General Evaluation (minimum requirements)

Transcription

1 GL of 15 General Evaluation (minimum requirements) History of current injury and medical treatment Past medical and social history on the child AND on the mother if : A) Child is 18 months old or less B) Child is less than 5 years old AND breastfed within past 12 months Serology testing: 2 red top tubes (pre and post-transfusion samples if available, negotiated with coroner/me when applicable) At least 2 ml needed for pre-transfusion sample. ABO typing with sub-typing of ABO(A) donors HLA cross-matching (19 yellow top tubes, 1 red top tube); if <0kg or unstable donor, 4 yellow tops and 1 red top. Consult with placement coordinator prior to draw to determine minimum number of tubes needed. Current physical examination, including height in cm (measured by TC) and weight in kg. Establish accurate dry weight by using admission weight or clarify by reweighing and calculating I&O s. CXR on all donors, interpreted by a radiologist, to exclude pathology e.g. TB or CA Continuous arterial pressure monitoring CVP monitoring. If patient has a femoral line must have dependable peripheral IV prior to OR. ABG, H&H, serum electrolytes every six hours during management ation of ALL medications given from time of injury to organ procurement. ation of hourly I&O, CVP pressures, SaO2, systolic and diastolic BP, and time/dosage of vasoactive and other medications, from initiation of management. ation of core temperature, in degrees Celsius, every two hours from time of initiation of management (conversion take temp in degrees F, minus 2, multiply by 5, divide by 9 = degrees C) ation of significant hypotension (see age specific parameters), estimated time of episodes of cardiorespiratory arrest, any episodes of CPR and Defibrillation Two sets of blood cultures, one urine culture, and one sputum culture, additional cultures as clinically indicated Organ specific information for heart, lung, kidney, liver and small bowel on all donors with consent for these organs, pancreas specific evaluation on donors > 20 kg.

2 GL of 15 Kidney Specific Evaluation (minimum requirements) Urinalysis with micro at time of admission, at the initiation of management, and prior to OR. BUN and creatinine at time of admission, every 6 hours during management, and prior to OR. Calculate creatinine clearance from admission and peak creatinine using the Cockcroft- Gault formula. Pancreas Specific Evaluation (minimum requirements) Amylase at admission and initiation of management Lipase at admission and initiation of management Blood glucose values every six hours Liver Specific Evaluation (minimum requirements) AST/SGOT, ALT/SGPT, Alk Phos, Bilirubin (total and direct), GGT, LDH & Alb at time of admission, initiation of clinical management and every 6 hours until OR. PT, INR and PTT at admission, initiation of clinical management and within six hours of organ offer. Heart Specific Evaluation EKG within 12 hours of organ offer (interpreted by a cardiologist) Echocardiogram within 12 hours of organ offer (interpreted by cardiologist) CPK (total and MB%) within 12 hours of organ offer (Troponin I acceptable) ABG (continued next page)

