Guidelines for the Evaluation and Management of Pediatric Organ Donors (weight < 40 kg)

Transcription

1 Table f Cntents I. Purpse II. Initial Evaluatin Dcumentatin Transplant labs Cultures Lines Studies III. Mid-America Transplant Organ Recvery Center Decisin t transprt Pediatric transprt cnsideratins IV. Organ Specific Testing & Evaluatin Kidney Pancreas Liver Lung Heart V. Dnr Management Gals VII. Prblems & Adjustments Fluid balance and electrlytes Intravascular vlume Sdium Ptassium Glucse Calcium Magnesium Phsphrus Hemdynamics Hyptensin Hypertensin Bld and bld prducts Anemia Cagulpathy Thrmbcytpenia Hypalbuminemia Ventilatr trubleshting Oxygenatin prblems Ventilatin prblems Metablic acid-base disrders Metablic acidsis Metablic alkalsis VIII. Appendix VI. Management Prtcls Mnitring Labs Maintenance fluid Medicatins Studies Ventilatr and lung IX. BSA calculatin Systlic bld pressure by age Hypertensin by age Creatinine clearance calculatin Renal prtective prtcl Brnchscpy Assrted pediatric equipment References SOP-ORG-LOC-67, Rev. 7 Page 1 f 24

2 I. Purpse These guidelines are intended t maximize the dnatin ptential f pediatric rgan dnrs by prviding ptimal and cnsistent care t the rgans and tissues f infants, children and adlescents wh have met criteria fr brain death and whse parents r guardians have cnsented t rgan dnatin. These guidelines may nt be suitable fr the management f living patients r adult dnrs and will be updated regularly. II. Initial Evaluatin Dcumentatin 1. Histry f injuries and treatment; current febrile illness, current infectin and/r bacterial clnizatin 2. Past medical and scial histry (including malignancy and risk factrs fr HIV, hepatitis B and C) 3. Hme medicatins and drug allergies Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.35" + Indent at: 0.6", Tab stps: Nt at 0.5" 4. Current medicatins including thse administered in the 24 hrs prir t Mid-America Transplant arrival and all antibitics administered since hspital admissin 5. All bld transfusins administered since hspital admissin 6. Physical exam including height, dry weight and bdy surface area (see Appendix fr calculatin f BSA) 7. Perids f significant hyptensin (see Appendix fr age based nrms); fr cardipulmnary arrest, estimate the duratin f CPR and the time until return f spntaneus circulatin 8. Frm the start f Mid-America Transplant management nte the hurly: intake/utput, CVP, O2 saturatins by pulse ximetry, systlic/diastlic BP, cre temperature, and vasactive medicatins 9. Cpy f dnr medical chart Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.35" + Indent at: 0.6", Tab stps: Nt at 0.5" Transplant Labs 1. Serlgy and NAT testing: 2 purple and 2 tiger (SST) tp tubes. (Minimum f 5 ml divided between ne purple and ne tiger tp.) Obtain pre and pst transfusin if hemdilutin has ccurred. Pre transfusin samples must be negtiated with medical examiner. Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 2. ABO typing (Nenates and Infants may nt be able t be subtyped) 3. HLA typing: 1 yellw fr Labs Midwest, 3 green fr Barnes and 4 yellw fr SLUH Cultures 1. Bld: 2 sets f 2 aerbic cultures frm arterial and central lines (label clearly) 2. Tracheal aspirate: gram stain and culture 3. Urine: urinalysis and culture Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" SOP-ORG-LOC-67, Rev. 7 Page 2 f 24

3 Lines 1. Arterial line (radial preferred) fr ease f maintenance and pssible reductin in infectin risk a. Grade 1A evidence fr unfractinated heparin infusin at 0.5 units/ml at 1 ml/h t maintain patency in peripheral arterial lines in infants and children (Mnagle et al. Chest 2012) b. Cnsider additinal infusin f papaverine thrugh the arterial line fr suspicin f arterial spasm (mix 60 mg papaverine in 500 ml NS; run at 0.5 ml/hr) 2. Central line fr bld draws and CVP mnitring (right internal jugular preferred; femral CVPs may be inaccurate particularly with abdminal distensin, the lack f a gd bld return frm the CVP lumen and/r a pr wavefrm Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" Studies 1. Chest radigraph (with qualified physician interpretatin) 2. Brnchscpy (ptential lung dnrs nly, daytime requests appreciated) Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" III. Mid-America Transplant Organ Recvery Center Decisin t Transprt 1. Transprt f the rgan dnr t the Mid-America Transplant Organ Recvery Center helps t cntrl csts, reduce cld ischemic time, decrease surgen travel and imprve the predictability f OR availability. There may be ther benefits. Transprt shuld nt ccur when mvement f the dnr is likely t adversely affect their dnatin ptential. Adverse events during transprt are inversely related t the stability f the dnr and directly related t the time spent in transprt. 2. The decisin is made by the Directr f Organ Prcurement (r designee) in cnsultatin with the clinical crdinatrs and assciate medical directr. In general, mst suitable candidates fr transprt will meet the fllwing criteria: a. Stable airway that includes a cuffed endtracheal r tracheal tube b. An xygen saturatin f 95% n an FiO2 60%, a psitive end expiratry pressure (PEEP) 8 cm H2O and the ability t maintain adequate gas exchange in a cnventinal mde f mechanical ventilatin n a transprt ventilatr c. Nrmal sinus rhythm d. Circulatry supprt limited t dpamine at 10 mcg/kg/min (excluding lw dse vaspressin and thyrid replacement) 3. All ther dnrs will be cnsidered n a case-by-case basis. Pediatric Transprt Cnsideratins 1. Cmplicatins are ften secndary t inadequate stabilizatin f the airway and/r lack f apprpriate mnitring t recgnize disldgement f the ETT r ther devices. The ETT, vascular access lines and chest tubes are shrter and mre easily displaced than similar adult devices. a. Inspect and secure ETT, central lines, arterial lines, chest tubes, fley catheter, NG tubes, etc. prir t transprt b. Mnitr ETCO2, pulse ximetry, ECG and arterial bld pressure during transprt. SOP-ORG-LOC-67, Rev. 7 Page 3 f 24

