Organ DonationOrgan Donation

What Is the New York Organ What Is the New York Organ Donor Network (NYODN)?Donor Network (NYODN)?

Organ Procurement Organization (OPO)Organ Procurement Organization (OPO)

Federally-designatedFederally-designated

Oversight by Federal GovernmentOversight by Federal Government

58 OPO’s in the United States58 OPO’s in the United States

OPO’s serve as organ sharing unitsOPO’s serve as organ sharing units

Service AreaService Area

New York CityNew York City

(Bronx, Brooklyn, Manhattan, Queens, Staten Island) (Bronx, Brooklyn, Manhattan, Queens, Staten Island)

Long Island Long Island

5 counties in New York State 5 counties in New York State

(Rockland, Putnam, Orange, Westchester & Duchess)(Rockland, Putnam, Orange, Westchester & Duchess)

1 county in Pennsylvania 1 county in Pennsylvania (Pike)(Pike)

13 million persons13 million persons

> 100 hospitals> 100 hospitals

The Donor Network is the 2nd largest OPO in the USThe Donor Network is the 2nd largest OPO in the US

What Does What Does NYODN NYODN Do?Do?Receives all calls from hospitals on deaths & potential organ & Receives all calls from hospitals on deaths & potential organ & tissue donorstissue donors

Evaluates organ & tissue donor potentialEvaluates organ & tissue donor potential

For organs, sends nurses to hospitals to evaluate & maintain For organs, sends nurses to hospitals to evaluate & maintain potential donorspotential donors

Requests consent for organ & tissue donationRequests consent for organ & tissue donation

Arranges for recovery of organs & tissueArranges for recovery of organs & tissue

Determines appropriate organ allocation (UNOS)Determines appropriate organ allocation (UNOS)

Gets organs to appropriate Transplant CentersGets organs to appropriate Transplant Centers

Donor Family ServicesDonor Family Services

Community Education / Public AwarenessCommunity Education / Public Awareness

Hospital and Family ServicesHospital and Family Services

Source: New York Organ Donor Network

4 Types of Donors4 Types of Donors

BRAIN DEADBRAIN DEAD - Can donate organs and tissues - Can donate organs and tissues (ventilator-dependent patient)(ventilator-dependent patient)

Donor after Cardiac Death (DCD)Donor after Cardiac Death (DCD) – can – can donate kidneys, liver, lungs, and tissues donate kidneys, liver, lungs, and tissues (ventilator dependent patient)(ventilator dependent patient)

CARDIAC DEADCARDIAC DEAD - Can donate tissues - Can donate tissues

LIVING DONORLIVING DONOR - Can donate kidney, partial - Can donate kidney, partial liver or lung, bone marrow and bloodliver or lung, bone marrow and blood

Misconception: Can take organs even if not on ventMisconception: Can take organs even if not on vent

Intestines

Lungs

KidneysPancreas

Corneas

Liver

Bone

Skin

Femoral Veins

Saphenous Veins

Tendons

Heart & Heart Valves

Organs & Tissues That Can Be Transplanted

New York Organ Donor Network

The Essential The Essential IssueIssueNeed for Organ Donation in Need for Organ Donation in U.S.U.S.

6,1905,9845,7915,4195,1004,5204,5097,151

82,749

73,82465,005

50,130

37,60929,415

21,914

88,149

24,89120,96120,494 22,953

19,04416,62715,467

27,035

010,00020,00030,00040,00050,00060,00070,00080,00090,000

100,000

1990 1992 1994 1996 1998 2000 2002 2004

Deceased Donors Size of Waiting Lists TransplantsSource: United Network for Organ Sharing

98,357 as of 8:09am on 3/19/0898,357 as of 8:09am on 3/19/08

RegulationsRegulations CMS CMS (formerly HCFA)(formerly HCFA) - Hospitals - Hospitals

Conditions of ParticipationConditions of Participation

Hospitals required to:Hospitals required to:

– Notify OPO of Notify OPO of all all deaths immediately after expirationdeaths immediately after expiration

– Notify OPO of all Notify OPO of all imminent deaths (Any ventilator imminent deaths (Any ventilator dependent patient who exhibits neurological injury dependent patient who exhibits neurological injury indicating evolvement to brain death)indicating evolvement to brain death)

Maintain patient viability to evaluate for brain death.Maintain patient viability to evaluate for brain death.