3 GL104. of 15 Lung Specific Evaluation (minimum requirements) CXR within three hours of organ offer (interpreted and if a trauma case request radiologist to be specific regarding thoracic trauma - i.e. location and nature of rib fractures, etc) Measurement (in cm) of length of right lung and left lung, width of lungs at aortic knob, width at diaphragm, and chest circumference. Challenge ABG on 1.00 FiO2 and PEEP 5 cm H2O for fifteen minutes, and then decrease FiO2 to lowest % to maintain PO2 of ABG within two hours of organ offer Gram stain and KOH within 24 hours of organ offer ABG every 4 hours and post vent changes. Optional Evaluations (pending specific circumstances of donor) Transesophageal echocardiography (consider if unable to obtain adequate imaging on TTE) Bronchoscopy (therapeutic or diagnostic) Ultrasound for suspected pathologies (kidney stones, polycystic disease) Hemodynamic monitoring by pulmonary artery catheter. This will only be requested in a very rare instance, as it is usually contraindicated on pediatrics. Check with APC prior to placement of Swan. DO NOT use PAWP with children < 5yrs. of age, CVP IS ADEQUATE FOR VOLUME STATUS. Consider Swan in cases of prolonged hemodynamic instability (longer than 4-6 hours) requiring multiple vasopressors. May be used in cases of known depressed cardiac function (diagnosed by echo, if repeat echo being considered) and where moderate to severe pulmonary dysfunction is present in the absence of pulmonary history. Serial Echos: consider a repeat echo in cases with an initial EF of less than 50% and/or wall motion abnormalities (consult with APC first). Ensure that Solumedrol has been administered, that electrolyte imbalances have been corrected, that acidosis/alkalosis has been corrected, CVP of < 6, and vasopressors are low and continue to be weaned. Lateral Decubitus CXR or Chest CT consider after consultation with APC or lung transplant surgeon in cases of potential lung trauma and/or pleural effusion per CXR. If performing a lateral decubitus be sure to extend arms overhead, place good lung closest to XRAY machine, and poor lung closest to XRAY plate. Thyroxine replacement (T or T4) maybe requested by outside transplant centers. If requested, either ask them for their protocol, or contact the APC for a dosing regimen. If possibility of DIC add DIC panel or D-dimer to lab draw

4 GL of 15 CLINICAL MANAGEMENT Organ Perfusion Goals: Optimum Hemodynamic parameters as indicated below Urinary output of 1- ml/kg/hr CVP 4-6 mmhg PAWP 5-12 mmhg (ONLY for ages>5.) Airway: Pearl FYI: ETT SIZE = (16 + age in years)/4 Lip Line Reference Approx. cm = X ETT Size 2 X ETT Size = Suction Cath. Size, Foley Size, NGT size Breathing & Circulation: (Min. Systolic BP Calc: SBP=70+ (age in years X 2) Vital Signs Approx. by Age/Weight Considerations: Age Pulse SBP Resp Weight (kg) Approx.: Newborn > kg 1 mo > kg 6 mo > kg 1 yr > kg 2- yr > kg 4-5 yr > kg 6-8 yr > kg 8-10 yr > kg Assessment: Continuous arterial pressure monitoring (left radial site preferred) Continuous EKG monitoring Hourly CVP recordings (or PA with CO q 4hrs and/or with significant changes) Hourly urine output measurements Urine specific gravity every six hours or as needed with evidence of DI.

5 GL of 15 Interventions: Hypotension (Systolic BP < 70mmHg in newborn - 1yr, < 85mmHg 1yr - 10yrs) * Give Solumedrol 15-0mg/kg as soon as possible and every 12 hours (may give every 8 hours as needed). * Initiate Dopamine infusion for hypotension. Start at -5mcg/kg/min. Titrate up to 10mcg/kg/min and if inadequate response, initiate: * Phenylephrine (neosynephrine) mcg/kg/min. * May also consider Epinephrine gtt. Start at 0.05 mcg/kg/min and titrate to effect up to 1mcg/kg/min.Or you may consider Vasopressin gtt units/kg/min. Review case with APC when moving to this option. * If fluid resuscitation is deemed necessary (CVP < 4) administer Lactated Ringers or Plasmalyte fluid bolus of 10-20ml/kg over 15 minutes, repeat once if needed to maintain CVP 4-8. * If hypotension persists after fluid resuscitation, solumedrol administration and vasopressor infusion, administer Hespan or Albumin 5% (protocol below) CLINICAL CONDITION PREFERRED COLLOID COMMENTS Anemia/Acute Hemorrhage PRBCs Infuse per protocol on page 10, use warmer if possible Coagulopathy/Acute FFP Infuse per protocol on page Hemorrhage 8 Hypotension without acute Hespan hemorrhage Hypotension Albumin 5% 10 ml/kg 10ml/kg, 0ml/kg total over a 24h period IF child remains hemodynamically unstable consult APC for further management assistance. Hypertension * Assess AIRWAY/OXYGENATION. * For sustained Normocomplex Tachycardia w/ Hypertension: Esmolol Infusion: Start infusion 50mcg/kg/min, titrate up to 200mcg/kg/min. (can increase every 5-10 min). No loading dose necessary for pediatrics. * For persistent hypertension (over 60 mins) with normal HR: Nipride Infusion: titrate mcgs/kg/min.