4 c. The transprt team shuld have the skills and equipment t reestablish a lst pediatric airway using head psitining, jaw thrust, ral airway, lyryngeal mask airway (LMA) and bag-valve-mask (BVM) ventilatin. Cmpetency in endtracheal intubatin is preferable althugh LMA and BVM can be used until a skilled individual is available. A cuffed replacement ETT must accmpany the dnr at all times. d. Understanding basic cncepts f mechanical ventilatin and the ptential cmplicatins assciated with psitive pressure ventilatin will be necessary t address gas exchange and hemdynamic prblems. e. In the event venus access is lst, the transprt team shuld be skilled in IV r intrasseus needle placement until vascular access can be (re) established. f. Familiarity with needle drainage f pleural air will be necessary in the event f a pneumthrax until a chest tube can be placed. 2. Cre temperature stability may be cmprmised in infants and small pediatric dnrs during extremes in temperature; bundle dnr accrdingly in cld weather. IV. Organ Specific Testing & Evaluatin Kidney 1. Urinalysis with micr: at the time f admissin (if available); at initiatin f Mid-America Transplant management; and within 24 hrs f crss clamp 2. BUN, creatinine and creatinine clearance (see Appendix fr calculatin): at the time f admissin (if available); peak values; and within 4 hrs f rgan ffer Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 3. Optinal: Ultrasund fr suspected pathlgy (histry f kidney stnes, plycystic disease r ther urlgic abnrmalities) 4. Optinal: See Appendix fr Renal Prtective Prtcl prir t cardiac catheterizatin r CT scan with cntrast Pancreas 1. Hemglbin A1C 2. Amylase at admissin (if available) and at initiatin f Mid-America Transplant management 3. Lipase at initiatin f Mid-America Transplant management Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 4. Bld glucse (see Management Prtcls) Liver 1. AST (SGOT), ALT (SGPT), alkaline phsphatase, bilirubin (ttal and direct), GGT and albumin at admissin (if available), at initiatin f Mid-America Transplant management and within six hurs f rgan ffer. Utilize Piccl liver panel cartridge at Mid-America Transplant. Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 2. PT, INR, PTT at initiatin f Mid-America Transplant management and within six hurs f rgan ffer 3. Optinal: DIC panel if dnr is currently in DIC r at risk SOP-ORG-LOC-67, Rev. 7 Page 4 f 24

5 Lung 1. Chest radigraph: review during Initial Evaluatin and repeat within 3 hrs f rgan ffer. The interpretatin by a qualified physician shuld be specific regarding pssible thracic trauma (e.g. lcatin/age f rib fractures, lung cntusins, etc.) Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 2. ABGs (recrd peak inspiratry and plateau pressures) a. Baseline n 8-10 cm H2O PEEP, tidal vlume 6-8 ml/kg and lwest FiO2 (preferably 40%) t maintain a PaO2 f mm Hg; b. Within 4 hrs. f rgan ffer repeat n PEEP 5 cm H2O and 100% FiO2 (allw 30 min fr equilibratin); target PaO2 > 300 mm Hg 3. Tracheal aspirate gram stain and culture within 24 hrs. f rgan ffer 4. IPV treatments t be administered Q4 hurs with albuterl. If pt's has mucus plugging, atelectasis, r infiltrates, use Q2 hurs and add 2-3cc f Mucmyst. Driving pressures are set between psig and initial frequency is set at 300 Hz. The frequency shuld be drpped in 50 Hz increments every 3 minutes reaching a final setting f 100 Hz fr the last 2 minutes. ( 5. Brnchscpy early and as needed n all ptential lung dnrs (daytime requests are be appreciated) Heart lead EKG after brain death interpreted by a qualified physician 2. Surface echcardigram interpreted by a cardilgist under the fllwing cnditins: a. At least 8 hrs after first examinatin cnsistent with brain death b. Electrlytes have been crrected (particularly inized calcium, serum ptassium and serum magnesium); ph is Frmatted: Numbered + Level: 2 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75", Tab stps: Nt at 1" Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.1" + Indent at: 0.35", Tab stps: Nt at 0.5" Frmatted: Indent: Left: 0.4", Numbered + Level: 2 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75", Tab stps: Nt at 1" c. T4 replacement has infused fr at least 4 hurs d. Slumedrl has been administered e. CVP is 5-10 cm H2O f. Off pressrs fr at least 2 hrs (any dse f epinephrine, nrepinephrine, phenylephrine r vaspressin at >20 milliunits/kg/hr); a dpamine infusin less than 10 mcg/kg/min is acceptable if pressrs cannt be weaned; if n prgress n pressrs after 8 hrs cntact Team Leader r AOC 3. CPK (ttal and MB%) and trpnin I at initiatin f Mid-America Transplant management and within 6 hrs f rgan ffer; repeat at 8 hr intervals if fund t be elevated) 4. Optinal: serial echcardigrams if the EF <50% and there is n histry f pr cardiac functin; TEE if surface echcardigram is a subptimal study; r PA catheterizatin fr pr functin by echcardigram and either severe pulmnary dysfunctin, high vlume resuscitatin r difficulty weaning ff pressrs Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.1" + Indent at: 0.35", Tab stps: Nt at 0.5" V. Dnr Types N specific SCD r ECD definitins exist fr pediatric patients at this time SOP-ORG-LOC-67, Rev. 7 Page 5 f 24

6 VI. Pediatric Dnr Management Prtcls (initiate n every dnr) Gals ( The Pediatric Organ Dnatin Bundle ) 1. Mean arterial pressure (mmhg) 1.5 x age in years + 55; Newbrns gestatinal age Minimize pressrs t dpamine at < 10 mcg/kg/min 3. CVP <12 mm Hg Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 4. Urinary utput >0.5-3 cc/kg/hr 5. ph Serum Na+ <160 meq/l 7. Serum glucse mg/dl 8. PaO2:FiO2 rati 3 Mnitring 1. Cntinuus ECG 2. Arterial and central venus pressure wavefrms 3. Respiratry rate, SpO2 Cre temperature (gal C; F) a. Warming may be achieved with an external warming device, increasing the inspired air temperature (watch fr precipitatin in the vent circuit), r warming infused fluids and bld prducts; cnsider warmed NG lavage if the cre temperature is less than 93.2 F Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" Frmatted: Numbered + Level: 2 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.55" + Indent at: 0.8", Tab stps: Nt at 1" b. Cling may be achieved with evaprative cling techniques r use f a cling blanket Labs (cnfirm the smallest quantity f bld required) 1. ABG challenge Q4 hrs (see belw); standard ABG 30 min fllwing vent changes a. ABG challenge n PEEP 5 cm H2O and 100% FiO2 (allw 30 min fr equilibratin); target PaO2 > 300 mm Hg b. Standard ABG n current PEEP and lwest FiO2 (preferably 40%) t maintain a PaO2 f >100 mm Hg Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent at: 0.45", Tab stps: Nt at 0.5" Frmatted: Indent: Left: 0.5", Numbered + Level: 2 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.7" + Indent at: 0.95", Tab stps: Nt at 1" c. Recrd peak inspiratry and plateau pressures with all ABGs 2. Electrlytes (Na+, K+, Cl-, HCO3-) every Q4 hrs and after electrlyte replacement; keep ptassium between 3-5 mml/l 3. Inized calcium Q4 hrs, mre frequent checks and aggressive replacement may be necessary fr hypcalcemia and/r pr cardiac functin r arrhythmias Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent at: 0.45", Tab stps: Nt at 0.5" 4. Glucse Q4 hrs; Q1 hr while n insulin infusin 5. Magnesium Q8 hrs, mre frequent checks and aggressive replacement may be necessary fr hypmagnesemia and/r arrhythmias 6. Hemglbin and hematcrit Q8 hrs, mre frequent checks and transfusin may be necessary fr severe anemia and/r active bleeding 7. Lactate Q 8 hrs, mre frequent checks may be necessary fr persistent metablic acidsis SOP-ORG-LOC-67, Rev. 7 Page 6 f 24