Request for organ donation will be made only by trained Request for organ donation will be made only by trained requestors.requestors.

NYSDOH, The Joint Commission, & CMS regulations all agree on organ donation.NYSDOH, The Joint Commission, & CMS regulations all agree on organ donation.

**Implemented Implemented August 1999August 1999

Standard LD.3.110Standard LD.3.110““The organization Leaders implements policies and procedures The organization Leaders implements policies and procedures developed with the medical staff’s participation for procuring and developed with the medical staff’s participation for procuring and donating organs and other tissues.”donating organs and other tissues.”

Elements of Performance for LD.3.110 (A4):Elements of Performance for LD.3.110 (A4):The hospital notifies the OPO in a timely manner of a patient who has died, The hospital notifies the OPO in a timely manner of a patient who has died,

or whose death is imminent, as follows or whose death is imminent, as follows in the following waysin the following ways: :

In accordance with clinical triggers defined jointly with hospital medical In accordance with clinical triggers defined jointly with hospital medical staff and the designated OPO staff and the designated OPO Within time requirements jointly agreed to by the hospital and Within time requirements jointly agreed to by the hospital and designated OPO designated OPO (ideally, within one hour)(ideally, within one hour) Prior to the withdrawal of any life-sustaining therapies including medical Prior to the withdrawal of any life-sustaining therapies including medical or pharmacological supportor pharmacological support

Latest Revision Effective Latest Revision Effective 1/1/071/1/07

Source: Joint Commission Resources, http://www.jcrinc.com/12858/

Brain Death Determination: Brain Death Determination: The Beginning…The Beginning…What do you do?What do you do?

Starts with injury to brain and loss ofStarts with injury to brain and loss of reflexes…reflexes…1.1. Recognize brain death and start BD protocolRecognize brain death and start BD protocol

2.2. Notify the OPO of possible donorNotify the OPO of possible donor

3.3. Support blood pressure with pressors/fluidsSupport blood pressure with pressors/fluids

4.4. Do notDo not mention donation to the family mention donation to the family

5.5. Allow the OPO to approach after brain death has Allow the OPO to approach after brain death has been discussed with family members or if family been discussed with family members or if family brings up disconnectionbrings up disconnection

The Role of a Family Services CoordinatorThe Role of a Family Services Coordinator Serve as a link between hospital staff and the Serve as a link between hospital staff and the potential donor familiespotential donor familiesSupport families, answer their questions & Support families, answer their questions & address their concernsaddress their concernsProvide the opportunity for organ & tissue Provide the opportunity for organ & tissue donationdonationOffer resources to families (Offer resources to families (bereavement, burial bereavement, burial assistance, victim servicesassistance, victim services))Inform families of our Donor Family Services Inform families of our Donor Family Services programprogram

Organ Donation Can Occur in Organ Donation Can Occur in Two WaysTwo Ways

Heart-Beating DonorsHeart-Beating Donors: : Patient is Patient is declared dead based on declared dead based on Brain Death Brain Death CriteriaCriteria

Non-Heart-Beating DonorsNon-Heart-Beating Donors: : Patient is Patient is declared dead based on declared dead based on Cardio-Cardio-Pulmonary CriteriaPulmonary Criteria

DefinitionsDefinitions

Brain Death:Brain Death: T The irreversible cessation of brain he irreversible cessation of brain function, including the brain stem.function, including the brain stem.

