Download PROTOCOL PEDIATRIC SMALL BOWEL TRANSPLANT

PROTOCOL PEDIATRIC SMALL BOWEL TRANSPLANT
DATE:
PATIENT NAME:
MEDICAL RECORD #:
ATTENDINGS/CONSULTING SERVICES
PICU:
TRANSPLANT:
SURGERY:
OTHER CONSULTANTS: DR.JOHN
(312 –996-9291, BEEPER 3634)
ANESTHESIA, PLASTIC SURGERY
MONA BOTTKE BEEPER 3632
PEDS and TX PHARM D STAFF
DIETARY CONSULT
RADIOLOGY
PATHOLOGY
1. Draw blood for: Chem 7, PI, Mg, Liver function, CBC, PT, PTT. Type and cross match
(per transplant service 2 units). Check transplant service for special labs on
donor/recipient).
2. CXR (EKG and ECHO).
3. History and physical exam. Need height, weight, and surface area
4. UA, urine culture, other cultures. (stat)
5. Notify Ramona Bottke, (3632) out patient follow-up, Kathy Lusher for discharge plans,
Lucy Ramirez for social issues and transport.
6. Pre-transplant immunosuppressive medications per transplant service; call Transplant
PharmD for transplant medication protocol.
POST OPERATIVE SMALL BOWEL TRANSPLANT ORDERS
VITALS:
BP, HR, RR, Q ½ - 1 hour
CVP q 1 hour
TEMP q 1 – 6 hours
Daily weights and urine—specific gravity
Strict I & O q ½ - 1 hour FIRST 2-4 DAYS THEN Q 2-4HRS
FLUIDS:MAINTENANCE(IWL+STOOL LOSSES+URINE LOSSES+WOUND
LOSSES+THIRD SPACE AND OTHER LOSSES)
IWL – 400cc – 600cc/M2 (can be given as D5W, 2NS or Hyperal) plus urine replacement
cc/cc plus other losses.
STOOL REPLACEMENT:
CC/CC WITH RINGERS LACTATE
URINE REPLACEMENT: OBTAIN UA AND URINE LYTES DAILY
DURING FIRST TWO WEEKS THEN AS NEEDED
DW5% 0 .45%NS
+
20-35MEQ/L OF KCL (ADJUST KCL CONCENTRATION IN IV FLUID BASED ON SERUM
K+. Keep Serum K ABOVE 3MEQ/L)
+
BICARBONATE 30-70 MEQ/L TO KEEP SERUM BICARBONATE AT 21-23 MEQ/L
(solution to match urine losses of electrolytes)
WOUND AND SKIN LOSSES:
REPLACE – WITH 5%ALBUMIN
1
THIRD SPACE FLUID LOSSES:
REPLACE WITH 25%ALBUMIN ½-1G/KG OVER 2-4
HRS FOLLOWED BY 1-2MG/KG OF LASIX TO MOBILIZE
NORMAL SALINE BOLUS FOR:
CVP < 10-12 cms.
Urine output less than 2cc/hr/kg
BP lower than the parameter (<110/70 – 120/80 mmHg).
Inform TRANSPLANT SERVICE IF THERE ARE ANY major changes in stool out put.
TRANSFUSION:
Avoid unless acutely indicated. Inform Transplant and Renal Services.
BLOOD PRESSURE:
High BP (parameters to be set by DR.JOHN AND TX SERVICE) give IV medication
(Hydralazine or Labetalol), Q 3-6 hours; important not to drop the BP quickly to avoid
thrombosis of the graft and/or CNS problems.
FEVER:
Tylenol
Work up for infection (bacterial, viral and fungus), (blood, urine, STOOL, tracheal aspirate and
wound).
CMV PCR, EBV PCR
BACTERIAL; AEROBIC AND ANAEROBIC CULTURE
LABS:
ELECTROLYTES
Serum lytes, BUN, Cr, Ca, Mg ,Pi Q 4-6 hrs X 1-2 days, then q 8 hr, then q 12 hr, and then
once a day
LIVER FUNCTION STUDIES DAILY OR AS NEEDED
(micro blood samples please).
URINE:
Na, K, Cl, Cr once a day as needed.
UA and urine for protein/creatinine 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 or as needed
CSA /FK506 level:
Trough level in a.m. daily to three times a week (keep CSA level at 250-270 & FK 12-20).
CHEST:
X ray as needed.
CULTURES:
Blood, line, urine, throat, stool as indicated (bacterial, viral, fungal).
Stoma and wound culture as needed.