7 8. BUN, creatinine and creatinine clearance (see Appendix fr calculatin) Q24 hrs and within 4 hrs f rgan ffer (see als Organ Specific Testing and Evaluatin: Kidney) 9. Liver panel (AST [SGOT], ALT [SGPT], alkaline phsphatase, bilirubin [ttal and direct], GGT and albumin) Q24 hrs and within 6 hrs f rgan ffer (see als Organ Specific Testing and Evaluatin: Liver) 10. PT, INR and PTT Q24 hrs and within 6 hrs f rgan ffer (see als Organ Specific Testing and Evaluatin: Liver) 11. CPK (ttal and MB%) and trpnin I Q24 hrs, repeat Q8 hrs if elevated and within 6 hrs f rgan ffer (see als Organ Specific Testing and Evaluatin: Heart) 12. Amylase and lipase at initiatin f Mid-America Transplant management and as requested by the transplant center (see als Organ Specific Testing and Evaluatin: Pancreas) 13. HCG fr female dnrs >12 yrs f age at initiatin f Mid-America Transplant management 14. Bld, urine and tracheal aspirate cultures at initiatin f Mid-America Transplant management (see als Initial Evaluatin: Cultures) Maintenance fluid 1. Enteral nutritin shuld be stpped unless instructed therwise by a transplant surgen 2. Strict measurement f intake and utput each hur is essential 3. Ttal fluid vlume shuld be ml/m 2 /day including maintenance fluids, medicatin infusins, backup fluids, scheduled medicatins, etc. Standard calculatins fr daily pediatric fluid requirements (e.g. 100 ml/day fr the 1 st 10 kg, 50 ml/day fr the 2 nd 10 kg and 20 ml/day fr all subsequent kg) typically verestimate the needs f the ventilated patient by 20%. Obesity may als cntribute t an verestimatin f fluid needs. a. Hurly intake may exceed expected vlumes during fluid resuscitatin and when administering the hypernatremia prtcl b. Gal is t achieve urine utput f >0.5-3 ml/kg/hr, adequate rgan perfusin withut evidence f rising lactic acidsis and minimal rgan tissue edema Frmatted: Indent: Left: 0", Numbered + Level: 1 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.2" + Indent at: 0.45", Tab stps: Nt at 0.5" Frmatted: Indent: Left: 0.5", Numbered + Level: 2 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.7" + Indent at: 0.95", Tab stps: Nt at 1" c. Be prepared fr rapid changes in sdium with diabetes insipidus r SIADH d. Use the tw tables belw t select the initial maintenance fluid. Dextrse may be mitted if the dnr is hyperglycemic. Usually easier t administer additinal ptassium that take it away Serum Sdium Equal t r less than 140 meq/l D5 NS r NS Base Fluid meq/l D5 ½ NS r ½ NS meq/l D5 ¼ NS r ¼ NS 161 r greater meq/l D5 ¼ NS r ¼ NS (see hypernatremia prtcl) SOP-ORG-LOC-67, Rev. 7 Page 7 f 24

8 Serum Ptassium KCl/liter KCl blus >5.0 meq/l nne nne meq/l 10 meq nne meq/l 20 meq See hypkalemia prtcl < 2.5 meq/l 20 meq See hypkalemia prtcl cnsider IV replacement Medicatins 1. Lacrilube PRN and eyes clsed with tape t prevent infectin and crneal abrasins in ptential eye dnrs 2. Slumedrl 15 mg/kg IV x 1 ver 30 min Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 3. T4 mixed 200 mcg/250 ml D5 ½NS (this has been cncentrated and run at 500 mcg/250 ml when additinal vlume was prblematic) a. May eliminate dextrse if hyperglycemic and run in NS r ½NS b. There are OPOs wh mix in ¼NS r D5W depending upn serum sdium and dextrse cncentratins. The 1/4NS infusin may be sufficiently hyp smtic t prmte hemlysisuse with sme cautin. There is little data n the use f D5W as a carrier fluid fr T4. Frmatted: Numbered + Level: 2 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75", Tab stps: Nt at 1" c. Fllw the age based dsing prtcl belw AGE Blus (mcg/kg) Infusin (mcg/kg/hr) 0-6 ms ms yrs yrs yrs >16 yrs d. Increase the infusin as needed t a maximum f 1.4 mcg/kg/hr t wean pressrs e. Measure glucse within 30 min f starting T4; measure K+ within 2 hrs f starting T4 f. After 30 min the dnr may becme tachycardic; temperature and bld pressure may als rise; T4 has als been assciated with elevated K+ requirements and acidsis g. T4 shuld be infusing fr at least 4 hrs prir t the initial echcardigram (see als Organ Specific Testing and Evaluatin: Heart); if pressr requirements are high it may take 6 r mre hurs t see the full effects 6. Cntinue Hspital antibitics until yu receive Sputum GS results. Then review with CMO r AMD fr antibitic rders. (see als Initial Evaluatin: Cultures and Organ Specific Testing and Evaluatin: Lung) Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 7. Albuterl 2-4 puffs MDI Q4 hrs SOP-ORG-LOC-67, Rev. 7 Page 8 f 24

