(Page 1 of 5) Code Status Full code Status/Admit/Transfer/Discharge Surgical Procedure(s) and date performed (if applicable): Cardiologist: Cardiac Surgeon: Intensivist: Patient Care CMV status Donor CMV status Recipient Measure weight daily Chest tubes to 20 cm water suction and record output hourly Blake drains to bulb suction, strip drain and record output Q1H for 12 hours, then Q2H Nasogastric tube to low intermittent suction Monitoring Parameters Heart rate to (bpm) SpO2 to (%) Central venous pressure (CVP) to (mmhg) Mean arterial pressure (MAP) to (mmhg) Systolic blood pressure (SBP) to (mmhg) Central Venous Monitoring Lines Add heparin 2 units/ml to central line fluid if no other fluids running through lumen 0.9% Sodium Chloride at 1 ml/hr Arterial Monitoring Lines Add papaverine 0.12 mg/ml to arterial line fluid (peripheral arterial lines only) 0.9% Sodium Chloride with heparin 2 units/ml at 1 ml/hr Pacemaker Settings Temporary pacemaker settings Mode Rate Atrial Pacing: Output (ma), Sensitivity (mv) Ventricular Pacing: Output (ma), Sensitivity (mv) Activity Bed rest Signature: College ID: Print Name: Pager: PTN Review Date: November 15 2016 PTN# CTPoLv1 Exp Date: November 15 2019 Page 1 of 5
(Page 2 of 5) Medications Immunosuppression and Premedication acetaminophen mg (15 mg/kg/dose) PO/PR/NG/NJ once daily for five days; administer prior to daily thymoglobulin infusion (Maximum 1 g/dose) diphenhydramine mg (1 mg/kg/dose) IV once a day for five days; administer prior to daily thymoglobulin infusion (Maximum 50 mg/dose) Post Operative Day 0 (Date / / ) methylprednisolone mg (2 mg/kg/dose) IV once given immediately prior to thymoglobulin infusion initiation infusion initiated 6 hours after arrival in the Paediatric Intensive Care Unit Post Operative Day 1 (Date / / ) methylprednisolone mg (1.5 mg/kg/dose) IV once given immediately prior to Post Operative Day 2 (Date / / ) methylprednisolone mg (1 mg/kg/dose) IV once given immediately prior to thymoglobulin infusion initiation Post Operative Day 3 (Date / / ) methylprednisolone mg (0.5 mg/kg/dose) IV once given immediately prior to Thymoglobulin (rabbit ATG) mg (1 to 1.5 mg/kg/dose) IV once infused over 12 hours; Post Operative Day 4 (Date / / ) methylprednisolone mg (0.25 mg/kg/dose) IV once given immediately prior to Thymoglobulin (rabbit ATG) mg (1 to 1.5 mg/kg/dose) IV once infused over 12 hours; PTN Review Date: November 15 2016 PTN# CTPoLv1 Exp Date: November 15 2019 Page 2 of 5
(Page 3 of 5) Routine Medications mupirocin 2 % topical ointment in each nostril Q12H for 10 doses or until nasal swab result is negative nystatin 400,000 units 4 times a day swish and swallow ranitidine mg (1 mg/kg/dose ) IV Q8H (Maximum 50 mg/dose) co-trimoxazole mg (2.5mg TMP/kg/dose) PO Q12H at 0800 and 2000H on Monday, Wednesday and Friday (5mg TMP/kg/day on 3 days/week for PJP prophylaxis. Maximum 160mg TMP/800 SMX per day.) Start on post operative day. valganciclovir (for patients at-risk for CMV disease) mg (7 x BSA x egfr) PO daily at 2000H (Maximum 900 mg/dose) mycophenolate mofetil (MMF) mg (300-600 mg/m2/dose) IV/PO Q12H at 0800h and 2000h (Maximum 1000 mg/dose) Start on post operative day (start within first 72 hrs after transplant, initial may be 1/4 to 1/2 maintenance dose tacrolimus for patients LESS than 40 kg mg (0.025-0.05 mg/kg/dose) (dose to target trough 10 to 12 mcg/l) PO/NG