ULTRASOUND, CT SCAN:
Abdominal/graft as indicated.
2
ENDOSCOPY/ SMALL INTESTINAL BIOPSY Q WEEKLY OR AS NEEDED TO R/O
REJECTION; PER TRANSPLANT SERVICE AND SURGERY SERVICE.
DURING NPO GIVE IV SOLUTION WITH ELECROLYTES TO REPLACE URINE AND
INSENSIBLE LOSSES
MEDICATIONS:
Immunosuppression medications per Transplant Service KEEP IN TOUCH WITH
TRANSPLANT SERVICE REGARDING IMMUNOSUPPRESSION MEDS CHANGES
Need to change CSA, FK506 (TACROLIMUS) daily, Imuran, TG/OKT3, based on WBC, GI
FUNCTION, LIVER FUNCTION AND REJECTION, and infection status.
ANTIBIOTICS; ADJUST FOR LIVER AND RENAL FUNCTION
Pre-medicate patient with Tylenol and Benadryl prior to ATG/TG/OKT3 immune suppressant
medications.
PHYSIOTHERAPY OT AS SOON AS POSSIBLE TO AVOID MUSCLE WASTING AND
OTHER COMPLICATIONS
PAIN CONTROL/AND ITS COMPLICATIONS; PICU/PAINMANAGEMENT TEAM
SPECIAL TESTS;
FAT ABSORPTION TEST: 72 HRS STOOL COLLECTION.*
DIETICIAN TO MEASURE DIETARY FAT CONTENT DURINGTHIS PERIOD (72HRS)
Fecal Fat Protocol
Name Fat, Quantitative, Stool
CPT 82710
Synonyms Fat Quantitative; Fat, Quantitative, 72-Hour Stool Collection; Lipids, Total,
Quantitative, Stool; Quantitative Fecal Fat, 72-Hour Collection
Laboratory Core Laboratory
Referral to Referred
Request Form Computer Order or Test Request Form 1095
Phone Results and specimen information: 6-4440; technical/clinical information: 6-3972
Availability Daily, 24 hours
Turnaround Time 1 week
Special Instructions Requisition must state date and time collection started and date and
time collection finished.
Specimen 72-hour stool collection
Volume Entire collection
Minimum Volume 20 g or 80 mL
Container Wide mouth container
Patient Preparation Adult patients should be on a standard diet containing 100 g fat per day
for at least 3 days before test is started and during the test.
Causes for Rejection Improper container, foreign matter other than feces inside container,
patient not on special diet, not 72-hour collection
Reference Range 0-6 g/24 hours
Use Diagnose the presence of steatorrhea, supporting a diagnosis of one of the
malabsorption syndromes, including nontropical sprue, Crohn's disease, chronic pancreatitis,
cystic fibrosis, Whipple's disease
Limitations Fecal fat collection does not provide a diagnostic explanation for the presence of
steatorrhea.
Contraindications: Patient taking mineral oil. Patient having barium enema within previous
week
Additional Information: The three major causes of steatorrhea, which is a pathological
increase in fecal fat, are impairment of intestinal absorption, deficiency of pancreatic digestive
enzymes, and deficiency of bile. Fecal fat quantitation measures total fatty acids in stool; not
only dietary triglycerides (neutral fats) and lipolytic byproducts (split fats) but also fatty acids
3
of phospholipids and cholesterol esters. Identification of types of stool fat (eg, free fatty acids,
triglycerides, neutral fats, phospholipids) is of little value. Fecal fat excretion >6 g/day is
abnormal but nonspecific.
XYLOSE ABSORPTION;*
145G/M2 IV
NPO 4-6HRS
Protocol for Xylose Test
D-XYLOSE TEST (per Johns Hopkins: The Harriet Lane Handbook: A Manual for Pediatric
House Officers, 16th ed., Copyright © 2002 Mosby, Inc.)
Purpose: To screen for small bowel malabsorption by measuring the amount of D-xylose
absorbed after an oral load. Unreliable in patients with edema, renal disease, delayed
gastric emptying, severe diarrhea, rapid transit time, or small bowel bacterial
overgrowth.
Method: Have infants fast for 4 to 6 hours, older children for 8 hours. Give a 14.5 g/m2
(maximum 25 g) oral load of D-xylose as a 10% water solution. Ensure adequate
urine output using supplementary oral or intravenous (IV) fluid, collect all urine for 5
hours, and send for quantitation. Alternatively, send serum specimens for D-xylose
concentration before the load and 30, 60, 90, and 120 minutes after the load.