9 Studies 1. CXR Q6 hrs read by radilgist r qualifying physician. May space radigraphs t Q8 hrs if film clear and n deteriratin in xygenatin ver time. Repeat within 3 hrs f rgan ffer (see als Organ Specific Testing and Evaluatin: Lung). May space radigraphs t Qday if lungs ruled ut (still want t insure ETT psitin, etc) Frmatted: Numbered + Level: 1 + Numbering Style: 1, 2, Indent at: 0.25", Tab stps: Nt at 0.5" 2. Brnchscpy as needed (see als Organ Specific Testing and Evaluatin: Lung) 3. Echcardigram n earlier than 8 hrs after the first examinatin cnsistent with brain death. T4 shuld be n fr at least 4 hrs prir t echcardigram (see als Organ Specific Testing and Evaluatin: Heart) 4. See Appendix fr Renal Prtective Prtcl prir t any cardiac catheterizatin r CT scan with cntrast Ventilatr and lungs 1. General gals a. PaO2 > 300 (during trials n FiO2 100% and PEEP 5 cm H2O) b. ph c. PaCO mm Hg Frmatted: Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75", Tab stps: Nt at 0.5" 2. Cuffed endtracheal tube inflated t 25 cmh2o 3. Elevate HOB 30 (VAP prphylaxis) 4. Suctin ETT and hyppharynx Q2 hurs and as needed (Pediatric ETTs are smaller than adult tubes and can readily becme bstructed with secretins. Instill 3-5 ml f sterile saline dwn the ETT fr thick secretins prir t suctining.) 5. High lateral turns Q2 hrs and PRN 6. Chest physitherapy Q2-4 hrs a. Vest therapy can be used fr infants, children and adlescents > 1 yr f age b. Vibratry and/r percussive therapy can be used fr infants < 1 yrs f age c. The Intrapulmnary Percussive Ventilatr (IPV) can be used t aid in mucus remval. Fllw the manufacturer instructins t set up and add either nrmal saline r hypertnic saline; lwer the ETT cuff pressure slightly t aid the mvement f mucus and avid cclusin f the ETT when excessive secretins are present (a PEEP valve may be useful n the expiratry utlet f the IPV machine if saturatins drp). Driving pressures are set between psig and initial frequency is set at 300 Hz. The frequency shuld be drpped in 50 Hz increments every 5 minutes reaching a final setting f 100 Hz fr the last 5 minutes. ( Frmatted: Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75", Tab stps: Nt at 0.5" 7. Ventilatr settings (may nt be pssible in the setting f ARDS, pneumnia, etc.) a. Vlume cntrlled ventilatin, humidified circuit b. Tidal vlume 6-8 ml/kg c. PEEP 8-10 cmh2o Frmatted: Numbered + Level: 1 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75", Tab stps: Nt at 0.5" d. FiO2 40% e. PIP < 30 cmh2o f. I:E rati in the range f 1:1 r 1:2 SOP-ORG-LOC-67, Rev. 7 Page 9 f 24

10 8. Cnsult Pediatric Critical Care if unable t achieve gals VII. Prblems & Adjustments Fluid balance and electrlytes 1. Intravascular vlume a. Hypervlemia (AKA vlume verlad; CVP >12 mmhg; may see pulmnary vascular cngestin) 1) Review fluid balance, gal vlume requirements and reduce/eliminate unnecessary infusin vlume 2) If n lw dse vaspressin ( milliunits/kg/hr) fr diabetes insipidus cnsider reducing dse r stpping infusin briefly t allw urine utput t catch up 3) Administer fursemide (Lasix ) mg/kg IV (max initial dse 20 mg), cnsider small initial dses and increase as needed 4) If repeated dses f fursemide are ineffective cnsider bumetanide (Bumex ) 0.1 mg/kg IV Q6 hrs (max initial dse 2 mg), refractry urine utput suggests renal insufficiency r verestimatin f vlume status 5) Mannitl 25% 0.5 grams/kg IV ver 3-5 min may be tried t enhance diuresis, repeat as necessary Q4-6 hrs t maintain urine utput b. Hypvlemia (CVP <5 mmhg, heart rate high, lw urine utput lw) 1) Review fluid balance and gal vlume requirements; determine cause f hypvlemia 2) If diabetes insipidus is present (dilute, large vlume urine in the absence f diuretics r excessive glucse lad; rising serum sdium) initiate vaspressin infusin at 0.5 milliunits/kg/hr. Duble the dse every 15 min t a maximum f 10 mcg/kg/hr targeting urine utput f 1-2 ml/kg/hr. If urine utput remains high at the maximum vaspressin dse yu may need t cnsider cc per cc hurly replacement f urine utput greater than 2 ml/kg/hr with ¼NS. 3) NS r lactated Ringers may be used t increase CVP int the 5-12 mmhg range; blus ml/kg ver 30 min and repeat as necessary 4) Cnsider a ml/kg blus f 5% albumin fr hypvlemia presenting with hypalbuminemia (<2 mg/dl); administer ver 60 min 5) Cnsider administering PRBC (10 ml/kg) fr hypvlemia presenting with anemia (hemglbin <7 g/dl) 6) Avid CVP >12 mmhg during fluid resuscitatin 2. Sdium (nrmal range typically meq/l) a. Hypernatremia (may be assciated with primary liver nn-functin) 1) Treat hypvlemia and/r diabetes insipidus aggressively (see under Hypvlemia abve) 2) Change IVF in accrdance with Management Prtcls: Maintenance fluid recmmendatins; cnsider remixing ther large vlume infusins in ¼NS 3) If serum sdium >160 meq/l institute the Hypernatremia Prtcl SOP-ORG-LOC-67, Rev. 7 Page 10 f 24

