Cool site pour acheter des pilules Ne pas se perdre venir sur.

Pediatric Donor Management
Guidelines for Clinical Management of Organ Donors: Weight < 40 kg Organ Perfusion & Hormonal Replacement Guidelines:
• Normal HR, SBP: (see chart below) • Urinary output of 1-3 cc/kg/hr • CVP 6-10 mmHg Normal Heart
Normal Resp.
Fluid Challenge
Systolic BP
(20 mL/kg)


• Continuous arterial pressure monitoring • Continuous ECG monitoring • Hourly urine output
• Urine specific gravity at initiation of donor management and consider with the suspicion of DI


• Consult pediatric intensivist/medical director OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 1 of 7 Hypotension:
• Assess for excessive fluid losses above intake: o Output > intake and urine output < 1 mL/kg/hr o If polyuria present, refer to DI Prevention/Treatment Guideline • Evaluate for evidence of recent blood loss: o Confirm that the most recent Hct is > 30% o Reaffirm w/ an immediate repeat Hct and treat per Hematology Guidelines • Initiate intervention for signs of continued hemorrhage (i.e., external, GI, urinary, abdominal): consult intensivist • Assess recent CVP • Assess for ECG changes: o Repeat ECG and maintain at bedside o Consult MD for interpretation • Assess for evidence of ongoing severe infection, drug or other allergic reactions (i.e., due to blood transfusion), pericardial effusion, or hemo/pneumothorax: o Obtain a chest radiograph o Consult MD for interpretation • Discontinue medications that may contribute to hypotension (i.e., anti-hypertensives, beta-blockers)
• Correct intravascular volume (pre-load) = CVP > 6. Note: Take into account fluid and electrolyte
status, refer to Fluid Balance and Electrolytes Guideline o Start a fluid bolus of LR or 0.9% NS at 20 mL/kg, reassess, repeat x 2 if needed: consult
intensivist/medical director
o Colloid solutions may be preferred for repeated fluid challenges (5% albumin: 20 mL/kg) o Maintain CVP = 6-10 • Levophed (Norepinephrine) Infusion: 0.05-2 mcg/kg/min (do not exceed 2 mcg/kg/min) if so then add: o Phenylephrine infusion start at 0.1-0.5 mcg/kg/min and titrate up to maintain minimum acceptable blood pressure, maximum dose of 0.5 mcg/kg/min o Solumedrol 15 mg/kg IV over 30-60 minutes (consider repeat every 12 hrs if already given) o Consider Dopamine 2-20 mcg/kg/min o Consider Epinephrine Infusion: dose 0.1-1 mcg/kg/min o Consider Vasopressin Infusion: 0.3-2 milliunits/kg/min if urine output > 1 ml/kg/hr ƒ Consult pediatric intensivist, medical director, or transplant surgeon if higher doses
of vasoactive agents are required
o For a low EF (<45%), a positive inotropic agent (i.e., milrinone) should be used: consult
intensivist/medical director
ƒ Milrinone: dose 0.25-0.75 mcg/kg/min (no bolus, watch for vasodilation, may need alpha ƒ Dopamine: dose 2-20 mcg/kg/min ƒ Dobutamine: dose 2-20 mcg/kg/min • Reassess: Hct, Electrolytes, and pH for correctable causes of hypotension (acidosis, anemia, and • Consider Hormone Replacement Therapy, refer to section Hormone Replacement Therapy
Hormone Replacement Therapy:
• Improvement in cardiovascular lability • Reduction in electrocardiographic abnormalities • Reduction in acid-base disturbances • Improvement in the suitability of organs for transplantation OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 2 of 7 Assessment:
• Reserve hormone replacement therapy for: o Unstable donors requiring dopamine at a dose of more than 10 mcg/kg/min or multiple pressors o An ejection fraction < 45% (serial echocardiograms after hormone replacement – recommended) Intervention:
• Correct K+ > 3.5 • Correct CVP > 6 o Dextrose 200 mg/kg for infant/neonate or 1 gm/kg for child o 0.1 unit/kg Regular Insulin o 30 mg/kg Solumedrol over 30-60 minutes o T4 bolus then start infusion according to tables below: T4 (levothyroxine) bolus T4 (levothyroxine) infusion
• Wean vasoactive agents as able • Wean T4 or DC for persistent tachycardia outside acceptable normal, or hemodynamic instability Dysrhythmia:
• Send STAT electrolytes including Ca, Mg, and Phos • Supraventricular Tachycardia: o Administer Adenosine 100 mcg/kg rapid IV push for clinically significant (symptomatic BP or HR >
200. Consider fluid status and oxygenation. If no effect within 2 minutes, repeat at 200 mcg/kg (max single dose = 12 mg) o If no response within 2 minutes, consider Amiodarone 5 mg/kg infused over 5-60 minutes, may
repeat dose of 5 mg/kg, then infusion at 5-15 mcg/kg/min. Monitor for hypotension: consult w/
pediatric intensivist/cardiac transplant physician/medical director prior to administering

