Patient Care Orders GSICU/Adult Liver Transplant Transfer Orders: 3C3/4 to 3G2 E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART All orders to be reassessed and approved by accepting care team.

1. Check Caution Sheet for any allergies before ordering. 2. Medication orders must include drug, dose, route, frequency and, if applicable, duration. 3. If medication order is STAT or URGENT, notify RN and place a large X

in the STAT/URGENT box at right. 4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking the

order out.

STAT / URGENT

Use checkbox for medication orders ONLY

Physician Signature: ………………………………………………………Date/Time: ……………………………………………………………..

All orders to be reviewed and approved by accepting patient care team. Critical Care Orders: GSICU University of Alberta site. October 2010 Draft PAGE 1 OF 5 Critical Care Quality Improvement Initiative

+ + Affix patient label within this box.

Order Rationale

Transfer from GSICU care to Hepatobiliary/Transplant Surgery Accepting Physician:

Dr Bigam Dr Kneteman Dr Shapiro Other: ………………………….

Charge RN/Ward clerk to notify Attending Physician or Transplant

Fellow of patient location and arrival.

Charge RN/Ward Clerk to contact attending physician on patient admission. Attending Physician / Resident / Fellow to review transfer orders upon arrival to ensure continuity of care.

Pre-Transplant diagnosis:

Recipient Status CMV Positive Negative EBV Positive Negative

ABO Incompatible transplant

Donor Status CMV Positive Negative EBV Positive Negative

Philosophy of Care: Full resuscitative measures, MET/CODE activation, and

readmission to ICU as required.

Patient Vitals and Monitoring: Vitals Q4H for 24 hours, then to be re-assessed by ward team. Other………………………………………………………………………….

……………………………………………………………………………. Foley catheter to urometer, with input and output monitoring….

Q1H Other: …………………………….

Notify resident if… -Urine output less than 30mL/h or greater than 300mL/h for 2

consecutive hours. -Temperature greater than 38ºC -Heart rate greater than 100 or less than 60 beats per minute -Systolic blood pressure less than 100 or greater than 160 mm Hg -Diastolic blood pressure less than 60 or greater than 100 mm Hg

MET Activation Criteria •Airway Threatened - Stridor •Breathing - Acute change in RR <8 or >36 - Acute change in SpO2 <90 despite mask O2 at 10L/min •Circulation - Acute change in heart rate <40 or >140 - Acute change in SBP <90mmHg •LOC - Acute change in level of consciousness •Worried about your patient! Range for BP systolic varies according to different patients and disease states however, BP < 90mmHg is generally of concern and should be addressed by physician staff. If in doubt about condition of your patient, notify housestaff and Attending Physician! MET activation for more serious decompensation if within philosophy of care guidelines for patient.

Patient Safety and Activity: Activity as tolerated (no restrictions) Bed rest Elevate head of bed 30 degrees or higher as tolerated Incentive spirometry hourly while awake. Deep breathing and coughing every 2 hours while awake. Daily patient weights

Elevation of head of bed reduces likelihood of subclinical aspiration and development of hospital associated pneumonia.

Patient Care Orders GSICU/Adult Liver Transplant Transfer Orders: 3C3/4 to 3G2 E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART All orders to be reassessed and approved by accepting care team.

1. Check Caution Sheet for any allergies before ordering. 2. Medication orders must include drug, dose, route, frequency and, if applicable, duration. 3. If medication order is STAT or URGENT, notify RN and place a large X

in the STAT/URGENT box at right. 4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking the

order out.

STAT / URGENT

Use checkbox for medication orders ONLY

Physician Signature: ………………………………………………………Date/Time: ……………………………………………………………..

All orders to be reviewed and approved by accepting patient care team. Critical Care Orders: GSICU University of Alberta site. October 2010 Draft PAGE 2 OF 5 Critical Care Quality Improvement Initiative

+ + Affix patient label within this box.

Dressings: Dressing changes daily and PRN Wound Vac (see separate order sheet) Other:

Drains: Nasogastric tube to low intermittent suction, may irrigate with 20 mL

Normal Saline PRN. Jackson Pratt drains, reprime Q4H and PRN. Chest tube(s) to underwater seal

–20 cm H2O suction straight drainage Other (signify)……….. Other drains:

Deep Vein Thrombosis Prophylaxis/Therapeutic Anticoagulation: Heparin 5000 units subcutaneously Q12H (standard) Heparin …………units subcutaneously Q…….H Pneumatic compression stockings. NO HEPARIN, patient coagulopathy or HITT Heparin 25,000 units in 250mL D5W at ……………units per hour IV.