11 Administer 50 ml (infant) t 150 ml (child) f tap water via NG, instill fr 1-2 hurs, then check residual; cnsider repeating Check sdium every 2 hurs Frmatted: Indent: Left: 1.18", Hanging: 0.28", Bulleted + Level: 1 + Aligned at: 1.25" + Tab after: 1.5" + Indent at: 1.5", Tab stps: Nt at 1.5" b. Hypnatremia Check fr glucse in the urine and bld (can lead t free water lss and hypernatremia); if the urine is psitive and the dnr is hyperglycemic cnsider initiating the Hyperglycemia Prtcl (see belw); if the urine is psitive but the dnr is nt hyperglycemic cnsider reducing r remving dextrse frm IVFs 1) Change IVF in accrdance with Management Prtcls: Maintenance fluid 2) Vaspressin may be assciated with a fall in serum sdium; cnsider reducing the dse if pssible 3) Cnsider replacing sdium as levels drp belw 130 meq/l. Enteral sdium supplementatin can be very effective in raising serum sdium and des nt require central access. Begin with 1 meq/kg NaCl via NG Q4 hrs. If IV crrectin is required begin with 3-5 ml/kg 3% saline IV ver 1 hr. 3. Ptassium (nrmal range 3-5 meq/l, cardiac functin best meq/l) a. Hyperkalemia (arrhythmias) 1) If ptassium exceeds 5.5 meq/l stp all surces including IV and PO supplements as well as IVFs 2) If ptassium exceeds 6 meq/l and/r if there are EKG changes cnsult with assciate medical directr Administer albuterl 5 mg neb t temprarily decrease serum ptassium by meq/l and fursemide (Lasix ) 1 mg/kg IV (max initial dse 20 mg.) t increase actual (urinary) remval f ptassium frm the bdy, replace excessive diuresis with NS r administer empiric 10 ml/kg Frmatted: Bulleted + Level: 1 + Aligned at: 1.45" + Indent at: 1.7" If EKG changes are present, IV calcium chlride (20 mg/kg) r calcium glucnate (50 mg/kg) has a rapid nset f actin (1-3 min) and will last fr min; IV sdium bicarbnate (1-2 meq/kg) als wrks quickly (5-10 min) and lasts fr 1-2 hurs; flush lines well between dses f calcium and bicarbnate; IV glucse (5 ml/kg D10W) fllwed by insulin (0.1 units/kg) may als be useful and last fr 4-6 hrs NG (clamp x 60min) r rectal (retentin enema x 60 min) sdium plystyrene sulfnate (Kayexalate ) is ften necessary in severe hyperkalemia t remve ptassium frm the bdy. This is particularly true in renal failure. b. Hypkalemia (can cause arrhythmias) 1) Change IVF in accrdance with Management Prtcls: Maintenance fluid; the KCl per liter f IVFs may be increased frm 20 meq/l t 60 meq/l fr significant hypkalemia and/r nging lsses/displacement 2) NG replacement f ptassium (1 meq/kg t max f 20 meq) Q2 hrs is effective and safe fr mderate hypkalemia ( meq/l) withut significant arrhythmias 3) Fr hypkalemia <2.5 meq/l and/r significant arrhythmias cnsult with assciate medical directr; cnsider IV KCL 1 meq/kg (max 20 meq) ver 60 min 4) Nte that T4, albuterl, fursemide (Lasix ), bicarbnate, and insulin may lwer serum K+ SOP-ORG-LOC-67, Rev. 7 Page 11 f 24

12 4. Glucse (gals mg/dl) a. Hyperglycemia 1) If glucse remains >180 mg/dl x 2 measured an hur apart, begin insulin drip at 0.1u/kg/hr. Mnitr hurly and titrate by 0.01/u/kg/hr- avid insulin bluses as this may result in see-saw glucse levels 2) If glucse persistently >300 mg/dl cnsult Pediatric Critical Care b. Hypglycemia 1) Maintenance fluids in accrdance with Management Prtcls: Maintenance fluid; additinally, the T4 infusin can be run in dextrse 2) Fr cntinued hypglycemia may blus D25W at 2-4 ml/kg and then increase dextrse in maintenance fluids (D12.5 max cncentratin in peripheral line, higher cncentratins may run in a central line) 5. Calcium (ttal mg/dl; inized mml/l r mg/dl) a. Hypercalcemia 1) Fr significant elevatin administer nrmal saline (10 ml/kg) and fllw with fursemide (Lasix ) at mg/kg (max initial dse 20 mg) 2) Cautin: Hypercalcemia in cnjunctin with hyperphsphatemia may cause tissue precipitatin f calcium phsphate b. Hypcalcemia (hyptensin) 1) Administer calcium chlride 20 mg/kg IV ver 1hur (max 1 gram); als can use calcium glucnate IV 50 mg/kg ver 1 hr (max 1 gram) 2) Aggressive replacement f calcium may be needed t ptimize circulatry functin f the dnr. Repeat inized calcium after administratin f supplemental calcium 3) Use cautin administering calcium in the presence f high phsphate levels, it may cause tissue precipitatin f calcium phsphate 6. Magnesium ( meq/l) a. Hypermagnesemia 1) Mdest elevatins are rarely prblematic 2) Fr significant elevatin administer nrmal saline (10 ml/kg) and fllw with fursemide (Lasix ) at mg/kg (max initial dse 20 mg) b. Hypmagnesemia (arrhythmias) 1) Administer magnesium sulfate (50 mg/kg IV, max dse 1.5 grams) ver 1 hr 7. Phsphrus ( mg/dl) a. Hyperphsphatemia 1) Mdest elevatins are rarely prblematic 2) Hyperphsphatemia may be indicative f renal insufficiency, eliminate surces f extra phsphate 3) Phsphate binders (NG) are usually nt very effective SOP-ORG-LOC-67, Rev. 7 Page 12 f 24

13 b. Hypphsphatemia (pr cardiac cntractility, rhabdmylysis) 1) Phsphrus replacement is cmplicated by the varius sdium and ptassium cntents f replacement prducts which, while allwing sme flexibility may limit the dse r rate f infusin 2) Severe hypphsphatemia (< 1.5 mg/dl) mm phsphate/kg/dse IV ver six hurs Na phsphate: 3 mm phsphate and 4 meq Na per milliliter Frmatted: Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5" K phsphate: 3 mm phsphate and 4.4 meq K per milliliter (d nt exceed meq/kg/hr f ptassium when infusing this frmulatin) 3) Mderate hypphsphatemia (< 3.2 mg/dl) Cnsider Neutra-Phs pwder cntaining 250 mg (8 mml) P, meq Na, and meq K per packet. Dse at 20mg/kg/dse per NGT every 6 hurs fr a maximum dse f 80mg/kg/day Frmatted: Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5", Tab stps: Nt at 0.5" 4) Cnsult Assciate Medical Directr fr hypphsphatemia with cncurrent hypernatremia, hyperkalemia and/r renal insufficiency Hemdynamics and arrhythmias 1. Hypertensin (requiring treatment) a. Definitin 1) Sustained systlic BP greater than 150 mm Hg; r 2) Sustained systlic BP greater than the 99 th percentile + 5 mm Hg adjusted fr age, sex and 50 th percentile height (see Appendix) b. Treatment 2. Hyptensin 1) Labetll: 0.25 mg/kg IV; may repeat r duble dse Q10 min PRN t a maximum blus dse f 20 mg; half-life 5.5 hrs in adults althugh this varies with age; BP cntrl with blus therapy might be maintained by starting an infusin at mg/kg/hr and titrating t a maximum f 3 mg/kg/hr; avid use in patients with bradyarrhythmias, heart blck, asthma and CHF 2) Nicardipine: start infusin at 1 mcg/kg/min IV and titrate t a maximum f 3 mcg/kg/min 3) Nitrprusside: start infusin at 0.1 mcg/kg/min IV and titrate every 5 min nt t exceed 5 mcg/kg/min; avid use in pulmnary r renal disease, side effects include thicyanate and cyanide txicity which may be attenuated by mixing 10 mg thisulfate per 1 mg nitrprusside a. Definitin 1) Mean arterial pressure (mm Hg) < 1.5 x age in years + 55 (see Appendix) b. Treatment 1) Cnfirm sinus rhythm SOP-ORG-LOC-67, Rev. 7 Page 13 f 24