6 GL of 15 Supraventricular Tachycardia * Consider fluid status, oxygenation, temperature, and electrolyte imbalance. If HR above normal and sustained and if BP allows consider using B-blocker. Contact APC for suggestions. For management of A-fib, A-flutter, or other arrhythmias consult APC and the American Heart Association PALS protocol. Goals: Fluid Balance and Electrolytes serum Na+, K+, Cl-, Ca, Mg, Phos will be within normal values urinary output of 1- ml/kg/hr blood glucose level mg/dl Assessment: blood electrolyte panels including Ca+, Mg+ and Po4 every six hours (or more often as needed i.e. after replacement) strict hourly intake and output Interventions: IV fluids * Administer maintenance IV fluids to maintain urinary output of 1- ml/kg/hr. (Use the calculation and table below to select fluid type and rate) * Maintenance Rate: - (May decrease rate to maintain CVP 4-6 PRN) < 10 kg - 4 ml/kg/hr kg 40ml + 2ml/kg/hr for every kg over 10kgs (e.g. 15kg = 40ml+ (2x5) = 50ml/hr) >20kg - 60ml + 1ml/kg/hr (e.g. 0kg = 60ml + 0 = 70ml/hr) SERUM SODIUM FLUID TYPE Less than 10 D5% NS D5% ½ NS D5% ¼ NS 149 or greater D5% ¼ NS and institute NGT Tap Water Protocol

7 GL of 15 NGT Tap Water Protocol * Turn suction to LWS to empty stomach * Put 10ml/kg tap water into stomach and clamp NGT * Repeat these steps every hour * Draw Chem 7, Ca+, Mg and Po4 at the start and Q hours. *If Na > 150 after 9 hours and/or CVP/PAWP are increased despite diuretics, contact APC for suggestions. * Remember to concentrate gtts in D5W, antibiotics IVP when possible. Correct K+, Ca+, Mg+ and Po4. (Correction of phosphorus is critical to resolution of hypernatremia. Hyperkalemia (use all in this order) *CaCl 10mg/kg, may repeat if necessary *D25 4ml/kg + 4u Insulin per 100ml of D25 (monitor blood glucose closely) *NaHCO 1meq/kg (May also use Albuterol, Kaexalate, and Lasix) Hypokalemia * Administer KCL (adjust in cases of oliguria or polyuria): SERUM POTASSIUM ADD KCL PER LITRE KCL BOLUS Greater than 5.0 None None meq/liter None meq/liter 0.5 meq/kg; over 1hr, may repeat X1 repeat K+ level Less than.0 Consult w/ APC 1.0 meq/kg; over 2hrs, may repeat X2 repeat K+ level Medication administration * Maximally concentrate all drips (replacements) as fluid status can change quickly and children can demonstrate CHF or pressor dependence from small changes in volume status. (continued on next page)

