na+ remains > 156 or not trending lower, consider repeating protocol or contact accepting liver program for guidance o Consult pediatric intensivist/medical director

Hypokalemia:
Note: Albuterol, Lasix, insulin, and hypothermia may depress K+ level: correct as necessary
• Administer KCl (adjust in cases of oliguria or polyuria)
• Recheck serum potassium 3 hrs after replacement complete
Serum Potassium
KCL Replacement
0.1-0.2 mEq/kg/hr (max rate 0.5 mEq/kg/hr) OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 4 of 7 Hyperkalemia:
• Consider possible causes (renal failure, excess administration of potassium)
• Remove all K+ from IV fluids
• Consider giving Lasix for diuresis (if fluid status is stable)
• Consider administration of dextrose, insulin, and sodium bicarbonate: consult with intensivist
• Re-check levels 30 minutes after every dose and replace appropriately

Hypomagnesemia:

Serum Magnesium
MgSo4 Replacement (max dose 2 gms)

Hypocalcemia:
• Assess via serum ionized calcium level
Serum ionized calcium
Calcium replacement
10-20 mg/kg of calcium chloride per central line
20-40 mg/kg of calcium gluconate
Hypophosphatemia:
Note: For renal insufficiency or creatinine clearance < 20, reduce replacement dosing by 50%
Serum Phosphorus
NaPO4 or KPO4 Replacement
Hematology Guidelines:
• Hematocrit > 30% • Platelet count > 20,000 Assessment:
• Obtain CBC, PT/PTT/INR at the beginning of donor management and perform a physical assessment ASAP in trauma cases where active bleeding may be a concern Interventions:

Serum Blood Counts
Serum Blood Type
Platelets < 20,000 (consult liver transplant surgeon prior to infusion of any platelets)
• Consider Vitamin K if persistently elevated PT: consult with pediatric intensivist/medical director
• Recheck labs 1 hr after infusion and give additional treatments if necessary • Keep 2 units PRBCs ahead • If donor received blood transfusions prior to IDS arrival or there is active bleeding, keep 4 units ahead • If donor exhibits consumption or dilutional coagulopathies and is not actively bleeding, treatment may not be • Note: Treatment is reserved for donors who appear to have continuing significant blood loss evidenced by:
physical assessment, hemodynamic instability, changes in coagulation parameters
OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 5 of 7 Oxygenation & Ventilation Guidelines:
• Continuous SaO2 > 95%, PaO2 >100 torr, pH 7.35-7.45, pCO2 30-50, FiO2 40%, PEEP 5 Assessment:
• ABG every 6 hrs (every 4 hrs if possible on potential lung donor), and 30 minutes after each ventilation adjustment and w/ any apparent change in function o Note: During active placement of lungs do ABGs every 3 hrs
• Peak inspiratory pressures with ABG (if possible lung donor) • CXR on initiation of management (and every 4-6 hrs if possible on potential lung donor) o Note: CXR must be read by an MD: consultation w/ MD should be a priority
• For suspected pulmonary contusion, effusion, or COPD changes consider High Resolution Chest CT

Oxygenation:
• Consider therapeutic bronchoscopy: consult with pediatric pulmonologist, if:
o An O2 ABG challenge has a PO2 with < 350 torr o Donor has clinical evidence of aspiration o Suspected mucous plugs o Upon center request o Heavy oropharyngeal bleeding or drainage • Use bronchodilator every 4 hrs as recommended by pediatric pulmonologist/intensivist
Consider Open Lung Recruitment (if evidence of atelectasis AND hemodynamically stable)
Ventilation:
• Adjust tidal volume and ventilation rate (see previous section) to maintain pCO2 between 30-50 torr
• After adjusting minute ventilation, administer NaHCO3 1 mEq/kg IV to correct acidosis (hypernatremia
can be aggravated with repeat dosing), recheck ABG
• For extreme metabolic acidosis and high vasoactive requirement, ensure adequate fluid resuscitation has
been given and then consider THAM (tromethamine) administration:
o Base deficit x wt(kg) = mLs of 0.3 molar solution of THAM • Consult with pediatric intensivist for recommended best ventilator support

Atelectasis:
• In cases with persistent or segmental atelectasis (by CXR) consider increasing PEEP
• Consider bronchoscopy in cases of segmental atelectasis: consult pediatric pulmonologist/intensivist
Infiltrate:
• Consider aggressive diuresis
• Consider repeat Solumedrol if last dose > 12 hrs • If there are effusions present, consult for consideration of a chest tube • Chest PT and suction • Utilize HFCWO Vest whenever possible (20 minute cycle with a 1 hr 40 minute rest); do not draw ABG within 30 minutes of vest cycle, or during percussion
Note: If considering single lung transplant only – position good lung up.

OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 6 of 7 Temperature Guidelines:
Goals:
ƒ Temperature: 96.8-98.6° F or 36-37° C
Assessment:
• Monitor temperature every 2 hrs
Hypothermia:
• Apply external warming blankets, or heating devices; adjust room temperature to (76° F or 24° C)
• Adjust inspired air temperature on ventilator circuit between (90-98.6° F or 32-37° C)
• Administer all fluids and/or blood products via warming device
• Perform warmed NG lavage if temperature is less than (93.2° F or 34° C)
Infection Guidelines:
• Prevention and treatment of common nosocomial infections Assessment:
• Blood, urine and sputum cultures obtained at initiation of management • Sputum gram stain (on all possible lung donors) Interventions:
o Maintain current antibiotic regimen (based off culture sensitivity) o Administer cefazolin 25 mg/kg IV (max 2000 mg) every 8 hrs (after cultures obtained) o If potential lung donor: Administer ceftazidime 50 mg/kg IV (max 2000 mg) every 8 hrs (after cultures obtained) instead of cefazolin • Consult with pediatric intensivist or pharmacist for recommendation of antibiotics to cover unit
specific organisms
Miscellaneous Guidelines:
Spinal Reflexes:
o If spinal reflexes are present, and may cause discomfort to the donor family and/or medical staff, attempt to explain the cause and effect of such reflexes o If explanations are not sufficient, consult with pediatric intensivist/medical director OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 7 of 7

Source: http://www.organdonationalliance.org/wp-content/uploads/toolbox/IntermountainDonorServicesPediatricDonorManagementGuidelines-odt.pdf

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