14 2) Aggressively treat hypvlemia and electrlyte abnrmalities (particularly ptassium, calcium, magnesium and phsphrus) in accrdance with Prblems and Adjustments: Fluid Balance and Electrlytes 3) Ensure T4 prtcl has been initiated in accrdance with Management Prtcls: Medicatins; increase infusin as needed t 1.4 mcg/kg/hr 4) Intrpes and vaspressrs Dpamine: initiate infusin at 5 mcg/kg/min and titrate t a maximum dse f 20 mcg/kg/min; may increase heart rate and cause arrhythmias. Children <2 yrs f age clear dpamine readily and may require higher dses. Frmatted: Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5" 3. Arrhythmias Epinephrine: initiate infusin at mcg/kg/min; may be assciated with arrhythmias, tachycardia. Vaspressin: initiate at 0.3 milliunits/kg/min and titrate t 2 milliunits/kg/min (nte: nt the same dse fr treating diabetes insipidus); watch fr acidsis r ther signs f excessive vascular cnstrictin, may als cause fluid retentin and hypnatremia Nrepinephrine (Levphed ): initiate infusin at mcg/kg/min; watch fr acidsis r excessive vascular cnstrictin, may be assciated with exacerbatin f preexisting right ventricular impairment in cntractility 5) Cnsider echcardigraphy r ther diagnstic studies per Organ Specific Testing and Evaluatin: Heart a. Aggressively treat hypvlemia and electrlyte abnrmalities (particularly ptassium, calcium, magnesium and phsphrus) in accrdance with Prblems and Adjustments: Fluid Balance and Electrlytes b. Cnsult with assciate medical directr Bld and bld prducts 1. Anemia (< 7 g/dl) a. Cnsider the transfusin guidelines belw and measure the hemglbin Q6 hrs, use a bld warmer fr multiple transfusins, prfund hypthermia r DIC b. Brderline Hgb may be acceptable if BP stable, ff pressrs, n active bleeding, hemdilutinal anemia nly r if harvest planned within a few hrs. 2. Cagulpathy (INR 2 x cntrl) a. Cnsider the transfusin guidelines belw fr the administratin f fresh frzen plasma (FFP) and vitamin K; repeat PT, PTT and INR Q6 hr 3. Thrmbcytpenia (platelet cunt <50 K) a. Cnsider the transfusin guidelines belw fr the administratin f platelets 4. Hypalbuminemia a. Cnsider the transfusin guidelines belw fr the administratin f albumin SOP-ORG-LOC-67, Rev. 7 Page 14 f 24

15 Value Hemglbin < 7 g/dl INR 2 times cntrl Platelets <50K r <100K with active bleeding Albumin <2 mg/dl and significant edema r interstitial fluid lsses Infusin and Rate Transfuse leukcyte reduced PRBC s 10ml/kg ver 2 hrs (if CMV negative r unknwn, transfuse CMV negative bld) Transfuse FFP 10ml/kg ver 1 hr, cnsider vitamin K (phytnadine) 1 mg (infant), 2 mg (child) r 10 mg (adlescent) IV x 1 Transfuse randm dnr platelets 10 ml/kg ver 2 hrs Transfuse 5% albumin 10 ml/kg ver 1 hr, if vlume sensitive may administer 1 gram/kg f 25% albumin ver 6 hrs Gas exchange and ventilatr trubleshting 1. Oxygenatin prblems a. Lw FiO2 r prfund alvelar hypventilatin are unlikely mechanisms f hypxemia n standard ventilatr settings with supplemental xygen b. Rule ut cngenital heart disease with intra- r extra- cardiac shunting (histry, echcardigram) c. Rule ut chrnic lung disease (histry, previus CXRs) d. Rule ut pulmnary hemrrhage (bld frm endtracheal tube e. Rule ut likelihd f pulmnary edema by CXR appearance; a cardigenic surce may be identified by echcardigram r PA catheter and addressed via intrpic supprt and crrectin f vlume verlad; specific therapy fr neurgenic pulmnary edema is largely anecdtal and currently is addressed by avidance f hyper- r hyptensin, crrectin f fluid verlad and titratin f PEEP. Cnsult with assciate medical directr. f. Address pssible pneumnic r inflammatry (nninfectius aspiratin, cntusin) infiltrates with empiric antibitic therapy (see Management Prtcls: Medicatins) adjusted fr results frm tracheal aspirates; therapeutic maneuvers fr atelectasis may als be useful (see belw) g. Atelectasis 1) Early therapeutic brnchscpy 2) High lateral turns Q2 hrs and PRN 3) Intrapulmnary Percussive Ventilatr (IPV)- see suggested prtcl under Organ Specific Testing and Evaluatin- Lung 4) Recruitment Adjust tidal vlume t ml/kg f ideal bdy weight; avid plateau airway pressures >30 cm H2O Adjust I:E rati t 1:1 if nt previusly dne Increase PEEP t 8-10 cm H2O if PaO2 <300 trr r if PaO2 drps by >50 trr frm previus value n ABG challenge (see Management Prtcls: Labs). Maintain PEEP f 10 cm H2O during management and allcatin. ABG challenge will cntinue t be n PEEP f 5 cm H2O (30 min prir and during Frmatted: Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5" Frmatted: Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5" SOP-ORG-LOC-67, Rev. 7 Page 15 f 24

16 ABG). Titrate PEEP dwnwards if PIP >35 cm H2O, decline in BP significant enugh t require increased pressr requirements r dnr instability. Cnsider prne psitining. Typically, the ptimal effect is seen after hrs Preparatin fr prning: Assure that the tip f the ETT is in the lwer third f trachea Assess security f the ETT, vascular lines, drainage catheters and Sp prbe and reinfrce if necessary Prtect and cver eyes (if dnating eye tissue) Mve ECG electrdes t lateral aspect f arms and hips Cil and secure bladder catheter t inner thigh Suctin the ETT and rpharynx Temprarily cap nnessential vascular lines and drainage catheters Acquire necessary blankets, sheets, pillws fr ptimal psitining Frmatted: Bulleted + Level: 2 + Aligned at: 1.75" + Indent at: 2" Turning t prne psitin: Infants can pssibly be turned by tw peple, lder children and adlescents will need at least three peple. In either situatin ne persn is always dedicated t the security f the head and ETT. Always turn twards the ventilatr; d nt discnnect the ETT (turn xygen t 100% during maneuver) Levitate technique (infants/tddlers): levitate up, turn 45 degrees, set back dwn n side, pause/reassess, levitate up, turn prne, psitin pillws and blankets t avid kinking vascular catheters and ETT, set dnr dwn Mummy technique (schl age/adlescents): slide dnr t the edge f the bed n the ppsite side frm the ventilatr, place new draw sheet ver the dnr, place desired pillws and blankets ver the draw sheet, place additinal full sheet ver pillws and blankets and tuck underneath the dnr, turn dnr 45 degrees tward the ventilatr, pause/reassess, psitin dnr prne and remve ld linens Keep head in alignment with the bdy, arms next t trs, tes f the upper leg pinted in the directin f the turn. Frmatted: Bulleted + Level: 2 + Aligned at: 1.75" + Indent at: 2" After turning: Reassess security and patency f all lines, catheters and tubes Recheck vitals Reattach capped ff lines and catheters Start weaning FiO2 Frmatted: Bulleted + Level: 2 + Aligned at: 1.75" + Indent at: 2" Returning t supine psitin: Precautins as abve Frmatted: Bulleted + Level: 2 + Aligned at: 1.75" + Indent at: 2" SOP-ORG-LOC-67, Rev. 7 Page 16 f 24

