Download PROTOCOL PEDIATRIC RENAL TRANSPLANT

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)