Indication: Abnormal arterial anatomy Venous patency Portal venous thrombus Other: ……………….

Acetylsalicylic acid (ASA) 80 mg orally/NG once daily.

DVT prophylaxis is standard of care for ALL ICU patients. Need for prophylaxis varies for hospitalized ward patients. Pneumatic compression indicated when heparin is contraindicated due to active or high risk of bleeding, coagulopathy or heparin induced thrombocytopenia and thrombosis (HITT). Low Dose Heparin Infusion is frequently used to maintain vascular patency following complex arterial reconstruction or with prior portal venous clot.

Gastrointestinal mucosal protection: Pantoprazole 40 mg IV twice daily. Lansoprazole 30 mg PO/NG daily. Other:

Proton pump inhibitor for acid reduction and prophylaxis of stress mucosal ulceration in all patients unless post total gastrectomy.

Fluid Therapy: Maintenance IV fluid (signify one) at ………………….mL/hour

Plasma-Lyte A Ringers Lactate (no added potassium CHLORIDE) with 20 mmol potassium CHLORIDE per liter with 40 mmol potassium CHLORIDE per liter 0.9% NaCl (Normal Saline) (no added potassium CHLORIDE) with 20 mmol potassium CHLORIDE per liter with 40 mmol potassium CHLORIDE per liter 0.45% NaCl (1/2 Normal Saline)

Additional IV fluids………………………………………………………….. Total IV+PO fluid intake =………………………mL/hour

Plasma-Lyte A= Na+140, K+5, Mg++3, Cl-98, Gluconate 23mEq/L, Acetate 27 mEq/L with pH 7.4 Contraindicated in only the most profound liver failure. Magnesium may precipitate with medications. Caution re: medication compatibilities. Ringers Lactate=Na+130, K+4, Mg++2, Lactate 28mEq/L, Ca+3 with pH 6.5. Contraindicated in only the most profound liver failure. Calcium may precipitate with medications and blood products. Caution re: medication compatibilities. Caution in renal failure due to K+ content. Normal saline=Na+154, Cl-154 with pH 5.5. Commonly results in metabolic acidosis and hypernatremia. 1/2NS and D5W result in minimal intravascular volume expansion and are not resuscitation fluids. Venous Access and Maintenance:

Lock peripheral IV sites as per Hospital Protocol Lock unused central line ports as per Hospital Protocol Lock dialysis lines as per Dialysis service.

Oxygenation Goals: Maintain O2 saturation greater than 90% (standard) Monitor 02 Saturations q…….hr O2 at …………………L/min Other:

Usual Goals for oxygenation and ventilation are saturations over 90%.

Patient Care Orders GSICU/Adult Liver Transplant Transfer Orders: 3C3/4 to 3G2 E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART All orders to be reassessed and approved by accepting care team.

1. Check Caution Sheet for any allergies before ordering. 2. Medication orders must include drug, dose, route, frequency and, if applicable, duration. 3. If medication order is STAT or URGENT, notify RN and place a large X

in the STAT/URGENT box at right. 4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking the

order out.

STAT / URGENT

Use checkbox for medication orders ONLY

Physician Signature: ………………………………………………………Date/Time: ……………………………………………………………..

All orders to be reviewed and approved by accepting patient care team. Critical Care Orders: GSICU University of Alberta site. October 2010 Draft PAGE 3 OF 5 Critical Care Quality Improvement Initiative

+ + Affix patient label within this box.

Bronchodilator therapy: (for patients with COPD/Asthma) Salbutamol 2 puffs (100mcg each) by metered dose inhaler

Q4H PRN for bronchospasm Q6H regular dosing Other:

Bronchodilator therapy is indicated for patients with reactive airways or known asthma only.

Physical Medicine and Rehabilitation: Consult Physiotherapy for patient mobilization and physical

conditioning. Consult Occupational Therapy:

Physiotherapy consult for patient mobilization and rehabilitation. Occupational Therapy consult for patient assessments, treatment and adaptive equipment recommendations.