17 Always turn away frm the ventilatr; d nt discnnect the ETT (turn xygen t 100% during maneuver) Reassess all lines, catheters and tubes after turning Check vitals Cnsider timing suctining and CXR after turn t supine psitin Cnsider APRV mde Imprves functinal residual capacity (FRC) and xygenatin thrugh sustained pressure (PHigh) ver a prlnged time perid (THigh). As with cnventinal ventilatin, the use f an initial PHigh > 30 cm H2O is avided t prevent stretch injury (hwever may be needed in dnrs with restrictive lung disease). Ventilatin ccurs during release f that PHigh ver a very shrt time perid (TLw). During TLw airway pressures fall t nearly reach a pre-set lwer pressure (PLw). (Airway pressures are rarely allwed t settle at PLw, rather sme degree f deliberate air trapping is desirable.) T maximize the release vlume (and ventilatin) the default PLw will usually be set at 0 cm H2O. TLw is set t achieve terminatin f expiratin when the expiratry flw falls between 25-75% f the maximum expiratry flw velcity (see diagram belw). The cmbinatin f TLw and THigh represents the entire respiratry cycle in DNDD dnrs; respiratry cycles (TLw + THigh) f 3-4 secnds will prvide functinal respiratry rates f br/min. Frmatted: Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5" Frmatted: Bulleted + Level: 2 + Aligned at: 1.75" + Indent at: 2" Initial Settings PHigh: when transitining frm vlume cntrl start at the plateau pressure ( peak pressure if airway resistance is lw); when transitining frm pressure cntrl ventilatin r HFOV start at 2-3 cm H2O abve the mean airway pressure Frmatted: Bulleted + Level: 3 + Aligned at: 2.25" + Indent at: 2.5" PLw: start at 0 cm H2O THigh: 2-5 secnds (start with THigh + TLw = 3-4 secnds) TLw: secnds (set t terminate expiratin when the expiratry flw has fallen t 25-75% f the maximum expiratry flw) SOP-ORG-LOC-67, Rev. 7 Page 17 f 24

18 Adjustments Imprve xygenatin: Increase PHigh in increments f 1-2 cm H2O (abve 35 cm H2O discuss with AOC r Medical Directr), if ph is there may be value in decreasing TLw by 0.05 secnds t be clser t 75% peak expiratry flw Frmatted: Bulleted + Level: 1 + Aligned at: 2.35" + Indent at: 2.6", Tab stps: Nt at 0.5" Imprve ventilatin: Discuss with Medical Directr. Optins include: increasing PHigh t increase the release vlume; increasing TLw t allw mre time fr alvelar emptying; and (irnically) either decreasing THigh t allw mre release cycles per minute r increasing THigh allwing mre time fr CO2 frm the alvelus t diffuse int the mre prximal airways 2. Ventilatin prblems (including increased PIP) a. DOPE algrithm 1) Displacement f endtracheal tube (check EtCO2, ETT depth) 2) Obstructin f airway (kinked ETT, mucus plug, brnchspasm) 3) Pneumthrax (listen t breath sunds, stat CXR) 4) Equipment (have Respiratry Therapy t examine circuit, vent, airleaks) b. Respiratry acidsis (hypventilatin with elevated PaCO2) SOP-ORG-LOC-67, Rev. 7 Page 18 f 24

19 1) Address issues identified by the DOPE algrithm 2) Cnsider wrsening lung cmpliance (edema, atelectasis, etc.) 3) Increase rate and/r TV (cnsider cnsulting assciate medical directr) c. Respiratry alkalsis (hyperventilatin with falling PaCO2) 1) Decrease rate and/r TV Metablic acid-base disrders 1. Metablic acidsis (base deficit >4-5 meq/l) a. Nrmal anin gap (Na + {Cl - + CO2 - } = 12 meq/l) 1) GI r renal lsses f bicarbnate (diarrhea, RTA mst cmmn) 2) Additin f a carbnic type acid r chlride (saline administratin, TPN mst cmmn) 3) Treatment Address underlying cause (diarrhea, saline infusins, etc) Buffer ph int an acceptable range (>7.2) by administering the fllwing IV sdium bicarbnate crrectin ver ne hur Frmatted: Indent: Left: 1.25", Bulleted + Level: 1 + Aligned at: 1.15" + Indent at: 1.4" meq sdium bicarbnate = (weight kg)(base deficit)(0.6) b. Elevated anin gap (Na + {Cl - + CO2 - } = >12 meq/l) 1) Renal failure with decreased acid excretin 2) Increased ket- acid prductin (DKA, starvatin, EtOH mst cmmn) 3) Ingestants and intxicants (methanl, ethylene glycl, salicylate, NSAIDs and paraldehyde mst cmmn) 4) Carbhydrate malabsrptin and metablic disrders resulting in rganic acidemias 5) Increased lactate prductin (tissue hypxia, muscular exercise, systemic disease, and inbrn errr f metablism mst cmmn) 6) Treatment Address underlying cause. If lactate is elevated (>3.5 mml/l) and CVP is <5 mmhg infuse ml/kg NS t imprve tissue perfusin. If lactate is elevated and CVP is 5-10 mmhg, rule ut cardiac dysfunctin Frmatted: Indent: Left: 1.25", Bulleted + Level: 1 + Aligned at: 1.15" + Indent at: 1.4" Buffer ph int an acceptable range (>7.20) by administering the fllwing IV sdium bicarbnate crrectin ver ne hur meq sdium bicarbnate = (weight kg)(base deficit)(0.6) 2. Metablic alkalsis (base excess >4-5 meq/l) 1) Excessive lss f H + (prlnged NG drainage, vmiting mst cmmn) 2) Excessive administratin r absrptin f bicarbnate (including prfund hypkalemia, hyperaldsternism, Cushing syndrme, etc) 3) Cntractin alkalsis frm lss f extracellular fluid SOP-ORG-LOC-67, Rev. 7 Page 19 f 24

