liver transplant v5 - seattle children'sliver transplant v5.0 operating room circulating nurse...
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Inclusion Criteria· Patient admitted for liver
transplant surgery
Exclusion Criteria· Kidney or intestine
transplant
Liver Transplant v5.0
Explanation of Evidence RatingsSummary of Version Changes
Last Updated: January 2019
Next Expected Revision: November 2019© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected]
Admission
Admission
Nursing Pre-Operative Checklist:
· Confirm the following forms are in chart and completed by
Surgical Team
· Operative Services H&P Exam Form 52523
· Consent to Operation Form 45101
· Informed Consent for Transfusion Form 51365
· Ensure patient is NPO and has IVF infusing per Liver
Transplant Plan
· Check CIS Blood Bank Summary to confirm RBCs are
available
· <30 kg: 5 units RBC
· >30 kg: 10 units RBC
· Bathe patient with chlorhexidine
· See Pre-Operative Care Policy and Procedure
· OR notifies floor when they are ready (do not contact
transplant coordinator or OR to request surgery time)
Drawing Labs
· Transplant labs are high priority.
Nurse to draw or contact lab or VAS
team to draw lab ASAP. If VAS team
unavailable, contact shift administrator
to request assistance from ICU or ED.
· Hand-deliver blood samples to lab, do
NOT use tube system
· See here for lab schedule
Admitting Orders
· Surgical Team (ARNP M-F, surgical resident after hours,
weekends, and holidays) place lab and radiology orders in CIS
Completes required forms
· Operative Services H&P Exam Form 52523
· Consent to Operation Form 45101
· Informed Consent for Transfusion Form 51365
Orders and initiates
· Pre Op Liver Transplant phase of Liver Transplant Plan
Orders in pending state
· Liver Transplant Thymoglobulin Immunosuppression
Plan
· Antibiotics Liver Transplant phase of Liver Transplant
Plan
· Surgeon sets OR time
Admitting Procedure
· Schedule: patient and family will arrive at Seattle Children’s
Hospital after being notified by the Transplant Coordinator of
the available donor organ
· Transplant Coordinator notifies
· Charge nurse on receiving unit at least 60 minutes before
patient arrives
· VAS team to be prepared to draw stat labs and start
peripheral IV (regardless of current access)
· Shift administrator and lab (and security as needed)
· Patient
· Goes to River C 6 surgical unit for height, weight, labs,
and admission
· Will be admitted to a single room on River 6 whenever
possible
For questions or clarification, contact Transplant Nurse Coordinator On-Call via paging operator (do not contact OR or
Transplant Nurse Coordinator to request surgery time)
· Obtain height and weight; enter into CIS immediately
· Draw labs (see Drawing Labs box above)
· After lab draw, send patient to radiology for chest x-ray
· Verify labs are being processed
· Check CIS for results. If uncertain, contact lab for
clarification.
· Confirm lymphocyte cross match has been sent to and
received at PSBC HLA Lab 206-689-6525
· Ensure orders were placed in CIS on inpatient encounter
· Pre Op Liver Transplant phase of Liver Transplant Plan
· Blood is ordered as “Liver Pack”
· Antibiotics Liver Transplant phase of Liver Transplant Plan
· Liver Transplant Thymoglobulin Immunosuppression Plan
· Confirm Anesthesia has seen patient
· Ensure pre-operative boarding pass is in chart with
anesthesia documentation
· Complete nursing documentation on pre-operative
boarding pass
Orient family to surgical floor, PICU Waiting Area, and PICU Front Desk. Obtain pager for updates from operating room staff.
· Check CIS Blood Bank Summary to confirm RBCs are
available
!