Donation after Cardiac Death (DCD):Donation after Cardiac Death (DCD): A A procedure in which organs are surgically procedure in which organs are surgically recovered following the pronouncement of death recovered following the pronouncement of death based on the “irreversible cessation of based on the “irreversible cessation of circulatory and respiratory functions”circulatory and respiratory functions”

Brain Death DeterminationBrain Death Determination

Know your hospital policyKnow your hospital policy While many policies are different, the criteria is While many policies are different, the criteria is

same everywhere (NYS released new guidelines same everywhere (NYS released new guidelines in Dec 2005)in Dec 2005)– No response to painful stimuliNo response to painful stimuli– No cranial reflexes: corneal, cold calorics, No cranial reflexes: corneal, cold calorics,

doll’s eyesdoll’s eyes– Pupils fixed and dilatedPupils fixed and dilated– No spontaneous respirations (Apnea trial)No spontaneous respirations (Apnea trial)– Confirmatory test not requiredConfirmatory test not required

Brain Death Determination: Brain Death Determination: EVALUATION PROCESSEVALUATION PROCESSOnce a Referral is MadeOnce a Referral is Made

On-site clinical evaluation by transplant On-site clinical evaluation by transplant coordinator - review of medical records coordinator - review of medical records

Physical examinationPhysical examination

Monitor organ function (lab testing)Monitor organ function (lab testing)

Establish suitability-patient declared brain Establish suitability-patient declared brain dead/patient is medically suitable dead/patient is medically suitable

Next of kin identifiedNext of kin identified

When time is right approach is made to When time is right approach is made to familyfamily

Criteria for Determining Criteria for Determining Brain Death - Part IBrain Death - Part I

PRE-EXISTING CONDITIONS

• Known mechanism of injury

• Absence of toxic CNS depression

• Absence of metabolic CNS depression

Criteria for Determining Criteria for Determining Brain Death - Part IIBrain Death - Part II

CLINICAL EVALUATION• No pupillary reflex• No corneal reflex• No oculocephalic reflex• No oculovestibular reflex• No gag or cough reflex• Apnea

Brain Death DeterminationBrain Death Determination

Imminent Death in accordance with the Imminent Death in accordance with the New York Organ Donor Network is New York Organ Donor Network is defined as “any ventilator dependent defined as “any ventilator dependent patient who exhibits neurological criteria patient who exhibits neurological criteria indicating evolvement to brain death”. indicating evolvement to brain death”. Categories of patient diagnoses that Categories of patient diagnoses that would give rise to “imminent deaths” of would give rise to “imminent deaths” of this definition are anoxia, traumatic head this definition are anoxia, traumatic head injury, brain tumor, and cerebral vascular injury, brain tumor, and cerebral vascular accident.accident.

Brain Death DeterminationBrain Death Determination

The determination of brain death is made by two clinical examinations:The determination of brain death is made by two clinical examinations:For adults:For adults: two clinical assessments should be six hour apart unless a confirmatory test two clinical assessments should be six hour apart unless a confirmatory test confirms the diagnosis of brain death. If a confirmatory test confirms the confirms the diagnosis of brain death. If a confirmatory test confirms the diagnosis of brain the clinical examination may be two hours apart. diagnosis of brain the clinical examination may be two hours apart.

The clinical examinations must be performed by an The clinical examinations must be performed by an attending physician credentialed in neurology, attending physician credentialed in neurology, neurosurgery or critical care intensivist (attending neurosurgery or critical care intensivist (attending physician in any intensive care unit) who has agreed to physician in any intensive care unit) who has agreed to perform brain death protocol by returning a signed perform brain death protocol by returning a signed review of this policy. Two separate attending physicians review of this policy. Two separate attending physicians should perform the two clinical exams.should perform the two clinical exams.