20 VIII. Appendix 4) Treatment The need t crrect this abnrmality in a dnr is unusual. Discuss with assciate medical directr Frmatted: Bulleted + Level: 1 + Aligned at: 1.35" + Indent at: 1.6" BSA calculatin Msteller s frmula fr BSA (m 2 ) = ([weight (kg) x height (cm)] / 3600) NATCO (m 2 ) = 4 x wt (kg) wt (kg) Mean bld pressure by age (50 th percentile MAP at 50 th percentile height) Mean arterial pressure (mm Hg) = 1.5 x age in years + 55 Systlic Bld Pressure by age (50 th percentile) Systlic arterial pressure (mm Hg) = 2 X age in years + 85 Severe hypertensin by age (> (99 th percentile + 5 mmhg) at 95 th percentile height) Bys Girls Age (yrs.) systlic diastlic systlic diastlic SOP-ORG-LOC-67, Rev. 7 Page 20 f 24

21 Creatinine clearance calculatins Age < 1yrs CrCl (ml/min) = (0.45)(height cm)(bsa) serum creatinine Ages 1-18yrs CrCl (ml/min) = (0.48)(height cm)(bsa) serum creatinine Renal Prtective Prtcl (pediatric) 15 mg/kg IV/PO n-acetylcysteine q12 hrs fr 24 hrs prir t cntrast study and 24 hrs afterwards (4 dses). Additinal hydratin (1½-2x maintenance) prir t and during the cntrast administratin is essential. SOP-ORG-LOC-67, Rev. 7 Page 21 f 24

22 Brnchscpy (Pediatric) Equipment (perdiatric) Equipment Newbrn ( kg) 6 Mnths 7.0 (7.0 kg) 1-2 Years (10-12 kg) 5 Years (16-18 kg) 8-10 Years (24-30 Kg) 12 Years (40 kg) Oral Airway Ventilatin Mask newbrn infant/child child child small/adult adult ETT cuff cuff cuff cuff cuff cuff Laryngscpe 2-3 Miller r 2-3 Miller r 1 Miller 1 Miller 1-2 Miller 2 Miller Blade Mac Mac Inline Suctin 6 Fr 8 Fr 8-10 Fr 10 Fr 12 Fr Fr Peripheral IV G G G G G G BP Cuff newbrn infant child child child/sm adult sm adult NG/OG 5-8 Fr 8 Fr 10 Fr Fr Fr 16 Fr Chest tube Fr Fr Fr Fr Fr Fr Fley 5-8 Fr 5-8 Fr 8-10 Fr 10 Fr Fr Fr LMA SOP-ORG-LOC-67, Rev. 7 Page 22 f 24

23 IX. References Transprt Ajizian SJ, Nakagawa TA: Interfacility transprt f the critically ill pediatric patient. Chest. 2007; 132: Bansal R, Esan A, Hess, D, et al: Mechanical ventilatr supprt in ptential lung dnr patients. Chest 2014; 146: Dhar R, Cttn C, Cleman J, et al: Cmparisn f high- and lw-dse crticsterid regimens fr rgan dnr management. J Crit Care 2013; 28:111.e1-7. Fineman LD, LaBrecque MA, Shih MC, et al. Prne psitining can be safely perfrmed in critically ill infants and children. Pediatr Crit Care Med. 2006; 7: Haque IU, Zaritsky AL: Analysis f the evidence fr the lwer limit f systlic and mean arterial pressure in children. Pediatr Crit Care. 2007; 8: Intrapulmnary percussive Ventilatr (IPV). accessed n December 8, Invasive medical devices. (2013) In Madden (Ed.), Pediatric Fundamental Critical Care Supprt. Munt Prspect, IL: Sciety f Critical Care Medicine. Katz K, Lawler J, Wax J, et al. Vaspressin pressr effects in critically ill children during evaluatin fr brain death and rgan recvery. Resuscitatin. 2000; 47: Krishnamrthy V, Brbely X, Rwhani-Rahbar A, et al. Cardiac dysfunctin fllwing brain death in children: prevalence, nrmalizatin, and transplantatin. Pediatr Crit Care Med. 2015; 16:e107-e112. Krishnan J, Mrrisn W. Airway pressure release ventilatin: a pediatric case series. Pediatr Pulmnl. 2007; 42: Ktlff RM, Blsser S, Fulda GF, et al: Management f the ptential rgan dnr in the ICU: Sciety f Critical Care Medicine/American Cllege f Chest Physicians/Assciatin f Organ Prcurement Organizatins cnsensus statement. Crit Care Med. 2015; 43: Mallry GB, Schectr MG, Elidemir O: Management f the pediatric rgan dnr t ptimize lung dnatin. Pediatr Pulmnl. 2009; 44: Mnagle P, Chan A, Gldenberg N, et al. Antithrmbtic therapy in nenates and children. Chest ;e737s-e801s. SOP-ORG-LOC-67, Rev. 7 Page 23 f 24

24 Nakagawa, T (Ed.): Updated pediatric dnr management and dsing guidelines. Oak Hill, VA., NATCO Nakagawa TA. (2017). Prcess f rgan dnatin and pediatric dnr management. In Fuhrman and Zimmerman (Ed.), Pediatric Critical Care (pp ). Philadelphia, PA: Elsevier Saunders. Niemann CU, Feiner J, Swain S, et al: Therapeutic hypthermia in deceased rgan dnrs and kidney-graft functin. N Engl J Med 2015; 373: Patel MS, De La Cruz S, Sally M. et al. Active dnr management during the hspital phase f care is assciated with mre rgans transplanted per dnr. J Am Cll Surg. 2017; 225: Ream RS, Armbrecht ES. Survey f U.S. rgan prcurement rganizatins regarding pediatric rgan dnr management. Pediatr Crit Care Med. 2016; 17:e459-e468. Ream RS, Armbrecht ES. The pediatric rgan dnr: specific dnr management practices amng U.S. rgan prcurement rganizatins. Prg Transplant (in press). Sally M, Ewing T, Crutchfield M, et al. Determining ptimal threshld fr glucse cntrl in rgan dnrs after neurlgic determinatin f death: a united netwrk fr rgan sharing regin 5 dnr management gals wrkgrup prspective analysis. J Trauma Acute Care Surg. 2014; 76: Zuppa AF, Nadkarni V, Davis L, et al: The effect f a thyrid hrmne infusin n vaspressr supprt in critically ill children with cessatin f neurlgic functin. Crit Care Med. 2004; 32: SOP-ORG-LOC-67, Rev. 7 Page 24 f 24