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Advisory Committee on Organ Transplantation

U.S. Department of Health and Human Services

Recommendations to the Secretary

CRITICAL PATHWAY FOR THE ORGAN DONOR (APPENDIX 3)

Printer friendly Critical Pathway for the Organ Donor (Adobe Acrobat — get the free Reader External Web Site Policy)

Collaborative Practice

The following professionals may be involved to enhance the donation process. Check all that apply.

  • Physician
  • Critical care RN
  • Organ Procurement Organization (OPO)
  • OPO Coordinator (OPC)
  • Medical Examiner (ME)/Coroner
  • Respiratory
  • Laboratory
  • Radiology
  • Anesthesiology
  • OR/Surgery staff
  • Clergy
  • Social worker

Phase I: Referral

Collaborative Practice

  • Notify physician regarding OPO referral
  • Contact OPO ref: Potential donor with severe brain insult
  • OPC on site and begins evaluation: Time ___Date ___
  • Ht____ Wt ____ as documented
  • ABO as documented _____
  • Notify house supervisor/charge nurse of presence on unit

Labs/Diagnostics

none

Respiratory

  • Pt on ventilator
  • Suction q 2 hr
  • Reposition q 2 hr

Treatments/Ongoing Care

none

Medications

none

Optimal Outcomes

none

Phase II: Declaration of Brain Death and Consent

Collaborative Practice

  • Brain death documented
    Time _____ Date _____
  • Pt accepted as potential donor
  • MD notifies family of death
  • Plan family approach with OPC
  • Offer support services to family (clergy, etc)
  • OPC/Hospital staff talks to family about donation
  • Family accepts donation
  • OPC obtains signed consent & medical/social history
    Time _____ Date _____
  • ME/Coroner notified
  • ME/Coroner releases body for donation
  • Family/ME/Coroner denies donation — stop pathway — initiate post-mortem protocol — support family

Lab/Diagnostics

  • Review previous lab results
  • Review previous hemodynamics

Respiratory

  • Prep for apnea testing: set FiO2 @ 100% and anticipate need to decrease rate if PCO2. 45 mm Hg

Treatments/Ongoing Care

  • Use warming/cooling blanket to maintain temperature at 36.5 ºC — 37.5 ºC
  • NG to low intermittent suction

Medications

none

Optimal Outcomes

The family is offered the option of donation & their decision is supported.

Phase III: Donor Evaluation

Collaborative Practice

  • Obtain pre/post transfusion blood for serology testing (HIV, Hepatitis, VDRL, CMV)
  • Obtain lymph nodes and/or blood for tissue typing
  • Notify OR & anesthesiology of pending case
  • Notify house supervisor of pending donation
  • Chest & abdominal circumference
  • Lung measurements per CXR by OPC
  • Cardiology consult as requested by OPC
  • Organ recovery process discontinued — donor organs unsuitable for transplantation

Labs/Diagnostics

  • Blood chemistry
  • CBC + diff
  • UA o C & S
  • PT, PTT
  • ABO o A Subtype
  • Liver function tests
  • Blood culture X 2 / 15 minutes to 1 hour apart
  • Sputum Gram Stain & C & S
  • Type & Cross Match ____ # units PRBCs
  • CXR o ABGs
  • EKG o Echo
  • Consider cardiac cath
  • Consider bronchoscopy

Respiratory

Continue Phase II

  • Maximize ventilator settings to achieve SaO2 98 — 99%
  • PEEP = 5cm O2 challenge for lung placement FiO2 @ 100%, PEEP @ 5 X 10 min
  • ABGs as ordered
  • VS q 1

Treatments/Ongoing Care

Continue Phase II

  • Check NG placement & output
  • Obtain actual Ht _____ & Wt _____ if not previously obtained

Medications

  • Medication as requested by OPC

Optimal Outcomes

The donor is evaluated & found to be a suitable candidate for donation.

Phase IV: Donor Management

Collaborative Practice

  • OPC writes new orders
  • Organ placement
  • OPC sets tentative OR time
  • Insert arterial line/ CVP/2 large-bore IVs

Lab/Diagnostics

  • Determine need for additional lab testing
  • CXR after line placement (if done)
  • Serum electrolytes
  • H & H after PRBC Rx
  • PT, PTT
  • BUN, serum creatinine after correcting fluid deficit
  • Notify OPC for
    ___ PT14___ PTT 28
    ___ Urine output is
    1 mL/Kg/hr
    ___ 3 mL/Kg/hr
    ___ Hct 30 / Hgb 10
    ___ Na 150 mEq/L

Respiratory

Continue Phases II and III

  • Notify OPC for
    ____ BP 90 systolic
    ____ HR 70 or 120
    ____ CVP 4 or 11
    ____ PaO2 90 or
    ____ SaO2 95%

Treatments/Ongoing Care

Continue Phase II

Medications

Continue Phase III

  • Fluid resuscitation — consider crystolloids, colloids, blood
  • DC meds except pressors & antibiotics
  • Broad-spectrum antibiotic if not previously ordered
  • Vasopressor support to maintain BP 90 mm Hg systolic
  • Electrolyte imbalance: consider K, Ca, PO4, Mg replacement
  • Hyperglycemia: consider Insulin drip
  • Oliguria: consider diuretics
  • Diabetes insipidus: consider antidiuretics
  • Paralytic as indicated for spinal reflexes

Optimal Outcomes

Optimal organ function is maintained

Phase V: Recovery

Collaborative Practice

  • Checklist for OR
  • Supplies given to OR
  • Prepare patient for transport to OR
  • IVs o Pumps
  • O2 o Ambu
  • Peep valve
  • Transport to OR
    Date ________
    Time ________
  • OR nurse reviews consent & brain death documentation & checks patient's ID band

Diagnostics

  • Labs drawn in OR as per surgeon or OPC request
  • Communicate with pathology: Bx liver and/or kidneys as indicated

Respiratory

Continue Phases II and III

  • Portable O2 @ 100% FiO2 for transport to OR
  • Ambu bag and PEEP valve
  • Move to OR

Treatments/Ongoing Care

Continue Phase II

  • Set OR temp as directed by OPC
  • Post mortem care at conclusion of case

Medications

Continue Phase III

  • DC antidiuretics
  • Diuretics as needed
  • 350 U heparin/kg or as directed by surgeon

Optimal Outcomes

All potentially suitable, consented organs are recovered for transplant.

The Critical Pathway was developed under contract with the U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Transplantation.

 


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