Brain Death DeterminationBrain Death Determination Three Cardinal Findings in Brain Death - Coma, Absence of brainstem reflexes and Three Cardinal Findings in Brain Death - Coma, Absence of brainstem reflexes and

Apnea (all 3 must be present)Apnea (all 3 must be present)::Coma (unresponsiveness):Coma (unresponsiveness):

1. No response to sound including name; no grimacing to pressure applied to 1. No response to sound including name; no grimacing to pressure applied to nailbeds (unless its spinally mediated), supraorbital ridge or tempo-mandibular joint; nailbeds (unless its spinally mediated), supraorbital ridge or tempo-mandibular joint;

2. No motor response to pain in all extremities.2. No motor response to pain in all extremities.Absence of brainstem reflexes:Absence of brainstem reflexes:– No pupillary response to light, size: mid-position (4 mm) to dilated (9 mm)No pupillary response to light, size: mid-position (4 mm) to dilated (9 mm)– No oculocephalic response (“Doll’s Eyes”):No oculocephalic response (“Doll’s Eyes”):

May be tested only when no fractures or instability of the cervical May be tested only when no fractures or instability of the cervical spine are apparentspine are apparent

No eye movements to neck rotationNo eye movements to neck rotationNo vertical eye movement with neck flexionNo vertical eye movement with neck flexion

– No oculovestibular reflex (“Cold Calorics”)No oculovestibular reflex (“Cold Calorics”) -Technique:-Technique: a. Visualize the tympanic membrane to ensure that excessa. Visualize the tympanic membrane to ensure that excess cerumen is removed and to check for rupturecerumen is removed and to check for rupture b. The patient remains supine with head tilted forward at 30 degreesb. The patient remains supine with head tilted forward at 30 degrees c. Irrigate the external ear canal with 50 cc of ice water c. Irrigate the external ear canal with 50 cc of ice water d. Observe eye movement for one minuted. Observe eye movement for one minute e. Allow 5 minutes before testing opposite sidee. Allow 5 minutes before testing opposite side

APNEA TEST: TechniqueAPNEA TEST: TechniquePatient must be apneic with adequate stimulus (pCO2 >60mmHg, pH <7.40). The apnea test is generally performed after the second examination of brainstem reflexes. The apnea test need only be performed once when its results are conclusive.

a. Check ABG record. Baseline ABG must be available b. Adjust ventilatory settings to achieve pCO2 of >35 mm Hg c. Ventilate patient with FiO2 100% for 10 minutes d. Connect pulse oximeter e. Disconnect ventilator f. Place cannula in trachea, deliver 100% O2 at 6L/m g. Observe for respiratory movements h. Adequate hypercarbia (pCO2 > 60 mm Hg or PCO2 increase is 20 mm Hg over baseline normal PCO2) j. Observe for respiratory movements and draw ABG after approximately 8 minutes from the beginning of the apnea test k. Return patient to the ventilator at the completion of the apnea test

APNEA TEST, Cont.APNEA TEST, Cont.Interpretation:a. If respiratory movements are absent and arterial pCO2 is > 60 mm Hg or increased 20 mm Hg over baseline normal, the apnea test result is positive

b. If respiratory movements are observed, the apnea test is negative c. If respiratory movements are not observed and the pCO2 is < 60 mm Hg

or increase in PCO2 < 20 mm Hg from baseline, the apnea test is indeterminate and should be repeated Precautions:

a. The apnea test may be done only when the following conditions are met: -Temperature > 36.5 degrees C (97.7 F)

-Systolic blood pressure > 90 mm Hg -Euvolemia. -Normal PO2 (PO2 > 60 mm Hg on FIO2 < 60%) b. Discontinue apnea test if:

– Patient develops hypotension (systolic BP < 90 mm Hg)– Patient develops significant oxygen desaturation– Cardiac arrhythmias develop– If any of the above events occur, immediately draw an ABG if possible

and: reconnect the patient to the ventilator.– If PCO2 is > 60 mm Hg or PCO2 increase is > 20 mm Hg over baseline

normal PCO2, the apnea test is result positive.

