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Evaluation for signs and symptoms of infection
Elevated temperature, general malaise, upper respiratory infection and urinary symptoms
Assess indwelling catheter sites
hemodialysis line
HLA at time of Work-Up
1 red and 1 yellow top (minimum of 2 mL in each)
Complete Blood Count with Differential (CBCd)
Complete Metabolic Panel (CMP)
Urinalysis (UA) and Urine Culture
HCG if female >12 yo
Urine (blood if oliguric or anuric)
PT/ PTT/ INR
If PD catheter:
PD Cell Count
Gram Stain and Culture
If HD catheter:
Blood culture from both lumens
Plasmapheresis
HD
Eculizumab
CVVH in OR?
Surgical Consent Obtained by Transplant Surgery
If donor is classified as high risk, high risk consent must be obtained by transplant surgery.
NPO on arrival, unless otherwise instructed by surgeon
STRICT I&Oโs
If polyuric, keep patient with positive fluid balance.
If oliguric/anuric, give more than insensibles to make slightly positive over time.
Potassium Free fluid.
Antihypertensives:
Discontinue Lisinopril and other antihypertensives if indicated.
Aim for Blood Pressure on higher end of normal.
Consider IVIG:
For patients that are undergoing desensitization prior to transplant and in patients with preformed DSAs, treatment as follows:
1 g/kg over 12 hours, administered immediately prior to transplant (do not give if patient has received IVIG 2 mg/kg in the last 7 days.) Remaining 1 g/kg given after transplant. Administer thymo intraop, IVIG administered immediately after if concerned about sensitization.
Pre-medication: Administer the following medications 30 minutes before infusion and Tylenol/ Benadryl every 6 hours during infusion:
Decadron (0.15 mg/kg max 8 mg)
Tylenol (15 mg/kg max 650 mg)
Benadryl (1 mg/kg max 50 mg)
Thymoglobulin (ATG):
Coordinate with pharmacy for Thymoglobulin and Methylprednisolone to go with patient to the OR (not to be administered on the floor). Ensure pharmacy does not receive order until donor anatomy is reported and is satisfactory.
Methylprednisolone:
Intra-operative single dose of 10mg/kg is given immediately prior to reperfusion. The full dose, ordered with the preoperative admission orders, should accompany the patient to the OR. Maximum 500 mg.
CellCeptยฎ (MMF):
One dose 600 mg/m2/dose given IV, preferably after anatomy is known.
Fever in a transplant patient
During the first few months post transplant, requires more conservative management (more immunosuppressed). Likely admission for 48h rule out, especially if central line.
Consider CBC/CRP/Procalcitonin, RFP, Mg, UA, UCx, BCx
Consider Respiratory Pathogen PCR, GI PCR
Missed medication/Took medication late/Emesis after medication
Redose if LESS than 30 min since medication dose if emesis. Depending on how much trouble weโre having with immunosuppression, we might consider a FULL redose vs only half. Yeah
Can use judgement about timing and frequency of medication in decision to give dose if medication missed
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