o Consult with pediatric intensivist/medical director for treatment recommendations Fluid Balance, Glucose & Electrolyte Guidelines:
• Serum Na+, K+, Cl-, Mg, Ca, and Phos within normal values Assessment:
• Serum electrolyte panels every 6 hrs (if patient on an insulin drip, check blood glucose every 1 hr and serum K+ every 2 hrs) • Serum K+, Ca+, Mg and Phos at initiation of management and following replacement (ideally correct to within normal limits prior to echocardiogram) • Consider eliminating dextrose if there are current or potential concerns about hyperglycemia OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 3 of 7 • Hypoglycemia:
For serum glucose < 60 mg/dL give 2 ml/kg of D10; repeat glucose check in 1 hr • Consult pediatric intensivist/medical director
IV Fluids:
• Administer maintenance IV fluids at a rate of:
o 4 mL/kg for 1st 10 kg, then
o 2 mL/kg for 2nd 10 kg, then
o 1 mL/kg for every kg in weight thereafter
• Goal: to achieve output of 1-3 cc/kg/hr and CVP 6-8 mmHg after initial fluid resuscitation Oliguria/Polyuria:
• Check urine specific gravity if urine output increases or color is pale
• Administer DDAVP if urinary output > 5 cc/kg/hr and specific gravity is 1.005 or less AND/OR serum
sodium is rising:
o Infuse 0.5 mcg/hr IV
o Titrate to decrease UO to 3-4 mL/kg/hr
o Do not give within 4 hours of the OR
• Consider Vasopressin Drip: give 0.5-1 milli-units/kg/hr IV and titrate to decrease UO to 3-4 mL/kg/hr Treatment of diabetes insipidus should consist of pharmacologic management to decrease but not completely stop urine output. Replacement of urine output with ¼ or ½ normal saline should be used in conjunction with pharmacologic agent to maintain serum sodium levels between 130-150 mEq/L.
• Administer Lasix 1 mg/kg IV push (max dose 20 mg) if urinary output < 1cc/kg/hr and SBP > minimum

Serum Sodium
Fluid Type
Hypernatremia Protocol:
ƒ Current Na-Desired Na/Current Na x 1000mL/L x 0.6L/kg of body weight = mL/kg ƒ Desired Na is usually 145 unless otherwise directed by pediatric intensivist/medical director o Replace 1/2 of fluid volume deficit with 0.25% NS over 2-3 hrs (or more rapidly if the donor is hypotensive), then reassess serum sodium. If Na+ remains > 156 or not trending lower, consider repeating protocol or contact accepting liver program for guidance o Consult pediatric intensivist/medical director

Note: Albuterol, Lasix, insulin, and hypothermia may depress K+ level: correct as necessary
• Administer KCl (adjust in cases of oliguria or polyuria)
• Recheck serum potassium 3 hrs after replacement complete
Serum Potassium
KCL Replacement
0.1-0.2 mEq/kg/hr (max rate 0.5 mEq/kg/hr) OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 4 of 7 Hyperkalemia:
• Consider possible causes (renal failure, excess administration of potassium)
• Remove all K+ from IV fluids
• Consider giving Lasix for diuresis (if fluid status is stable)
• Consider administration of dextrose, insulin, and sodium bicarbonate: consult with intensivist
• Re-check levels 30 minutes after every dose and replace appropriately


Serum Magnesium
MgSo4 Replacement (max dose 2 gms)

• Assess via serum ionized calcium level
Serum ionized calcium
Calcium replacement
10-20 mg/kg of calcium chloride per central line
20-40 mg/kg of calcium gluconate
Note: For renal insufficiency or creatinine clearance < 20, reduce replacement dosing by 50%
Serum Phosphorus
NaPO4 or KPO4 Replacement
Hematology Guidelines:
• Hematocrit > 30% • Platelet count > 20,000 Assessment:
• Obtain CBC, PT/PTT/INR at the beginning of donor management and perform a physical assessment ASAP in trauma cases where active bleeding may be a concern Interventions:

Serum Blood Counts
Serum Blood Type
Platelets < 20,000 (consult liver transplant surgeon prior to infusion of any platelets)
• Consider Vitamin K if persistently elevated PT: consult with pediatric intensivist/medical director
• Recheck labs 1 hr after infusion and give additional treatments if necessary • Keep 2 units PRBCs ahead • If donor received blood transfusions prior to IDS arrival or there is active bleeding, keep 4 units ahead • If donor exhibits consumption or dilutional coagulopathies and is not actively bleeding, treatment may not be • Note: Treatment is reserved for donors who appear to have continuing significant blood loss evidenced by:
physical assessment, hemodynamic instability, changes in coagulation parameters
OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 5 of 7 Oxygenation & Ventilation Guidelines:
• Continuous SaO2 > 95%, PaO2 >100 torr, pH 7.35-7.45, pCO2 30-50, FiO2 40%, PEEP 5 Assessment:
• ABG every 6 hrs (every 4 hrs if possible on potential lung donor), and 30 minutes after each ventilation adjustment and w/ any apparent change in function o Note: During active placement of lungs do ABGs every 3 hrs
• Peak inspiratory pressures with ABG (if possible lung donor) • CXR on initiation of management (and every 4-6 hrs if possible on potential lung donor) o Note: CXR must be read by an MD: consultation w/ MD should be a priority
• For suspected pulmonary contusion, effusion, or COPD changes consider High Resolution Chest CT

• Consider therapeutic bronchoscopy: consult with pediatric pulmonologist, if:
o An O2 ABG challenge has a PO2 with < 350 torr o Donor has clinical evidence of aspiration o Suspected mucous plugs o Upon center request o Heavy oropharyngeal bleeding or drainage • Use bronchodilator every 4 hrs as recommended by pediatric pulmonologist/intensivist
Consider Open Lung Recruitment (if evidence of atelectasis AND hemodynamically stable)
• Adjust tidal volume and ventilation rate (see previous section) to maintain pCO2 between 30-50 torr
• After adjusting minute ventilation, administer NaHCO3 1 mEq/kg IV to correct acidosis (hypernatremia
can be aggravated with repeat dosing), recheck ABG
• For extreme metabolic acidosis and high vasoactive requirement, ensure adequate fluid resuscitation has
been given and then consider THAM (tromethamine) administration:
o Base deficit x wt(kg) = mLs of 0.3 molar solution of THAM • Consult with pediatric intensivist for recommended best ventilator support

• In cases with persistent or segmental atelectasis (by CXR) consider increasing PEEP
• Consider bronchoscopy in cases of segmental atelectasis: consult pediatric pulmonologist/intensivist
• Consider aggressive diuresis
• Consider repeat Solumedrol if last dose > 12 hrs • If there are effusions present, consult for consideration of a chest tube • Chest PT and suction • Utilize HFCWO Vest whenever possible (20 minute cycle with a 1 hr 40 minute rest); do not draw ABG within 30 minutes of vest cycle, or during percussion
Note: If considering single lung transplant only – position good lung up.

OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 6 of 7 Temperature Guidelines:
ƒ Temperature: 96.8-98.6° F or 36-37° C
• Monitor temperature every 2 hrs
• Apply external warming blankets, or heating devices; adjust room temperature to (76° F or 24° C)
• Adjust inspired air temperature on ventilator circuit between (90-98.6° F or 32-37° C)
• Administer all fluids and/or blood products via warming device
• Perform warmed NG lavage if temperature is less than (93.2° F or 34° C)
Infection Guidelines:
• Prevention and treatment of common nosocomial infections Assessment:
• Blood, urine and sputum cultures obtained at initiation of management • Sputum gram stain (on all possible lung donors) Interventions:
o Maintain current antibiotic regimen (based off culture sensitivity) o Administer cefazolin 25 mg/kg IV (max 2000 mg) every 8 hrs (after cultures obtained) o If potential lung donor: Administer ceftazidime 50 mg/kg IV (max 2000 mg) every 8 hrs (after cultures obtained) instead of cefazolin • Consult with pediatric intensivist or pharmacist for recommendation of antibiotics to cover unit
specific organisms
Miscellaneous Guidelines:
Spinal Reflexes:
o If spinal reflexes are present, and may cause discomfort to the donor family and/or medical staff, attempt to explain the cause and effect of such reflexes o If explanations are not sufficient, consult with pediatric intensivist/medical director OCG4014 Initial Doc: 12/08/09 Revision 0: QI/Doc Approval: KAV Page 7 of 7


Microsoft word - document

Who Should Take Statins? (My John McDougal, M.D.) Cholesterol-lowering medications, commonly referred to as statins, are considered so beneficial that some enthusiastic doctors declare, “they should be put into the drinking water.” The pharmaceutical companies and their sales staff (most medical doctors) would like you to believe that simply lowering your cholesterol number is the major

1 - artigo-aberturas-rev-est-36.indd

Ainda em cartaz, “Estamira”: A Psicanálise nas telas do Cinema Ainda em cartaz, “Estamira”: A Psicanálise nas telas do Cinema Still in theaters, “Estamira”: Psychoanalysis in Cinema screens Thiago Robles Juhas Niraldo de Oliveira Santos Resumo O presente trabalho tem como objetivo discutir e articular as relações entre o cinema e a Psica- nálise. Para ist

Copyright © 2010-2014 Predicting Disease Pdf