Approval & Citation
Liver Transplant v5.0
Operating Room
Circulating Nurse
· Organ Chain of Custody Form (if applicable)
· Login of Organ Form
· ABO Verification
· Implant Record
Anesthesiologist
· Initiate in CIS
· Antibiotics Liver Transplant phase of Liver Transplant Plan
· Liver Transplant Thymoglobulin Immunosuppression Plan
· Check for blood availability
· Order fentanyl, versed, vasoactive medications if needed
Operative Team
· In addition to standard surgical checklist:
· ABO Verification
· Blood products ordered
· Organ status
Operating Room
Close of Case
Circulating Nurse
· Document graft reperfusion on ABO Verification Form
· Follow process for vessel storage P&P
· Send donor lab sample to lab for HLA crossmatch
Surgical Signout
· Complete ABO Verification
· Extubation plan
Phase
Change
Phase
Change
Explanation of Evidence RatingsSummary of Version ChangesApproval & Citation
Last Updated: January 2019
Next Expected Revision: November 2019© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected] [email protected]
Liver Transplant v5.0
Postoperative Management
(Order Liver Transplant Plan, Postop ICU and Transfuse Plasma Phases)
Follow Clinical P&P and Guidelines of Care (GOC):
· Post Liver Transplant GOC
· Intubated/Mechanically Ventilated GOC
· Systemic Heparin P&P and Liver Transplant Anticoagulation GOC
Medications - See Patient-Specific Roadmap in CIS
· Immunosuppression (thymoglobulin or basiliximab, tacrolimus, methylprednisolone/prednisone/
prednisolone)
· Surgical antibiotic prophylaxis x 24 hours
· Acetaminophen PRN fever and mild pain
· Trimethoprim-sulfamethoxazole
· Ganciclovir
· Nystatin
· Pantoprazole
· Thrombosis prevention
· ICU Team manages pain/sedation per Comfort and Sedation GOC
Hematology
· For patients with red cell antibodies, keep 2 units of RBC crossmatched for 24 hours post-op
· Order plasma transfusion 5 mL/kg IV over 4 hours, q 12 hours
OR to ICU Handoff
· Surgeon and anesthesiologist handoff to ICU
· In ICU, complete Checklist for OR to ICU Handoff (pink sheet)
!Draw
tacro levels as
trough at 0830h
Administer AM tacro
at 0900h
!
Do not use
Vasopressin
Postoperative - ICU
!Call
transplant team
for concern of
bleeding or
hypotension
Transfer Criteria
· Not requiring ventilatory support
· Not requiring hemodynamic support
· Good organ function
· Intensity of care
Care Progression
Patient/Family Education
· Medication teaching to be initiated by transplant pharmacist as soon as possible
· Transplant NP or RN will arrange formal discharge education
!
No ill care providers
or visitors. No
flowers or plants.
Phase
Change
Phase
Change
· Immunosuppression (thymoglobulin or basiliximab, tacrolimus, methylprednisolone/prednisone/
prednisolone)
v
Explanation of Evidence RatingsSummary of Version ChangesApproval & Citation
Last Updated: January 2019
Next Expected Revision: November 2019© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected] [email protected]
Liver Transplant v5.0
Postoperative Management – Surgical Floor
Medications - See Patient-Specific Roadmap in CIS
· Thrombosis prevention OR aspirin
· Immunosuppression (tacrolimus; methylprednisolone/
prednisone/prednisolone; if ordered, basiliximab day 4)
· Trimethoprim-sulfamethoxazole
· Valganciclovir
· Nystatin
· Magnesium if needed
· Acetaminophen and/or oxycodone PRN
Follow GOC:
· Post Liver Transplant Guideline of Care (GOC)
· If biopsy performed: Liver Biopsy and Rejection GOC
Follow Clinical P&P:
· If NG Tube: Gastric Suction Policy and Procedure (P&P)
· Infection Control for Organ Transplant Patients P&P
· IV Line Maintenance
· Systemic Heparin
Labs:
· Daily labs as ordered, may require two labs daily (one for AM
labs, another for timed tacro trough)
Discharge
Instructions· If applicable: PE1262
Bile Drainage Tube
(Catheter)
!