8 GL of 15 Diabetes Insipidus * At initiation of management, if pt is on a Vasopressin gtt and it is controlling DI, leave it running. Normal range of vasopressin gtt varies between u/kg/hr to 0.05u/kg/hr. Consult with APC or PICU attending for titration management. Hypertension may occur while on vasopressin due to inotropic effects. If so, D/C vasopressin before starting any hypertension meds. * If Vasopressin not working or pt not on vasopressin gtt, administer DDAVP if urinary specific gravity is or less. Infuse mcgs/kg of DDAVP in 2ml per mcg of D5W over 20 minutes. (May repeat dose at 0.2 mcgs/kg after 2 hours if inadequate response). Do not infuse within 4 hours of OR. Diuresis * Administer Lasix 0.5-1mg/kg slow IV push if CVP >8 or urinary output less than 1 ml/kg/hr and SBP > 90. Repeat at 1-2 mg/kg after 1 hour if response inadequate. Repeat as necessary every two hours. * Administer Bumex mg/kg (max 2mg/dose) every 6 hours (max 10mg/24hours) * Administer Mannitol 25% 0.25gm-1.0gm/kg/dose IV over 0 minutes, if urinary output less than 1ml/kg/hr. Repeat as necessary every two hours. Hyperglycemia * Administer Regular Insulin 0.1 unit/kg IV for glucose > 250 mg/dl. Repeat glucose level 0mins after insulin. If glucose > 250 give 0.2units/kg Regular Insulin IV. Recheck in 0 minutes along with UA for glucose. If urine + for glucose and/or glucose remains >250 call APC to review and discuss initiation of insulin gtt. * Remove 5% dextrose from maintenance IV fluids Hypoglycemia *Administer D25 2ml/kg (continued next page)

9 GL of 15 Hypocalcemia * Administer Calcium Chloride 20mg/kg IV if ionized calcium < 1.0 or total calcium < 8.5 meq/liter (give no faster than 100mg/min to avoid bradycardia). Watch for hypocalcemia if greater than 4 pedi-packs (or 15cc/kg) of PRBCs have been infused. * Consider Calcium Chloride infusion 10-0 mg /hr to maintain therapeutic levels (can assist w/ improving cardiac function.) This is rarely needed. Please consult with APC. Hypomagnesemia * Magnesium Replacement: Mg of give 25mg/kg of MgSO4 Mg of <1.4 give 50mg/kg of MgSO4 Recheck Level Hypophosphatemia: *Use NaPhos or Kphos to replace. Max Rate of 0.4mmol/kg/hr If Phos < 1.5 give 0.16mmol/kg and recheck. Replace to hospital normal value. Goals: Hematology Hgb greater than 8 Gms/dl and Hct greater than 24% Platelet count 20,000 to 400,000 PT less than 2 times control value Assessment: CBC with platelet count at initiation of management and every 6 hours PT/PTT at initiation of management and as needed (continued next page)

10 GL of 15 Interventions: Administer leukocyte reduced PRBCs (obtain serology and HLA lab samples prior to infusion whenever possible). Use warming unit if available, blood warmer is critical in pediatrics, hypothermia, and multiple transfusions. If unable to obtain leukocyte reduced, use bedside filtration. HEMATOCRIT NUMBER OF UNITS INFUSED Greater than 25% none 20-25% As needed to keep Hct > 25% Less than 20% consult with APC Type and crossmatch 20ml/kg Leukocyte reduced PRBCs Administer PRBCs 15ml/kg. Be sure to document volume administered. Administer FFP 10 ml/kg infused as a single dose, only in cases of active hemorrhage, when the PT is greater than 2 times the control value, and when the platelet count has decreased by 50% (consider acidosis and hypothermia) Administer Platelets 0.1unit/kg for platelet count less than 20,000 (consult with Blood Bank for correct dose) Goals: Oxygenation and Ventilation Continuous SaO2 greater than 95% PaO torr (if lungs are r/o maintain PaO2 greater than 90 torr) ph pco torr Assessment: Continuous SaO2 oximetry monitoring ABG every six hours (every four hours if possible lung donor), and 0 minutes after each ventilator adjustment Peak inspiratory pressures with ABG if possible lung donor CXR on initiation of management (and every 4 hours if possible lung donor). If lungs r/o by APC then CXR every 12 hours appropriate. CXR must be read by an MD.

