liver transplant v5liver transplant v5.0 operating room circulating nurse · organ chain of custody...

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

[email protected]

http://www.seattlechildrens.org/terms-of-use#medical

mailto: [email protected]


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




contact: [email protected] [email protected]




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









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






http://www.seattlechildrens.org/pdf/PE1262.pdf



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


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


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


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








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


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.


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


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.


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


http://www.seattlechildrens.org/pdf/liver-transplant-pathway.pdf

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