Patient Analgesia: morphINE ……………mg subcutaneously Q4H prn. Other:……………………...…………….……………………….………… Patient controlled analgesia (see PCA order sheet) Other:

Morphine dosing highly variable and should be individualized for the patient and clinical circumstances. Individualized patient assessment required (i.e. response to medication, assessing alleviation of pain, and reassessment prn

Nutritional Support: Consult Transplant Dietician for nutritional assessment and suggestions.

NPO May have ice chips only Regular diet Full fluids Clear fluids Advance diet as tolerated Diabetic diet ……………Calories CDA

Tube feeds:………..……………………………at…..…………mL/hour

Target Goal: ……………..mL/hour (increase to target as per protocol) Free water flushes through feeding tube, ………mL every …… hours.

Total Parenteral Nutrition (TPN)

Amino acid solution (TRAVASOL) at ……………………….mL/hour Lipid solution at …………………………….mL/hour

Chemstrips Q6H while on TPN.

DO NOT insert enteral tubes (NG or OG) in patients with Roux-en-Y hepaticojejunostomy, or with recent variceal bleeding or banding. If in doubt ask attending physician.

Microbiological Cultures and Precautions Blood, abdominal drain fluid and sputum cultures (if productive cough)

with temperature greater than 38.5 degrees (if not previously cultured during that febrile episode).

If persisting fever, once daily blood cultures. Significant organism isolation, if prior positive culture or high risk of

colonization with significant organism. If diarrhea present, stool for C difficile toxin PRN (once every 72

hours) Please notify Transplant Infectious Disease Service of patient’s location for follow up and monitoring.

Patients previously positive for MRSA or VRE remain on precautions and do not require re-culture on admission. Isolation continues until patient is OFF antibiotics and three negative cultures at one-week intervals are obtained.

Urine cultures have limited usefulness or significance in patient with indwelling catheter

Patient Care Orders GSICU/Adult Liver Transplant Transfer Orders: 3C3/4 to 3G2 E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART All orders to be reassessed and approved by accepting care team.

1. Check Caution Sheet for any allergies before ordering. 2. Medication orders must include drug, dose, route, frequency and, if applicable, duration. 3. If medication order is STAT or URGENT, notify RN and place a large X

in the STAT/URGENT box at right. 4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking the

order out.

STAT / URGENT

Use checkbox for medication orders ONLY

Physician Signature: ………………………………………………………Date/Time: ……………………………………………………………..

All orders to be reviewed and approved by accepting patient care team. Critical Care Orders: GSICU University of Alberta site. October 2010 Draft PAGE 4 OF 5 Critical Care Quality Improvement Initiative

+ + Affix patient label within this box.

Antimicrobial Prophylaxis: Nystatin 500,000 units four times daily, after meals and at bedtime

swish and swallow Sulfamethoxazole 400 mg – triMETHOprim 80 mg (cotrimoxazole)

one single strength tablet daily po, starting post op day 2. OR if allergic to sulfa…

Pentamidine 300 mg inhaled every 30 days. Start Date: …………… CeftriAXone 1 gram IV every 24 hours for two doses post-surgery.

OR if allergic to cephalosporines, or severe Penicillin allergy…. Clindamycin 600 mg IV q8h AND CIPROfloxacin 400 mg IV q12h

for 48 hours post-surgery. Start Date: ……………

PJP prophylaxis with cotrimoxazole is standard of care but frequently not started until 14-21 days post transplant and may be delayed in patients with thrombocytopenia and/or leukopenia. May be started earlier in some patients.

Viral Prophylaxis and Monitoring: If Recipient CMV negative AND Donor CMV positive:

•ValGANCIclovir 900 mg orally daily for 14 weeks post-transplant. Starting date: …………… Projected Completion date: ………… •CMV-PCR weekly for 8 weeks when prophylaxis completed. Starting date: …………… Projected Completion date: …………

If Recipient CMV Positive AND Donor CMV Positive: •CMV PCR weekly from week 2 to 12 post transplant. Starting date: …………… Projected Completion date: …………

If Recipient EBV negative AND Donor EBV positive: •ValGANCIclovir 900 mg orally daily for 14 weeks post-transplant. (if not already receiving CMV prophylaxis) Starting date: …………… Projected Completion date: ………… •EBV viral load (PCR) weekly from week 4 to 20 Starting date: …………… Projected Completion date: ………… •EBV viral load (PCR) Monthly from month 6 to 12. Starting date: …………… Projected Completion date: …………

ValGANCIclovir dosing will require modification in renal impairment/failure. Please contact transplant/ID pharmacist for review.

