| Monitoring and access |
- Monitor temperature, heart rate and rhythm, SpO2, blood pressure, mean arterial pressure, continuously; monitor urine output, serially.
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- Insert two large bore intravenous lines. Consider inserting central venous catheter and/or PAC to monitor patient hemodynamics (placement of PAC is particularly important in patients with an ejection fraction <45% or requiring high dose inotropic medication). Insert arterial line.
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- Obtain echocardiogram for all potential donors. Repeat echocardiogram when patient has stabilized if initial echocardiogram shows significant cardiac dysfunction.
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- Early flexible bronchoscopy for inspection and airway clearance.
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| Electrolytes |
- Maintain serum Na >135 and <155 mEq/dL.
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- Maintain serum K >4 and <5 mEq/dL.
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- Assess serum Mg, Ca, PO4 and replace as needed.
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- Assess serum lactate and central or mixed venous oxygen saturation.
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- Correct metabolic acidosis with Na bicarbonate and mild hyperventilation. Aim for arterial pH 7.35 to 7.45.
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| Ventilation |
| Initial set-up |
- Mode: Typically, volume control.
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- Tidal volume: 6 to 8 mL/kg (use ideal predicted body weight¶).
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- Respiratory rate: 8 to 16 breaths/minute.
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- Initial FiO2: 100%Δ; after stabilization, titrate down to 40%, as tolerated.
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| Adjustments to initial settings |
- Adjust rate and tidal volume to maintain PaCO2 35 to 45 mmHg (4.67 to 6 kPa). Adjust tidal volume, pressure profile, and flow rate to keep peak airway pressure <30 cm H2O.
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- Titrate FiO2 and PEEP in tandem according to the FiO2/PEEP combinations below to maintain pulse oxygen saturation >95% or PaO2 >90 mmHg (12 kPa).
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| Autonomic storm with hypertension |
- Note, autonomic storm is typically transient. Hypertension and tachycardia should be treated with short-acting agents (eg, esmolol).
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| Goals for resuscitation |
- Normal core body temperature versus mild hypothermia.
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- Mean arterial pressure ≥60 mmHg.
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- SVR 800 to 1200 dynes/second/cm5.
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- Left ventricular stroke work index >15.
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- Dopamine dosage <10 mcg/kg/minute.
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- Urine output ≥1 mL/kg/hour.
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| Volume resuscitation |
- Maintain euvolemia: Assess volume status based on urine output, MAP, CVP, PAOP, and/or dynamic measures (eg, PPV, SPV).
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- Replete volume with isotonic crystalloids (eg, 0.9% saline, Lactated Ringer solution, Plasma-Lyte, Normosol).
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| Hematologic management |
- Correct abnormal INR or PTT (eg, ≥1.5 times control) with fresh frozen plasma.
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- Infuse packed RBC to maintain blood hemoglobin >7 mg/dL. A higher pre-procurement hemoglobin may be needed depending on the planned procedure.
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| Vasopressor and inotropic agents |
- After repletion of circulating volume, if MAP <60 mmHg, assess whether cause of hypotension is decreased SVR or decreased cardiac output.
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- Infuse arginine vasopressin as noted below for decreased SVR.
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- If MAP remains <60 mmHg and LVEF >45%, add vasopressor agent (eg, norepinephrine, phenylephrine).
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- If MAP remains <60 mmHg and LVEF <45%, add inotropic agent (eg, dobutamine, dopamine, epinephrine).
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| Hormonal resuscitation |
- Arginine vasopressin: 1 unit bolus intravenously, followed by continuous infusion of 0.01 to 0.04 units/minute, adjusted to maintain MAP >60 mmHg and urinary output 0.5 to 1 mL/kg per hour.
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- Hydrocortisone 300 mg IV, then 100 mg every 8 hours.
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- Insulin: There is no universally accepted insulin regimen. To achieve a target blood glucose range (120 to 180 mg/dL), avoid the use of glucose-containing intravenous fluids and administer insulin only when necessary.
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| Renal replacement therapy |
- Continuous renal replacement therapy may be used to facilitate management of severe volume overload, metabolic acidosis, or hyperkalemia in patients with diuretic-refractory oliguric or anuric acute kidney injury.
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| VTE/stress ulcer prevention |
- Low molecular weight heparin (eg, enoxaparin 40 mg SC every 12 hours) for donors with normal kidney function and without active bleeding OR low dose unfractionated heparin SC.
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- Proton pump inhibitor enterally.
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| Use these FiO2/PEEP combinations to achieve oxygenation goal: |
| FiO2 | 0.3 | 0.4 | 0.5 | 0.6 | 0.7 | 0.8 | 0.9 | 1.0 |
| PEEP | 5 | 5 to 8 | 8 to 10 | 10 | 10 to 14 | 14 | 14 to 18 | 18 to 24 |