Brain Death DeterminationBrain Death Determination

Confirmatory TestsConfirmatory TestsBrain death is a clinical diagnosis. In some patients, skull or cervical Brain death is a clinical diagnosis. In some patients, skull or cervical injuries, cardiovascular instability, or other factors may make it injuries, cardiovascular instability, or other factors may make it impossible to complete parts of the assessment safely. In such impossible to complete parts of the assessment safely. In such circumstances, a circumstances, a confirmatory testconfirmatory test verifying brain death is verifying brain death is necessary. Confirmatory tests are required necessary. Confirmatory tests are required ONLYONLY if the following if the following conditions which may interfere with the clinical examination are conditions which may interfere with the clinical examination are present and therefore make the diagnosis uncertain: present and therefore make the diagnosis uncertain: 1. Severe facial or cervical spine trauma1. Severe facial or cervical spine trauma

2. toxic levels of any sedative drugs, aminoglycosides, tricyclic 2. toxic levels of any sedative drugs, aminoglycosides, tricyclic antidepressants, antiepileptic drugs, anticholinergics, antidepressants, antiepileptic drugs, anticholinergics, neuromuscular blocking agents, or chemotherapeutic agentsneuromuscular blocking agents, or chemotherapeutic agents

3. Pulmonary dysfunction severe enough to make the apnea test 3. Pulmonary dysfunction severe enough to make the apnea test impossible to perform or interpret (I.e. sleep apnea, chronic CO2 impossible to perform or interpret (I.e. sleep apnea, chronic CO2 retention, uncorrectable hypoxemia).retention, uncorrectable hypoxemia).The consulting neurologist, neurosurgeon or intensivist makes the The consulting neurologist, neurosurgeon or intensivist makes the determination whether a confirmatory test is necessary and which determination whether a confirmatory test is necessary and which test should be used.test should be used.

Brain Death DeterminationBrain Death Determination

Confirmatory TestsConfirmatory Tests The following confirmatory tests are available:The following confirmatory tests are available:– Technetium-based nuclear brain scan: If no uptake of isotope in Technetium-based nuclear brain scan: If no uptake of isotope in

brain parenchyma and no cerebral blood flow, the test is positivebrain parenchyma and no cerebral blood flow, the test is positive– Electroencephalograph: 30 minutes of continuous EEG recording Electroencephalograph: 30 minutes of continuous EEG recording

showing electrocerebral inactivity, the test is positive. Tracings will showing electrocerebral inactivity, the test is positive. Tracings will comply with the minimum technical standards for EEG recording comply with the minimum technical standards for EEG recording as outlined by the American Electroencephalograph Society.as outlined by the American Electroencephalograph Society.

*The ICU setting may result in false readings due to *The ICU setting may result in false readings due to electronic backgrounds noise creating innumerable artifactselectronic backgrounds noise creating innumerable artifacts– Transcranial Doppler Ultrasonography: No diastolic flow or Transcranial Doppler Ultrasonography: No diastolic flow or

reversed flow or small systolic peaks in early systole without reversed flow or small systolic peaks in early systole without diastolic flow or with reversal of flow are consistent with the diastolic flow or with reversal of flow are consistent with the diagnosis of brain death. Lack of Doppler signal cannot be diagnosis of brain death. Lack of Doppler signal cannot be interpreted as confirmation of brain death because 10% of patients interpreted as confirmation of brain death because 10% of patients do have temporal windows.do have temporal windows.

– Conventional cerebral angiography: No intercerebral filling at the Conventional cerebral angiography: No intercerebral filling at the level of the carotid bifurcation of circle of ‘Willis, the test is positivelevel of the carotid bifurcation of circle of ‘Willis, the test is positive

Criteria for Donation After Criteria for Donation After Cardiac Death (DCD)Cardiac Death (DCD)

Patient has devastating non-recoverable illness or Patient has devastating non-recoverable illness or injury and is ventilator dependentinjury and is ventilator dependent

Decision is made for withdrawal of support Decision is made for withdrawal of support according to patient wishes and hospital policy according to patient wishes and hospital policy