Hepatitis B Protocol: •HepGam B 1,560U (5 mL) IV daily for one week post-transplant. Starting date: …………… Projected Completion date: ………… •HepGam B 1,560U (5 mL) IM to maintain anti-HBs target level •Anti-HBS titres Mon and Thurs from post-operative day 5 for 2 weeks. Starting date: …………… Projected Completion date: ………… •Anti-HBS titres weekly for two weeks. Starting date: …………… Projected Completion date: ………… • Anti-HBS titres every two weeks for two months Starting date: …………… Projected Completion date: ………… • Anti-HBS titres monthly for three months Starting date: …………… Projected Completion date: ………… •Continue nucleoside analog (ie. Entecavir, Tenofovir) patient was on prior to transplant. To be continued indefinitely. Drug Name: ..................................................mg ................times Daily

HepGam (HBIG) to be infused at half normal rate in renal failure. Dose modification may be required in renal failure. Anti-HBs target titres •≥400 IU/mL during first month AND until HBV DNA at time of transplant known. •≥250 IU/mL if HBV DNA detectable at transplant •≥100IU/mL if HBV DNA undetectable at transplant

Patient Care Orders GSICU/Adult Liver Transplant Transfer Orders: 3C3/4 to 3G2 E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART All orders to be reassessed and approved by accepting care team.

1. Check Caution Sheet for any allergies before ordering. 2. Medication orders must include drug, dose, route, frequency and, if applicable, duration. 3. If medication order is STAT or URGENT, notify RN and place a large X

in the STAT/URGENT box at right. 4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking the

order out.

STAT / URGENT

Use checkbox for medication orders ONLY

Physician Signature: ………………………………………………………Date/Time: ……………………………………………………………..

All orders to be reviewed and approved by accepting patient care team. Critical Care Orders: GSICU University of Alberta site. October 2010 Draft PAGE 5 OF 5 Critical Care Quality Improvement Initiative

+ + Affix patient label within this box.

Immunosuppression:

Routine Protocol, including tumor patients: -Basiliximab 20 mg IV in 50 mL Normal Saline, Post-Surgery day 4. Date: …………………… -Tacrolimus ……….mg PO/NG every Q12H -Mycophenolate MOFETIL …………….mg PO/NG Q12H

Renal/Neuro Toxicity Protocol -Basiliximab 20 mg IV in 50 mL Normal Saline, Post-Surgery day 4. Date: …………………… -Sirolimus ……….mg PO/NG every Q24H -Mycophenolate MOFETIL …………….mg PO/NG Q12H

Do not administer non-steroidal anti-inflammatory drugs (NSAIDS), amphotericin B, erythromycin, or aminoglycoside antibiotics, unless approved by Transplant Attending. These agents will alter immunosuppressive drug levels and can increase risk of nephrotoxicity. Tacrolimus usually dosed at 0.1mg/Kg PO/NG divided into BID dosing. Standard protocol maintains levels between 8-12. Main contraindications are renal insufficiency and neurotoxicity. Standard dosing of Cellcept (Mycophenolate mofetil) is 1000 mg BID. May be held in sepsis and neutropenia. Sirolimus is normally not used in immediate post-operative period due to risk of hepatic artery thrombosis but may be used subsequently in patients with renal failure or neurotoxicity from calcineurin inhibitors and in patients with hepatocellular carcinoma. Specific target levels of all drugs are at the discretion of the transplant team.

Schedule for initial routine investigations: Mark all requisitions POST LIVER TRANSPLANT

Daily for 7 days, then reassess for change to Mon, Wed, Friday. -Complete blood count and differential (CBC and diff.) -Renal function (Creatinine, Blood Urea Nitrogen) -Serum electrolytes (NA+ K+ Cl- CO2 Glucose) -Coagulation profile (PTT/INR) -Liver function (AST, ALT, LD, Total Bili, Alk Phos)

Every Monday and Thursday, Mg+, iCa++, PO4- levels Every Monday, total protein, albumin and Lipase Trough Tacrolimus OR Sirolimus levels, draw daily before 07:30.

Need for daily investigations to be assessed by Ward care team on patient arrival.

Date/Time Other:

Use additional standard order sheets as required.