(PATIENT WAS GIVEN 6 GRAMS OF XYLOSE)
Interpretation (urine)
Children >6 months old
5 hours urinary excretion of <15% of the oral load suggests
malabsorption.
15% to 24% is indeterminate.
>25% is normal.
Infants <6 months old: 5 hours urinary excretion <10% suggests malabsorption.
Interpretation (serum): Failure of the serum level to exceed 25 mg/dl in any of the
postabsorptive specimens suggests malabsorption
e.g.; Based on Zachary's last known height and weight,
14.3kg and 94.5cm, his BSA = sqrt (14.3 x 94.5 / 3600) = 0.61
D-Xylose and Tacrolimus Kinetics
Xylose levels are collected in a grey top tube. Please place this form when completed in the
bedside chart. Please page Kelly 4985 with questions.
1. Around 6am, draw baseline xylose level and tacrolimus trough. Record time
____________.
2. Give tacrolimus and then mix d-xylose powder in 50-100mL water and administer through
G-tube. Record time ____________.
3. Draw a xylose level at 30min, 1 hr, and 2 hrs. Draw tacrolimus at 1 hr, 2hr, 4hr, and a
trough before the 2pm dose.
Xylose 30min (6:30)
_________
Tacrolimus 1hr (7am) _____________
1hr (7:00am) _________
2hr (8am) _____________
2hr (8:00 am) _________
4hr (10am) _____________
8hr trough (2pm) _________
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FK506;* KINETICS AND AREA UNDER THE CURVE
SERUM B12, CARNITINE, VITAMIN D METABOLITES, AND AMINOACIDS AS NEEDED
STOOL ELECTROLYTES; WEEKLY OR AS NEEDEED
OTHER SPECIAL CARE;
STOMA CARE;
LINE CARE
CHEST TUBE CARE;
SKIN GRAFT CARE;
DISCHARGE PLANS;
TRANSPLANT PHARM D TO EDUCATE PARENTS REGARDING IMMUNESUPPRESSIVE
MEDICATIONS
PEDS PHARM D; GET THE MED LIST READY AND REINFORCE ABOUT MEDICATION
DOSAGE AND ITS COMPLICATIONS
KATHY LUSHER TO ORGANIZE FOR HOME SUPPLIES AND OTHER NEEDED
ARRANGEMENTS AS WELL AS INSURANCE ISSUES
LUCY RAMIREZ; TO ARRANGE FOR TRANSPORTATION AND CONFIRM ABOUT
INSURANCE
MONA BOTTKE; TRANSPLANT NURSE TO ARRANGE FOR OUT PATIENT CLINIC
FOLLOW UP
DR.HOLTERMAN AND HIS STAFF TO ARRANGE FOR WEEKLY BIOPSY AND SEDATION
DISCHARGE SUPPLIES;
DRESSING
IV FLUIDS
IV SET
WIGHING MACHINE
BP MACHINE
UA DIPSTICK
I/OLOG SHEETS
WEIGHING SCALE
IV MEDICATIONS
PAIN MEDS
VISITING NURSE
5
Cumulative Volume Status
5000
4000
Volume (cc)
3000
2000
1000
0
-1000
-2000
Cumulative
-3000
10
/
26
10 /02
/2
8
10 /02
/3
0/
11 02
/1
/
11 02
/3
/
11 02
/5
/
11 02
/7
/
11 02
/9
11 / 02
/1
1
11 /02
/1
3
11 /02
/1
5
11 /02
/1
7
11 /02
/1
9
11 /02
/2
1
11 /02
/2
3
11 /02
/2
5
11 /02
/2
7
11 /02
/2
9/
12 02
/1
/
12 02
/3
/0
12 2
/5
/
12 02
/7
/
12 02
/9
/0
2
-4000
Time
FLUID BALANCE CHART FOR TRANSPLANT SERVICE
Special labs (to send)
1.
EBV PCR Quantification
Contact person :
Dr. Kadkol, Shrihari. Director, Molecular pathology, MC 847. Pathology Rm. 446 CMW
phone: 312-996-7312
Specimen : Blood 2 cc in green top and label to send for EBV DNA quantification real time
PCR code 10186 and write as discuss and approve with Dr. Kadkol to be send out
Note : Please contact Dr. Kadkol before send specimen
2. Citrulline level
Contact person : Biochemical Genetic Lab (6-5326).
Specimen: Approximately 0.8 cc in a green top bullet tube to the Biochemical Genetic Lab (65326).
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