Cardio-pulmonary arrest will likely occur within 60 Cardio-pulmonary arrest will likely occur within 60 minutes after withdrawal of supportminutes after withdrawal of support

Patient has good kidney and liver functionPatient has good kidney and liver function

Location of withdrawal of support is changed to ORLocation of withdrawal of support is changed to OR

DCD ProcedureDCD Procedure

Decision is made for withdrawal of support;Decision is made for withdrawal of support;

Withdrawal of support is approved by hospital;Withdrawal of support is approved by hospital;

Patient is evaluated for medical suitability for organ Patient is evaluated for medical suitability for organ donation;donation;

Next of kin/authorized party is provided option of Donation Next of kin/authorized party is provided option of Donation After Cardiac Death and details about the procedure - After Cardiac Death and details about the procedure - including opportunity to be present in OR;including opportunity to be present in OR;

Next of kin/authorized party makes decision to donate Next of kin/authorized party makes decision to donate organs and written consent is obtained;organs and written consent is obtained;

Organ Recovery Team is notified and assembled;Organ Recovery Team is notified and assembled;

DCD Procedure (cont)DCD Procedure (cont)Patient will be transferred to OR on ventilator Patient will be transferred to OR on ventilator

and monitor;and monitor;Patient will be connected to monitor and Patient will be connected to monitor and anesthesia machine in OR;anesthesia machine in OR;Blood samples will be drawn;Blood samples will be drawn;Recovery team will prep and drape patient;Recovery team will prep and drape patient;Organ preservation solutions will be prepared;Organ preservation solutions will be prepared;Heparin will be given prior to withdrawal of support;Heparin will be given prior to withdrawal of support;Recovery team will leave the room;Recovery team will leave the room;Support will be withdrawn by Attending Support will be withdrawn by Attending MD/Designee;MD/Designee;

DCD Procedure (cont)DCD Procedure (cont)

Family will be escorted into OR and Family will be escorted into OR and provided emotional support;provided emotional support;

When patient’s heart and respirations When patient’s heart and respirations stop, family will be asked to leave room;stop, family will be asked to leave room;

Patient will be pronounced dead;Patient will be pronounced dead;

DCD Procedure (cont)DCD Procedure (cont)

Recovery team will re-enter room after family leaves;Recovery team will re-enter room after family leaves;

Abdominal incision will be made after waiting 5 minutes;Abdominal incision will be made after waiting 5 minutes;

Aortic cannula will be placed and aortic flush will be started;Aortic cannula will be placed and aortic flush will be started;

Chest may or may not be opened;Chest may or may not be opened;

Organs will be recovered;Organs will be recovered;

If patient does not arrest, patient will be transferred to If patient does not arrest, patient will be transferred to designated area and palliative care will be provided;designated area and palliative care will be provided;

Reminders about DCDReminders about DCD

Decision to withdraw support is separate from Decision to withdraw support is separate from donation discussion donation discussion Withdrawal of support process should not be Withdrawal of support process should not be modified in any way because the patient is going to modified in any way because the patient is going to donatedonateIf patient does NOT arrest within allotted time frame, If patient does NOT arrest within allotted time frame, the pt will be transferred back to the ICU or other the pt will be transferred back to the ICU or other pre-determined area. Comfort Care will continue as pre-determined area. Comfort Care will continue as per hospital policy. per hospital policy. The ventilator will NOT be reinstated. The pt was The ventilator will NOT be reinstated. The pt was going to be disconnected whether donation was going to be disconnected whether donation was taking place or not. taking place or not.