No ill care providers
or visitors. No
flowers or plants.
Postoperative – Surgical Floor
!Draw
tacro levels as
trough at 0830h
Administer AM tacro at
0900h
Consults
· Child Life
· Social work
Discharge Criteria
· Good graft function
· Stable immunosuppression
· Afebrile
· Stable nutritional status
· Completed Job Aid: Transplant Discharge Teaching
Checklist (for SCH only)
· Follow-up appointment scheduled
Phase
Change
Explanation of Evidence RatingsSummary of Version ChangesApproval & Citation
Last Updated: January 2019
Next Expected Revision: November 2019© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected] [email protected]
CBC
PT/INR
PTT
Thrombin Time
Fibrinogen
TEG (must be sent stat)
Other:
Virology:
Chem 7
AST/ALT
GGT
Alk Phos
Bilirubin (conj/unconj)
Magnesium
PHOS
ALB
GLUCOSE
TOTAL PROTEIN
+ HCG for female ≥ 12 years
CA - ionized
CMV IgG/IgM
EBV IgG/IgM
Hep C Antibody
HIV Serology (ELISA)
Type and Screen for Liver Pack
blood order
Print requisition from CIS
*HLA: Lymphocyte Crossmatch
Normal volume:Micro volume:
1 lavender = 1 mL
2 lt blue citrate
= 1.8 mL in each
1 lavender microtainer
= 0.5 mL
2 lt blue citrate
= 1.8 mL in each
Normal volume: Micro volume:
1 lavender = 3 mL 1 lavender = 3 mL
Normal volume: Micro volume:
1 red top = 6 mL 1 red top = 4 mLor
Normal volume:
Normal volume:
+ Female ≥ 12 yr: 1 gold = 1 mL
1 gold = 1 mL
Normal volume: Micro volume:
1 lavender = 3 mL
or
or
* Call Bloodworks Immunogetics Lab (206) 689-6580 for HLA sample requirement questions and for patients
less than 9 kg
** Call main laboratory at 7-2102 for ACD tubes. Attach Bloodworks Northwest form.
Liver Transplant Admit Labs v5.0
Patient Weight Sample Requirements (no serum separator)
1 red top = 5 mL**ACD = 10 mL
1 red top = 5 mL
1 red top = 7 mL
1 red top = 5 mL
1 red top = 7 mL
9-13 kg: +
14-21 kg: +
22+ kg: +
Post-transplant 9-21kg:
Post-transplant 22+ kg:
or
Heparanized syringe = 0.5 mL
**ACD = 20 mL
**ACD = 30 mL
ACD
Chemistry:
Hematology:
Return to Admit
2 lavender microtainer
= 0.5 mL in each
Standard ImmunosuppressionIf patient at standard risk for infection at time of transplant
Thymoglobulin
· Intraoperative POD 0: 2 mg/kg
· Postoperative POD 1: 3 mg/kg
· Doses may be rounded off, total dose will be 5mg/kg
Alternative ImmunosuppressionIf indicated per clinical acuity, active
infection, or recent thymoglobulin)
Basiliximab
· Dose
· <20kg: 10mg/dose IV
· >20kg: 20mg/dose IV
· Timing
· Intraoperatively POD 0
· POD 4
· Must be diluted in 50ml of NS
· Can be infused peripherally
Tacrolimus· Dose
· Initial tacrolimus dose 0.05-0.1mg/kg/dose orally every 12 hours (0900
and 2100). First dose of tacrolimus to be given greater than 12 hours
after arrival in PICU following liver transplant.
· Initial doses may be delayed if there is significant renal dysfunction.
