(Page 1 of 5) Code Status Full code Status/Admit/Transfer/Discharge Surgical Procedure(s) and date performed: Cardiologist: Cardiac Surgeon: Intensivist: Patient Care CMV status Recipient CMV status Donor Measure weight daily Chest tubes to 20 cm water suction and record output Q1H Blake drain to bulb suction, strip drain and record output Q1H for 12 hours, then Q2H Nasogastric/orogastric tube to 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 for weight LESS than 20 kg 0.9% Sodium Chloride at 2 ml/hr for weight EQUAL to or GREATER than 20 kg 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 for weight LESS than 20 kg 0.9% Sodium Chloride with heparin 2 units/ml at 2 ml/hr for weight GREATER than or EQUAL to 20 kg Pacemaker Settings Temporary pacemaker settings Mode Rate Atrial Pacing: Output (ma), Sensitivity (mv) Ventricular Pacing: Output (ma), Sensitivity (mv) Activity Bed rest PTN Review Date: November 15 2016 PTN# CTPoGv1 Exp Date: November 15 2019 Page 1 of 5
(Page 2 of 5) Medications Immunosurpression 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 5 days; administer prior to daily thymoglobulin infusion (Maximum 50 mg/dose) Post Operative Day 0 (Date / / ) methylprednisolone mg (2 mg/kg/dose) IV as a single dose to be given immediately prior to Thymoglobulin infusion initiation Thymoglobulin (rabbit ATG) mg (1 to1.5 mg/kg/dose) IV infusion over 12 hours; infusion initiated 6 hours after arrival in the Pediatric Intensive Care Unit Post Operative Day 1 (Date / / ) methylprednisolone mg (1.5 mg/kg/dose) IV as a single dose to be given immediately prior to Thymoglobulin infusion initiation Post Operative Day 2 (Date / / ) methylprednisolone mg (1 mg/kg/dose) IV as a single dose to be given immediately Thymoglobulin (rabbit ATG) mg (1 to 1.5 mg/kg/dose) IV infusion over 12 hours; infusion Post Operative Day 3 (Date / / ) methylprednisolone mg (0.5 mg/kg/dose) IV as a single dose to be given immediately Post Operative Day 4 (Date / / ) methylprednisolone mg (0.25 mg/kg/dose) IV as a single dose to be given immediately PTN Review Date: November 15 2016 PTN# CTPoGv1 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 for staph colonization is negative nystatin 400,000 units 4 times a day swish and swallow. If patient unable to swish or swallow swab entire oral cavity 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/800mg 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 to 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 dose may be 1/4 to 1/2 maintenance dose) tacrolimus if patient LESS than 40 kg mg (0.025 to 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 urine output is adequate and normal Cr. tacrolimus if patient GREATER than or EQUAL to 40 kg mg (1 to 2 mg ) 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 urine output is adequate and normal Cr. prednisone or PrednisOLONE mg (0.25 mg/kg/dose ) PO/NG Q24H (Maximum: 20 mg/day) Start on post operative day when methylprednisolone is finished PRN Medications ondansetron mg (0.15 mg/kg/dose) IV Q8H PRN nausea or vomiting (age at or above 6 months) (Maximum: 8 mg/dose) potassium chloride mmol (0.5 mmol/kg/dose) IV 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 Q8H until chest drains removed (Maximum: 2000 mg/dose) Antibiotic Prophylaxis - Open Sternum and Skin vancomycin mg (10 mg/kg/dose) IV as a single dose, subsequent dosing frequency to be determined based in vancomycin level drawn 8 hours after first dose, discontinue once chest closed cefotaxime mg (50 mg/kg/dose) IV Q8H disconcontinue once chest closed (Maximum: 2000 mg/dose) PTN Review Date: November 15 2016 PTN# CTPoGv1 Exp Date: November 15 2019 Page 3 of 5
(Page 4 of 5) Analgesia and Sedation acetaminophen mg (15 mg/kg/dose) PO/PR/NG/NJ Q6H for 4 doses, then PRN for pain (Maximum PO: 75 mg/kg/24 h; Maximum PR: 80 mg/kg/24 h) morphine bolus mg (0.05 mg/kg/dose) IV Q1H PRN to maintain Multidimensional Assessment of Pain Scale (MAPS) 0 IV Infusions Analgesia, Sedation and Paralysis morphine mcg/kg/h (0 to 20 mcg/kg/h) 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 0 to 1 mcg/kg/h continuous IV infusion; further titration by physician order only cisatracurium 0 to 1 mcg/kg/min continuous IV infusion; further 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 Total maintenance fluid rate ml/hr (50% maintenance) Dextrose 5% and 0.9% Sodium Chloride IV 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 for 4 hours; may have sips of fluids overnight Laboratory Blood gas, arterial Q2H for 4 hours, then Q4H until 0600h Every morning at 0600h Complete blood cell count with automated white blood cell differential Every morning at 0600h Sodium level, serum PTN Review Date: November 15 2016 PTN# CTPoGv1 Exp Date: November 15 2019 Page 4 of 5
(Page 5 of 5) 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# CTPoGv1 Exp Date: November 15 2019 Page 5 of 5