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PROTOCOL PEDIATRIC RENAL TRANSPLANT DATE: PATIENT NAME: MEDICAL RECORD #: ATTENDINGS PICU: NEPHROLOGIST: Ejohn TRANSPLANT: OTHER CONSULTANTS: 1. Draw blood stat for: Chem 7, Liver function,Ca,Mg,P, Cholesterol, Triglyceride, CBC, PT, PTT. Type and cross match (as per transplant service 2 units). 2. Check viral status as CMV titer EBV titer HSV I/II titer Hepatitis profile: (A, B, and C) HIV Nasal swab/wash for respiratory virus, throat C/S 3. CXR, EKG 4. UA, urine culture, urine protein/creatinine ratio. 5. History and Physical exam (body weight, height, body surface area) 6. For PD patient : Notify Ramona Bottke for PD (pager #3632) and send PD fluid for cell count (stat) and culture. 7. For HD patient : Notify technician on call (3-7602). Minimal or no Heparin during hemodialysis. 8. Pre-transplant immunosuppressive medications as per transplant service, call Transplant PharmD (60376) for transplant medication protocol. 9. Contact Transplant service for consent 10. Contact Anesthesia for consent 11. If K > 5.5, give Kayexalate 0.5 g/kg (PO or rectal suppo) after informing Dr. John 12. If HCO3 < 18, Give IV fluid with NaHCO3 13. NPO after midnight. Start IV fluid with 5%D + 0.2%NS + 10-20 mEq/L of NaHCO3 , no K. Total volume = Insensible water loss over 24 hr POST OPERATIVE RENAL TRANSPLANT ORDERS VITALS: BP, HR, RR, Q 1/2 - 1 hour CVP q 1 hour TEMP q 1 - 6 hours Daily weights Strict I & O q 1/2 - 1 hour FLUIDS: IWL - 400cc - 600cc/M2 (can be given as D5W . 2NS or Hyperal) plus urine replacement cc/cc. (In children less than 15-20 Kg urine replacement cc/cc at least 3-7 days and thereafter, modify as needed). In general, decrease urine replacement 80-90% and thereafter reduce by 10% until 24 hr urine output is about 2 - 2 1/2 Liters/day. URINE REPLACEMENT FLUID: Ringers lactate or solution to match urine losses of electrolytes (NaCl 110-130 mEq/L, HCO3 10-15 mEq/L, No dextrose in replacement fluid). NORMAL SALINE BOLUS FOR: CVP < 10-12 cms. Urine output <100 ml/hr. BP lower than the parameter (<110/70 - 120/80 mmHg). URINE OUTPUT GOAL Keep urine output as D0 : 100-500 cc/hr D1 : 100-400 cc/hr D2 : 100-300 cc/hr D3 : 100-200 cc/hr IF UO > upper limit, decrease or stop lasix drip JP DRAIN REPLACEMENT Replace with 0.9%NSS or 5%albumin NG TUBE REPLACEMENT Replace with 0.45%NS + 10 mEq/L KCl ( if Cr < 2.0) STOOL REPLACEMENT Replace with 0.45%NS + 10 mEq/L KCl ( if Cr < 2.0) + 10 mEq/L NaHCO3 TRANSFUSION: Avoid unless acutely indicated. Inform Transplant and Nephrology Services. BLOOD PRESSURE: High BP (parameters to be set by Nephrologist) 1. Decrease dopamine drip. 2. If BP still high or patient is not on dopamine, give IV medication (Hydralazine or Labetalol), or PO Nifedipine (5-10mg) Q 3-6 hours; important not to drop the BP quickly to avoid thrombosis of the graft and/or CNS problems. Note; Do not give labetalol in asthma, bradycardia patient Do not give hydralazine in SLE, tachycardic patient FEVER: Tylenol. Work up for infection (bacterial, viral and fungus) Blood, line, urine, throat as indicated (bacterial, viral, fungal). Viral : Send –CMV PCR/ titer, EBV titer, HSV C/S PD culture as needed. Note; Fever during and immediate after thymoglobulin infusion does not require C/S LABS: Serum Electrolyte, BUN, Cr Q 4-6 hrs X 1-2 days, then q 8 hr, then q 12 hr, and then once a day (micro blood samples please). URINE: Na, K, Cr q 4 -6 hrs, then q 8 - 12 hrs, then once a day as needed. UA and urine for pro/cr ratio to be done daily. Ca/P/Mg/LFT's: Daily or as needed. CBC: Q 8 - 12 hrs then daily as needed. PT/PTT: Q 6 - 12 hrs (keep PTT at 45-55). Will be adjust by transplant service CSA /FK506 level: Trough level to be drawn 1 hr before A.M. dose. Check daily to three times a week (keep CSA level at 250-270 & FK 10-15). CHEST: X-ray as needed. ULTRASOUND: Abdominal/graft as indicated. MEDICATIONS: Immunosuppression medications as per Transplant service. Check with transplant phramD daily. Need to change CSA/FK 506 daily, MMF, TG/OKT3, based on WBC, serum creatinine, and infection status. Pre-medicate patient with Tylenol and Benadryl prior to ATG/TG/OKT3 immune suppressant medications. RIDER If K < 3.0, give K rider If Mg < 1.5 or P < 3 , give rider HYPERAL Start Day #2 Volume equal to insensible water loss Duration : over 12-24 hr Protein 1gm-1.5/Kg/day. All vitamins. Na, K, Mg, Ca, P adjust as needed. Trace elements (when renal function is better). Zantac. Iron 2-3 times/week D/C Hyperal when patient's PO intake is good. In MMF patient For abdominal pain/ diarrhea/ colic/ emesis, give loperamide, metoclopramide or other anti emetic drug. In FK 506 patient For pain syndrome, give morphine, hydromorphone, or Tylenol with codeine Leukopenia If WBC < 3000, give G-CSF 1-3 days Adjustment of thymoglobulin and MMF to be done by transplant service In resident note, should document daily thymoglobulin, MMF, and FK dose since adjustment is made daily Inform Transplant service for 1. Bleeding, gross hematuria, no urine output 2. Immunosuppressive adjustment (Resident has to check result of FK level in afternoon and contact with Transplant pharmD for FK adjustment) 3. Heparin adjustment for PTT Inform Dr. John for fluid and electrolyte problems When you call Dr. John regarding urine output, blood pressure, fever, or other problems, please have the following information available 1. Intake/output for the day, urine output (cc/hr) 2. V/S (highest & lowest BP) 3. Medication including thymoglobulin, FK, MMF Last update 1/6/04 (10.00 AM)