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Dbd care bundle 20092012 _2_.doc

Donation after Brainstem Death
Donor Optimisation Extended Care Bundle
Trust / Regional collaborative / CCN logo Patient Name______________________ Date of Birth______________ Priorities to address are
1. Assess fluid status and correct hypovolaemia with fluid boluses Fluids and metabolic management
2. Introduce vasopressin infusion where required introduce flow monitoring 1. Administer methylprednisolone (dose 15mg/kg, max 1g)
3. Perform lung recruitment manoeuvres (e.g. following apnoea tests, 2. Review fluid administration. IV crystalloid maintenance fluid disconnections, deterioration in oxygenation or suctioning) 4. Identify, arrest and reverse effects of diabetes insipidus (or NG water where appropriate) to maintain Na+ <150 mmol/l 5. Administer methylprednisolone (all donors) 3. Maintain urine output between 0.5 - 2.0 ml/kg/hr
( If >4ml/kg/hr, consider Diabetes insipidus and treat promptly with vasopressin and/or DDAVP. Dose of DDAVP 1 - 4 mcg ivi titrated to effect) Cardiovascular (primary target MAP 60 80 mm Hg)
4. Start insulin infusion to keep blood sugar at 4 -10 mmol/l 1. Review intravascular fluid status and correct hypovolaemia
(minimum 1 unit/h; add a glucose containing fluid if required to maintain blood sugar) with fluid boluses
5. Continue NG feeding (unless SN-OD advises otherwise) 2. Commence cardiac output / flow monitoring
3. Commence vasopressin (0.5 - 4 units/h) where vasopressor
Thrombo-embolic prevention
required, wean or stop catecholamine pressors as able
1. Ensure anti-embolic stockings are in place (as applicable) 4. Introduce dopamine (preferred inotrope) or dobutamine if required 2. Ensure sequential compression devices are in place (as applicable) 5. Commence Liothyronine at 3 units/h (+/- 4 unit bolus) 3. Continue, or prescribe low molecular weight heparin (in cases of high vaso-active drug requirements or as directed by the cardiothoracic retrieval team) Respiratory (primary target PaO
Lines, Monitoring and Investigations (if not already done)
10 kPa, pH > 7.25)
1. Perform lung recruitment manoeuvres
1. Insert arterial line: left side preferable (radial or brachial) 2. Review ventilation, ensure lung protective strategy 2. Insert CVC: right side preferable (int jugular or subclavian) (Tidal volumes 4 - 8ml/kg ideal body weight and optimum PEEP (5-10cm H 3. Continue hourly observations as per critical care policy 3. Maintain regular chest physio incl. suctioning as per unit protocol 4. Maintain normothermia using active warming where required 4. Maintain 30 - 45 degrees head of bed elevation 5. Perform a 12-lead ECG (to exclude Q-waves) 5. Ensure cuff of endotracheal tube is appropriately inflated 6. Perform CXR (post recruitment procedure where possible) 6. Patient positioning (side, back, side) as per unit protocol 7. Send Troponin level in all cardiac arrest cases 7. Where available, and in the context of lung donation, perform (and follow-up sample where patient in ICU > 24 hours) bronchoscopy, bronchial lavage and - toilet for therapeutic purposes 8. Where available, perform an Echocardiogram 9. Review and stop all unnecessary medications DO Extended Care Bundle Version 20092012 Donation after Brainstem Death
Donor Optimisation Extended Care Bundle
Patient Name______________________ Date of Birth______________ collaborative / CCN logo Cardiac output / flow monitor used:
Physiological Parameters / Goals
Tick = achieved, x = not achieved
+2hrs +4hrs +6hrs +8hrs +10hrs +12hrs +14hrs +16hrs +18hrs PaCO2 5 - 6.5 kPa (or higher as long as pH > 7.25) SVRI (secondary goal) 1800 2400 dynes*sec/cm5/m2 DO Extended Care Bundle Version 20092012


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