Supporting Organ and Tissue Donation in Clinical Settings: The Pennsylvania Requirement _ ____________
STANDARDIZED DONOR MANAGEMENT GOALS
Parameter
Target Goal
Mean arterial pressure (MAP) Central venous pressure (CVP)
60–110 mm Hg 4–12 mm Hg
Ejection fraction PaO ₂ /FiO ₂ (PF ratio) Sodium
≥50%
≥300 on PEEP 5 135–155 mEq/L ≤180 mg/dL ≥0.5 cc/kg/hr
Blood glucose Urine output Vasopressors
≤1 agent, low-dose preferred
Arterial blood gas
pH 7.3–7.5
Source: [25; 26]
Table 1
Respiratory Management Protective lung ventilation strategies should be employed for all potential donors, regardless of whether lung donation is anticipated. Lungs have historically been recovered at low rates due to strict donor criteria and suboptimal donor respiratory management. The recommended strategy includes {26; 31]: • Head elevated 30 degrees with the endotracheal tube (ETT) cuff inflated to prevent aspiration • Early and repeated bronchoscopy (with minimal saline lavage) • Albuterol and acetylcysteine (as needed) for mucus clearance • Chest physiotherapy, suctioning, and positioning every four hours • Recruitment maneuvers (may improve lung function in eligible donors) The ventilator and blood gas goals include [26; 31]: • Tidal volume: 6–8 mL/kg ideal body weight • PEEP: 6–8 cm H ₂ O (higher PEEP ≥ 8 cm H ₂ O may be trialed in refractory hypoxemia) • FiO ₂ : Titrate to maintain PaO ₂ 80–120 mm Hg; minimize FiO ₂ to <0.40 when possible to reduce oxygen toxicity • Arterial blood gas ‒ pH 7.35–7.45 ‒ PaCO2 35–45 ‒ O2 saturation >95% • ≤40% oxygen (the lower the better to prevent oxygen toxicity) • Plateau pressure <30–35 • Peak inspiratory pressure (PIP) <35–40 (generally, mid-20s needed for acceptance) • Mean arterial pressure <20–25
Achieving all or most DMGs is associated with significantly higher rates of organ yield per donor and improved recipient outcomes [27]. Fluid and Vasopressor Management Aggressive fluid resuscitation is often required to address dia- betes insipidus-driven volume depletion and post-herniation hypotension. Isotonic crystalloids are generally preferred. Vasopressin (antidiuretic hormone) is a cornerstone of donor management. It simultaneously treats diabetes insipidus, supports hemodynamics, and reduces the need for high-dose catecholamine vasopressors. Norepinephrine (≤0.2 mcg/kg/ min) is the preferred catecholamine when vasopressin alone is insufficient; alternately, neosynephrine (≤1 mcg/kg/min) may be used. High-dose dopamine (>10 mcg/kg/min) is associated with worse heart and kidney outcomes; a dosage of ≤10 mcg/ kg/min should be used [28; 29]. Hormonal Resuscitation The Papworth protocol and subsequent research support the use of hormone replacement therapy in hemodynamically unstable donors. The regimen typically includes: • Methylprednisolone: 15 mg/kg IV bolus (addresses adrenal insufficiency, reduces inflammatory cytokine release) • Triiodothyronine (T3) or levothyroxine (T4): IV infusion to restore myocardial contractility • Vasopressin: 0.5–2.4 units/hour IV • Insulin: Continuous infusion targeting glucose 70–150 mg/dL This combination has been associated with increased cardiac procurement rates and improved hemodynamic stability [30].
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MDPA2326
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