· Subsequent dosing dependent upon serum trough levels
· Target trough levels:
· POD 2-90 10-12ng/dL
· POD 91-180 7-10ng/dL
· POD 181-365 5-7ng/dL
· POD >365 3-5ng/dL
· In an attempt to minimize neuro-and nephrotoxicity of this medication,
intravenous (IV) tacrolimus will NOT be used
+
OR
Liver Transplant v5.0
Immunosuppression Overview
+
Corticosteroid· Dose
· POD 0 methylprednisolone 10mg/kg IV (max 1,000 mg) IV in OR
· POD 1 methylprednisolone 2mg/kg (max 100mg) IV
· POD 2 methylprednisolone 1mg/kg (max 100mg) IV
· POD 3 methylprednisolone 0.5mg/kg (max 50mg) IV
· POD 4-14 methylprednisolone 0.25mg/kg (max 25mg) daily
· Switch from IV to oral per team. IV methyprednisolone to PO prednisone
conversion is 1:1
Individualizing Therapy:See Patient-Specific Roadmap in CIS
!
Screen for
drug interactions
with tacrolimus
Return to Postop ICU Return to Postop Floor
Explanation of Evidence RatingsSummary of Version ChangesApproval & Citation
Last Updated: January 2019
Next Expected Revision: November 2019© 2019 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
For questions concerning this pathway,
contact: [email protected] [email protected]
Return to Admit
CIS Blood Bank
Value Analysis: Central Lab Testing
VALUE ANALYSIS TOOL
DIMENSION CARE OPTION A CARE OPTION B PREFERRED OPTION ASSUMPTIONS MADE
DESCRIPTION OF CARE TREATMENT OPTION ePOC labs in ICU Send sample to core lab
OPERATIONAL FACTORS
Percent adherence to care (goal 80%) 100% 100% NEUTRAL
Care delivery team effects High retest rate (10-20%
repeat rate for glucose,
anecdotally higher for
other tests)
More effort required to
send sample to lab, but
routine. Less retesting
which requires analysis.
NEUTRAL Changing from epoc to
central lab in PICU is
being implemented
currently
BENEFITS / HARMS (QUALITY/OUTCOME)
Degree of recovery at discharge n/a n/a NEUTRAL
Effects on natural history of the disease over equivalent time n/a n/a NEUTRAL
Potential to cause harm n/a Hct by epoc is inaccurate,
other tests are generally
less reliable. Less blood
loss.
OPTION B
Palatability to patient/family n/a n/a NEUTRAL
Population-related benefits n/a n/a
Threshold for population-related benefits reached n/a n/a
COST (Arising from Options A or B) - express as cost per day
“ROOM RATE” ($ or time to recovery) n/a n/a NEUTRAL [estimate annual patient
volume]
“Dx/Rx” costs ($) Baseline Per encounter $40
savings in direct costs
now, $61 when lactate
cartridge is changed.
Avoid duplicate testing.
OPTION B For 15 patients/year,
$915 savings for liver
alone. Kidneys will 21
pts/year x ~$61 = $1281.
Total $2200/year for liver
and kidney not including
reduction in duplicate
testing.
APPLY VALUE ANALYSIS GRID
COST A > B A = B A < B Unclear
A costs more than B Make value judgement B B Do B and PDSA in 1 year
A and B costs are the same A
A or B, operational
factors may influence
choice
B
A or B, operational
factors may influence
choice, PDSA in 1 year
B costs more than A A A Make value judgement Do A and PDSA in 1 year
VALUE STATEMENT
FINAL CSW VALUE STATEMENT
NEUTRAL
Central lab testing is preferred over ePOC because it is more accurate with less need for retesting and less
expensive ($61/patient for liver transplant pathway in first 48 hours). Key assumptions include: retesting
creates waste. This recommendation is based on institutional quality assurance. A cost-minization strategy
approach was applied.
BENEFIT (QUALITY & OUTCOMES)
Return to Postop ICU
Evidence Ratings
To Bibliography
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:
· Have serious limitations
· Have inconsistent results
· If evidence does not directly address clinical questions
· If estimates are imprecise OR
· If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:
· The effect size is large
· If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
· If a dose-response gradient is evident
Guideline – Recommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).