Consequences of Brain Consequences of Brain DeathDeath

• Loss of Vasomotor tone - HypotensionAltered perfusion

• Hypothalamic dysfunction - Diabetes Insipidus

Hypothermia

• Pulmonary dysfunction - Apnea Infection

Neutrogena pulmonary edema

Potential Organ Donor: Potential Organ Donor: Clinical Management GoalsClinical Management Goals

• Hemodynamic Stability

• Normothermia

• Optimal oxygenation

• Fluid/electrolyte balance

• Prevent infection

Management of Patients Undergoing OD Management of Patients Undergoing OD Evaluation: Evaluation: ProceduresProcedures

Arterial catheter Arterial catheter

CVC catheter CVC catheter

Echocardiogram, if age Echocardiogram, if age << 65 for possible heart 65 for possible heart donationdonation

Cardiac Catheterization if directed, for possible Cardiac Catheterization if directed, for possible heart donationheart donation

fiberoptic bronchoscopy / bronchoalveolar fiberoptic bronchoscopy / bronchoalveolar lavage (FOB/BAL) if directed for possible lung lavage (FOB/BAL) if directed for possible lung donation donation

Management of Patients Undergoing OD Management of Patients Undergoing OD Evaluation: Evaluation: Mechanical VentilationMechanical Ventilation

Control Mode VentilationControl Mode Ventilation

Adjust frequency (breaths per minute) to Adjust frequency (breaths per minute) to maintain PaCO2 35-45 with normal pHmaintain PaCO2 35-45 with normal pH

Adjust Vt 5-10 cc/kilogram, maintaining Peak Adjust Vt 5-10 cc/kilogram, maintaining Peak Inspiratory Pressure < 35 cm H20Inspiratory Pressure < 35 cm H20

Adjust FiO2 to maintain SaO2 > 90 %Adjust FiO2 to maintain SaO2 > 90 %

Adjust Peep to maintain SaO2 > 90% on an fiO2 Adjust Peep to maintain SaO2 > 90% on an fiO2 of < 50% of < 50%

Management of Patients Undergoing OD Management of Patients Undergoing OD Evaluation: Evaluation: Hormonal Resuscitation ProtocolHormonal Resuscitation Protocol

Administer IV boluses of:Administer IV boluses of:– 20 micrograms T-4 (Thyroxine)20 micrograms T-4 (Thyroxine)– 15 milligrams/kilogram methylprednisolone (Solumedrol)15 milligrams/kilogram methylprednisolone (Solumedrol)– 1 unit Arginine Vasopressin1 unit Arginine Vasopressin– 10 units regular insulin (not if BG < 100) 10 units regular insulin (not if BG < 100) – 1 amp of D50 (50cc of D50% - contains 25 grams of glucose) – if blood 1 amp of D50 (50cc of D50% - contains 25 grams of glucose) – if blood

glucose < 300glucose < 300Start continuous infusions:Start continuous infusions:

– Start an Vasopressin drip: (concentration as per pharmacy). Start at 0.5 units Start an Vasopressin drip: (concentration as per pharmacy). Start at 0.5 units per hour. Titrate up by 0.5 units every 5 minutes to keep SBP >100, MAP > 60 per hour. Titrate up by 0.5 units every 5 minutes to keep SBP >100, MAP > 60 not to exceed a maximal dose is 4.0 units/hr.not to exceed a maximal dose is 4.0 units/hr.

– Start a drip of 200 micrograms T-4 (thyroxine) in 500cc normal saline at 25cc Start a drip of 200 micrograms T-4 (thyroxine) in 500cc normal saline at 25cc (10 micrograms) per hour. (10 micrograms) per hour.

– Titrate T-4 by 2 microgram increments to maintain desired blood pressure – Titrate T-4 by 2 microgram increments to maintain desired blood pressure – do not exceed 20 micrograms/hour do not exceed 20 micrograms/hour

– Reduce levels of other vasopressors (if in place) as much as possibleReduce levels of other vasopressors (if in place) as much as possible– Start insulin drip (concentration as per hospital pharmacy) at 1unit/hr and Start insulin drip (concentration as per hospital pharmacy) at 1unit/hr and

adjust rate to maintain blood glucose 80 – 150 mg/dl. adjust rate to maintain blood glucose 80 – 150 mg/dl. – Glucose determinations by finger stick or serum every 1 hr.Glucose determinations by finger stick or serum every 1 hr.

website: www.donatelifeny.org