Q12H at 0800h and 2000h. Start on post operative day Start after intestinal function return (usually 2nd or 3rd post operative day) and when UOP is adequate prednisone or PrednisOLONE mg (0.25 mg/kg/dose ) PO/NG Q24H (Max Dose = 20 mg daily) Start on post operative day when methylprednisolone is finished PRN Medications potassium chloride mmol (0.5 mmol/kg/dose) IV infusion via central line over 60 minutes as needed for serum potassium LESS than 3 mmol/l calcium chloride mmol/kg/day (0 to 2 mmol/kg/day) continuous intravenous infusion to maintain serum ionized calcium in range 0.9 to 1.2 mmol/l Antibiotic Prophylaxis - Closed Skin cefazolin mg (30 mg/kg/dose) IV Q H (Q8H if age greater than 7 days, Q12H if age at or below 7 days) until chest drains removed Antibiotic Prophylaxis - Open Sternum and Skin vancomycin mg (10 mg/kg/dose) IV as a single dose, subsequent dosing frequency to be determined based on Vancomycin level drawn 8 hours after first dose, discontinue once chest closed cefotaxime mg (50 mg/kg/dose) IV Q H (Q8H if age greater than 7 days, Q12H if age at or below 7 days) discontinue once chest closed Analgesia and Sedation acetaminophen mg (15 mg/kg/dose) PO/PR/NG/NJ Q6H for four doses, then as needed for pain chloral hydrate mg (15 mg/kg/dose) PO/NG/NJ Q4H PRN to maintain SBS -1 to 0 morphine bolus mg (0.05 mg/kg/dose) IV Q1H as needed to maintain MAPS 0 PTN Review Date: November 15 2016 PTN# CTPoLv1 Exp Date: November 15 2019 Page 3 of 5
(Page 4 of 5) IV Infusions Analgesia, Sedation and Paralysis morphine mcg/kg/hr (0 to 20 mcg/kg/hr) continuous IV infusion titrated to maintain MAPS 0 dexmedetomidine mcg/kg/h (0 to 0.7 mcg/kg/h) continuous IV infusion titrated to maintain SBS -1 to 0 and MAPS 0 fentanyl 1 mcg/kg/hr continuous IV infusion; initiation/titration by physician order only cisatracurium 1 mcg/kg/min continuous IV infusion; initiation/titration by physician order only Maintenance fluids 50% total fluids are calculated as follows: 2 ml/kg/h for the first 10 kg, 1 ml/kg/h for the second 10 kg, 0.5 ml/kg/h for every kg above 20 kg ml/hr total maintenance fluid rate (50% maintenance) Dextrose 10% and 0.9% Sodium Chloride IV for weight less than 5 kg Dextrose 5% and 0.9% Sodium Chloride IV for weight at or above 5 kg Vasoactive Infusions milrinone mcg/kg/min (0 to 0.75 mcg/kg/min) continuous IV infusion DOPamine mcg/kg/min (0 to 10 mcg/kg/min) continuous IV infusion nitroprusside mcg/kg/min (0 to 5 mcg/kg/min) continuous IV infusion EPINEPHrine mcg/kg/min (0 to 0.1 mcg/kg/min) continuous IV infusion Nutrition NPO PTN Review Date: November 15 2016 PTN# CTPoLv1 Exp Date: November 15 2019 Page 4 of 5
(Page 5 of 5) Laboratory Blood gas, arterial Q2H for 4 hours, then Q4H until 0600h Complete blood cell count with automated white blood cell differential Sodium level, serum Potassium level, serum Bicarbonate level, serum Chloride, serum Urea Creatinine (Cr), serum Magnesium (Mg) level, serum Blood gas, venous Q2H for 4 hours, then Q4H until 0600h Vancomycin level 8 hours after first dose Tacrolimus trough (pre-dose) (for patients on tacrolimus) CMV PCR monitoring EBV PCR monitoring Medical Imaging Radiograph, chest on admission to ICU and morning of first postoperative day Diagnostic Tests/Procedures 12-lead ECG on admission to ICU PTN Review Date: November 15 2016 PTN# CTPoLv1 Exp Date: November 15 2019 Page 5 of 5