Return to Admit Return to OR Return to Postop ICU Return to Postop Floor
Summary of Version Changes
· Version 1.0 (4/29/2014): Go live
· Version 2.0 (11/13/2014): Reduced plasma dose, clarified line placement requirements upon
admit, removed link to blood draw limits
· Version 3.0 (1/22/2016): CSW Value Analysis completed, changes include to recommend core
labs over ePOC (use ePOC when speed is more important than accuracy)
· Version 4.0 (4/4/2016): Added additional information for Admit Labs
· Version 4.1 (11/21/2016): Reformatted Admit Labs page for readability
· Version 4.2 (9/25/2017): Renamed email address
· Version 5.0 (1/10/2019): Updated anticoagulation recommendations
Return to Admit Return to OR Return to Postop ICU Return to Postop Floor
Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Children’s Healthcare System nor any other party who
has been involved in the preparation or publication of this work warrants that the
information contained herein is in every respect accurate or complete, and they are
not responsible for any errors or omissions or for the results obtained from the use of
such information.
Readers should confirm the information contained herein with other sources and are
encouraged to consult with their health care provider before making any health care
decision.
Return to Admit Return to OR Return to Postop ICU Return to Postop Floor
Bibliography
Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian, Susan Klawansky. Searches were performed in July and September, 2013. The following databases were searched – on the Ovid platform: Medline (2002 to date), Cochrane Database of Systematic Reviews (2005 to date), Cochrane Central Register of Controlled Trials (2002 to date); elsewhere – Embase (2002 to date), Clinical Evidence, National Guideline Clearinghouse, TRIP (2002 to date) and Cincinnati Children’s Evidence-Based Care Guidelines. Retrieval was limited to humans 0-18 and English language. In Medline and Embase, appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively, along with text words, and the search strategy was adapted for other databases using their controlled vocabularies, where available, along with text words. Concepts searched were liver transplantation and any of the following: immunosuppression, immunosuppressive agents, human herpesvirus 4, Epstein-Barr virus infections, cytomegalovirus, cytomegalovirus infections, pneumocystis pneumonia, pneumocystis carinii, lymphoproliferative disorders, steroids. All retrieval was further limited to certain evidence categories, such as relevant publication types, Clinical Queries, index terms for study types and other similar limits.
Susan Klawansky, MLS, AHIP November 18, 2013
To Bibliography, Pg 2
Return to Admit Return to OR Return to Postop ICU Return to Postop Floor
529 records identified through database searching
0 additional records identified through other sources
528 records after duplicates removed
528 records screened 377 records excluded
152 full-text articles assessed for eligibility142 full-text articles excluded, 5 did not answer clinical question 137 did not meet quality threshold
10 studies included in pathway
Identification
Screening
Eligibility
Included
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
Bibliography
Haddad E, McAlister V, Renouf E, Malthaner R, Kjaer MS, Gluud LL. Cyclosporin versus
tacrolimus for liver transplanted patients. Cochrane Database of Systematic Reviews
[Immunosup]. 2009;4.
Health Policy & Clinical Effectiveness Program, Cincinnati Children's Hospital Medical Center.
Evidence-based care guideline: pneumocystis carinii pneumonia prophylaxis following solid
organ transplants. . http://www.cincinnatichildrens.org/WorkArea/
linkit.aspx?LinkIdentifier=id&ItemID=87956&libID=87644. Updated 2007. Accessed 7/5/13,
2013.
Health Policy & Clinical Effectiveness, Cincinnati Children's Hospital Medical Center. Evidence-
based care guideline: cytomegalovirus prophylaxis following solid organ transplants. . http://
www.cincinnatichildrens.org/WorkArea/
linkit.aspx?LinkIdentifier=id&ItemID=87898&libID=87586. Updated 2007. Accessed 7/5/13,
2013.
Jonas S, Neuhaus R, Junge G, et al. Primary immunosuppression with tacrolimus after liver
transplantation: 12-years follow-up. Int Immunopharmacol [Immunosup]. 2005;5(1):125-128.