11 GL of 15 Interventions: Oxygenation * Administer 5 cm PEEP. Increase in increments of 2 cm to maximum of cm in cases of refractory hypoxemia as needed (Consult APC) * Adjust FiO2 to LOWEST possible percentage to achieve PaO2 of torr * TURN, BAG AND SUCTION (secretion dependent) A MINIMUM OF EVERY TWO HOURS or prn * Administer Solumedrol 15 mg/kg IV over 0 minutes. Administer drug as soon as possible. Consider repeat if at least 8hrs have passed and persistent infiltrates are present on CXR or oxygenation/hemodynamics are sub-par. * Consider therapeutic bronchoscopy for donors with evidence of aspiration, atelectasis (for removal of plugs). * If possible, obtain re-intubation with a larger tube if ETT is less than optimal size or if there is a leak that is interfering with ventilation/oxygenation. ETT size I.D. (internal diameter) is 16 + age (in yrs) -:- 4. * <8yrs of age - uncuffed ETT used as the narrow pediatric cricoid cartilage acts as a functional cuff. Ventilation * Pressure Cycled Ventilation (PCV); adjust PC to maintain peak inspiratory pressures (PIP) less than 0cm, with the tidal volume starting at 10cc/kg.Evaluate chest expansion frequently and evaluate peak pressure vs. chest expansion. * ALWAYS REMEMBER: Increased TV is measured exhaled volume and the PIP will be the Pressure set for PC. - Adjust flow to maximize I:E ratio 1:2 may be able to drop I:E ratio to 1:1 with APC support/guidance based on lung compliance. - Follow CXR for atelectasis, adjust accordingly. * Frequent turning is key * Frequent Oral suctioning w/ uncuffed tubes is essential * SIMV 10cc/kg TV while maintaining the PIP < 0cm for >20kg child if tolerates Volume control settings as opposed to Pressure Cycled. (ensure TV measured at airway not at ventilator) * Adjust rate to achieve minute ventilation to keep pco torr. * Adjust peak flow rates between 0-70 L/minute to achieve I:E ratio of 1:1 1:2 * Keep abdomen decompressed with NGT/OGT to suction

12 GL of 15 Inhaled Medications: for alveolar fluid clearance * Albuterol: 2.5mg nebulized Q4hrs prn (Albuterol may decrease K+, monitor and replace as indicated) * Budesonide (Pulmicort): 0.25mg (<20kg) / 0.5mg (>20 kg) BID (may use another corticosteroid on formulary at institution) Acidosis * Adjust tidal volume and ventilation rate (see previous section) to maintain pco2 between 5-45 torr. After adjusting minute ventilation to correct respiratory acidosis, administer NaHCO to correct metabolic acidosis, 1 meq/kg over 15 minutes for ph less than 7.25 or BE less than 5.0. * Repeat ABG s within 0 minutes and reevaluate. * Consider Tham to manage profound acidosis. - ml/kg for every multiple of negative four on base deficit (ex: BE is -4 give mg/kg, BE is -8 give 6ml/kg, etc) Alkalosis * Adjust minute ventilation to keep pco torr. Goals: Core Temperature of 6-7 degrees C Assessment: Temperature Monitor temperature, in degrees Celsius, continuously via core when possible. Skin leads (<2yrs), rectal or bladder temp probe in children >2 yrs. Interventions: Hypothermia * Apply external warming blankets, or heating devices * Adjust inspired air temperature on ventilator circuit between 4-6 degrees * Administer all fluids and/or blood products via warming device * Cover infant s heads to avoid ambient heat loss