Kelly D, Jara P, Rodeck B, et al. Tacrolimus and steroids versus ciclosporin microemulsion,
steroids, and azathioprine in children undergoing liver transplantation: Randomised european
multicentre trial. Lancet [Immunosup]. 2004;364(9439):1054-1061. Accessed 20040921; 9/3/
2013 1:16:54 PM.
Mattes FM, Hainsworth EG, Geretti AM, et al. A randomized, controlled trial comparing ganciclovir
to ganciclovir plus foscarnet (each at half dose) for preemptive therapy of cytomegalovirus
infection in transplant recipients. J Infect Dis [Immunosup]. 2004;189(8):1355-1361.
Otero A, Varo E, de Urbina JO, et al. A prospective randomized open study in liver transplant
recipients: Daclizumab, mycophenolate mofetil, and tacrolimus versus tacrolimus and
steroids. Liver Transpl [Immunosup]. 2009;15(11):1542-1552. Accessed 20091105; 9/3/2013
1:16:54 PM. http://dx.doi.org/10.1002/lt.21854.
Penninga L, Wettergren A, Chan A, Steinbruchel DA, Gluud C. Calcineurin inhibitor minimisation
versus continuation of calcineurin inhibitor treatment for liver transplant recipients. Cochrane
Database of Systematic Reviews [Immunosup]. 2012;3.
Shepherd RW, Turmelle Y, Nadler M, et al. Risk factors for rejection and infection in pediatric liver
transplantation. Am J Transplant [Immunosup]. 2008;8(2):396-403. Accessed 20080123; 9/3/
2013 1:16:54 PM.
Spada M, Petz W, Bertani A, et al. Randomized trial of basiliximab induction versus steroid therapy
in pediatric liver allograft recipients under tacrolimus immunosuppression. Am J Transplant
[Immunosup]. 2006;6(8):1913-1921.
Return to Admit Return to OR Return to Postop ICU Return to Postop Floor
Liver Transplant Pathway Approval & Citation
Approved by the CSW Liver Transplant for April 29, 2014
CSW Liver Transplant Team:
Transplant Division, Owner Andre Dick, MD
Transplant Division, Owner Patrick Healey, MD
Transplant Division, Anesthesiologist Douglas Thompson, MD
Transplant Division, Nurse Practitioner Keli Hansen, ARNP
Transplant Division, Coordinator Ellen Cella, RN, BSN
Transplant Division, Coordinator Marsha Larsen, RN
Transplant Division, Pharmacist Tuan Nguyen, PharmD
Transplant Division, Pharmacy Resident Jennifer Higuchi, PharmD
Transplant Division, Pharmacist Jennifer Pak, PharmD, BCPS
Clinical Effectiveness Team:
Consultant Jennifer Hrachovec, PharmD, MPH
Project Manager Pauline Ohare, RN, MBA
CE Analyst Suzanne Spencer, MBA, MHA / Nate Deam
CIS Informatician Mike Leu, MD
Surgical Unit, CNS Ashley Wagner, MN, RN, PCNS-BC, CPN
PICU Educator Hector Valdivia, RN
Librarian Susan Klawansky, MLS
Program Coordinator: Asa Herrman
Executive Approval:
Sr. VP, Chief Medical Officer Mark Del Beccaro, MD
Sr. VP, Chief Nursing Officer Madlyn Murrey, RN, MN
Surgeon-in-Chief Bob Sawin, MD
Retrieval Website: http://www.seattlechildrens.org/pdf/liver-transplant-pathway.pdf
Example:
Seattle Children’s Hospital, Dick A, Healey P, Thompson D, Hrachovec JB, Leu MG. O’Hare P, and
Wagner A. 2014 April. Liver Transplant Pathway. Available from: http://www.seattlechildrens.org/pdf/
liver-transplant-pathway.pdf
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