13 GL of 15 Infection Goals: Prevention and treatment of common nosocomial infections Assessment: Blood, urine and sputum cultures obtained at initiation of clinical management (if donor has been hospitalized greater than 72 hours or circumstances of admission r/t potential infectious process.) Sputum gram stain KOH on all possible lung donors Consider RSV plates if child admitted with respiratory failure. Interventions: Antibiotics * Cefotaxime: 200 mg/kg/day IV divided every 8 hours (If < 7 days old give 100 mg/kg/day divided every 12 hours) * Oxacillin: 50mg/kg IV every 6 hours * If KOH or sputum gram stain indicates presence of yeast administer Diflucan 6mg/kg IV one dose. * Consider adding other ABX (vanco, ceftazidime) if hospitalized > 5d and gram stain comes back positive. Consult with APC for treatment suggestions. Assessment for CIRCULATORY Status/Compromise AIRWAY/OXYGENATION: * ALWAYS CHECK FIRST WITH ANY CIRCULATORY CHANGE * Remove child from ventilator and "Bag" w/ pressure manometer to baseline PIP until instability source determined. Suspect mucous plug, kinked/dislodged ETT, etc * EMERGENCY EQUIPMENT. = Same size ETT and additional ETT 0.5 smaller at bedside for reintubation. * Ages Newborn to 5-year w/ a decrease in HR evaluate AIRWAY status FIRST. (continued next page)

14 GL of 15 CIRCULATORY STATUS: * Early hypoperfusion (including decreased organ perfusion) shows up in peripheral signs and kidney function LONG BEFORE a drop in SBP. (Evaluate fontanels, skin color; mucous membrane, capillary refill, pulses, temp, and UOP) * As CO decreases, the line between warmth and coolness ascends towards the trunk & Capillary Fill Time > 2secs * Total circulating blood volume approximates 75cc/kg * Appropriate size BP cuff on pediatrics is 2/ rd the length of the upper arm * If there is a decrease in SBP of 10mmHg or more, assess for potential hypo/hypervolemia * An increase in temperature may significantly increase heart rate. * Femoral CVP correlates to true CVP, and can be used to assess fluid status trends. * Primary cardiac arrest is rare, respiratory arrest more likely. In arrest and bradycardia, begin CPR/hyperoxygenation and look for airway problems first. 90% of pediatric cardiac arrests involve asystole and bradycardia, 10% involve V. Fib. * Peds will have increase in HR to increase their cardiac output, may indicate a preload problem (too high or too low) * Infant s Alpha-receptors more sensitive than Beta, very sensitive to alpha agents. * If requiring Alpha agents, use Swan (when >5y.o). If you see decreased urine output or acidosis with alpha agent allow a lower BP so less drug can be used. Circulation Emergencies Bradycardia: * Assess O2 delivery, airway, Epinephrine mg/kg IV OR 0.02 mg/kg via ETT if IV access unavailable, compressions for HR < 80 in newborns and infants. * IF unable to ventilate after troubleshooting, extubate and reintubate w/ new ETT Asystole: Same as above V. Fibrillation: 2 joules/kg, assess O2 delivery, repeat 4 joules/kg (per PALS). V. Tach: Defib as above if no response, consider Epi, Lidocaine or Amiodarone. Consider correctable causes (e.g. hyperkalemia, hypothermia) If no IV access immediately available within 90 seconds of attempts, consider Intraosseous line for meds, IVF and blood products. Works best in children < 6yrs (continued next page)

15 GL of 15 Miscellaneous Spinal Reflexes: * If spinal reflexes are present, and may cause distress to the donor family and/or hospital staff attempt to explain the cause and effect of such. If explanations are not sufficient, prudent use of a paralytic may be considered. Careful explanation of usage must be communicated to family and staff. Two clear brain death notes MUST have been written. * Consider Pavulon or Norcuron IVP. Start with 0.05mg/kg, may increase to 0.1mg/kg to effect. May repeat dose as indicated by return of spinal reflexes every 0mins or prn. Please use cautiously, esp. with pediatrics Pediatric Medication Administration: * All medications in pediatrics are weight based. Please check dosages carefully! No medication dose should exceed the standard adult practice dose. When pediatric patients enter the ages/weights of 40kg and/or years old, switch to adult dosages if the pediatric weight based calculations are making a dose too large.