Renal transplantation (paediatric): management of

Warning

Objectives

This SOP is intended for medical and nursing staff caring for paediatric renal transplant recipients, who may not have looked after transplant patients before. The SOP helps outline the management and advises of situations when it is necessary to seek assistance. The appropriate management of transplant patients in the first hours and days after the operation is crucial to a positive outcome, hence the detailed sections on early post-operative care.  

Errors in the first couple of days peri-and post-transplant can have life-long and life-limiting implications.

If in doubt seek advice from either the consultant paediatric nephrologist on-call or from the surgeons involved in the procedure.

1. SOP development

SOP Group

Dr Heather Maxwell, Mr Vlad Shumeyko, Mr Martyn Flett, Dr Ben Reynolds, Mrs Angela Lamb, Dr Alison Balfour, Dr Ann-Margaret Little, Dr Jocelyn Erskine, Dr Chris Kidson, Dr Douglas Stewart

Please contact Dr B Reynolds if there are issues with this SOP or any suggested improvements. Contact at: ben.reynolds@nhs.scot

SOP Development

The SOP has been developed after assessing current practice in the light of published evidence and guidelines. Much of the guidance is based on shared expert opinion and experience. This SOP should be used in conjunction with the following GGC NOPS

SOP Update

This SOP was updated June 2020, following work by the Paediatric sub-group of the Kidney Advisory Group for NHSBT, reflecting the UK harmonization of immunosuppression and anti-infective regimes. August 2020 incorporated an update to reflect changing anaesthetic practice. Changes for IV fluids, DD organ pathway, TransplantPath, analgesia/fentanyl pathways, and several editorial changes to reduce repetition were incorporated August 2024. All recent edits have been circulated to, and reviewed by, all members of the paediatric renal MDT

2. Introduction

Children may receive a transplant from a relative (Living Donor - LD), through the national kidney sharing scheme (NKSS) or from a deceased donor (DD). A LD or NKSS transplant will be planned in advance; a DD transplant will take place when a suitable organ becomes available and often takes place out of hours. The duties of relevant personnel are outlined in NOP005 [external link].

2.1 Deceased Donor Kidney

The consultant paediatric nephrologist on-call accepts a suitable kidney after phone calls from NHSBT. The initial calls usually take place before the kidney has been retrieved.

  • The consultant paediatric nephrologist will review information available through TransplantPath and decide whether or not to accept the kidney. Declining a kidney should always be done by two consultants – the on-call consultant and the child’s named consultant.
  • As of December 2024, ALL organ declines MUST be discussed with both a nephrologist and a surgeon.
  • The nephrologist will phone Ward 3C (0141 452 4521) to advise a kidney has been accepted, the expected arrival time (if known) and when the child should be admitted and start fasting.
  • The nephrologist will contact the on-call paediatric urologist for transplantation (rota available on Rotawatch).
  • The urologist will contact the on-call transplant surgeon from the Queen Elizabeth University Hospital (rota available on Rotawatch).
  • The urologist will contact the duty anaesthetist and/or emergency theatre co-ordinator and inform them that there is a deceased donor transplant planned and give the estimated time of operation. This information may be needed at the daily ‘bed huddle’.
  • The nephrologist will update the ‘Emergency Renal Transplant’ channel on MS Teams to advise that a DD transplant is planned.
  • Either Ward 3C nursing staff or the consultant will let the family know that a kidney may be available for their child.
  • During this phone call, staff will check if the patient has had any infections over the last 2 months and if they have had any recent blood transfusions.
  • After the phone call, the Ward 3C nursing staff will let the nephrologist know how the patient has been over the last 2 months if they contacted the family.
  • If the patient is on the virtual cross-match (vXM) list (no preformed antibodies and up to date antibody testing on at least 2 independent samples), the nephrologist will then contact the Consultant Clinical Scientist on-call (rota e-mailed monthly and numbers available on vXM Sheet) for confirmation that a vXM is acceptable. The laboratory crossmatch will be performed during working hours the next day. Contact should be made with the Histocompatibility and Immunogenetics (H&I) Laboratory during working hours to arrange transport of specimens (0141 301 7757/ 7755).
  • If the patient is not on the vXM list and needs a prospective crossmatch, Ward 3C staff will contact the H&I laboratory during working hours or, if out of hours, the tissue-typist on-call via Switchboard. This needs to be in sufficient time for a cross-match to take place as soon as the kidney arrives in the ward. Consider whether to request for peripheral blood from the donor to be sent to the H&I lab via ODT Hub to permit ‘wet’ cross-matching in a timely fashion.
  • Ward 3C nursing staff will inform PICU that a transplant is planned.
  • Once the arrival time of the kidney is confirmed by NHSBT, the nephrologist will inform Ward 3C. If necessary, the nephrologist will speak to the most senior of the medical receiving team on-call.

The patient should be fasted for 6 hours before the operation, unless anaesthetic colleagues advise otherwise.

  • The family should make their way to Ward 3C
  • If the patient is on peritoneal dialysis they should be left with no last fill. The parents should bring a sample of PD fluid with them (to be sent for cell count, microscopy and culture). If contacted during the night, the consultant receiving the offer will determine whether PD should be interrupted (if needed) and a manual drain performed, or if the PD can be completed as usual, and the family travel to hospital the following morning.
  • If the patient is on haemodialysis they may require an extra haemodialysis session before the transplant goes ahead – discuss this with the on-call nephrologist.
  • A copy of this SOP should be printed out for use by the attending medical staff. Further information relating to the child (The Transplant Plan) is held in Clinical Portal or in the ‘Transplantation’ folder of the Renal Share Drive. Print out this information. For most patients information can also be obtained from the renal unit database (SERPR). Admit as below.

2.2 Living Related Transplants

Living related transplants are planned in advance and the final cross-match will have already been carried out. Admit the child as below. Information will be available in the transplant plan, available online and in a hard copy kept on the ward.

3. Admission

3.1 Admit the child directly to ward 3C

The patient should be clerked in by the most senior of the junior medical staff on call. Much of the past medical history will be documented in the Transplant Plan. Note any past medical history of hypertension, asthma or seizures.

Attention should be paid to recent infections including peritonitis in PD patients and HD line infections, and any contact with infectious diseases. If the child is unwell or there are clinical concerns, please discuss with the consultant paediatric nephrologist on call immediately.

3.2 Investigations

Type

Investigation

Instructions

Haematology

FBC and coagulation

 

Blood Bank

Cross-match packed red cells

  • <20 kg: 2 units
  • 20-40 kg: 3 units
  • >40Kg: 4 units

Request for theatre

Biochemistry

U+E, LFTs, Bone, Mg, Glucose, CRP

 

Virology

Serology (10mls clotted blood) :CMV, EBV, VZV (only if negative previously)

 

PCR (3-5mls EDTA) EBV, CMV, adenovirus, BK 

 

 

COVID-19 swab

Send to Virology – Urgent if DD

Bacteriology

PD fluid 

In sterile universal 

Urine 

In boric acid container for culture

Tissue Typing

5-10ml clotted blood (large white)

3-4ml EDTA (large purple)

Send to the H&I Laboratory at Gartnavel General Hospital by taxi

  • Other investigations as clinically indicated e.g. CXR, ECG

3.3 Arrival of Deceased Donor Kidney

The donor kidney should be kept in ward 3C. Nursing staff should inform both the transplant surgeon, nephrologist and urologist when it has arrived (rotas available). If a prospective cross-match is required, the donor lymph node or spleen should be sent to H&I Laboratory at Gartnavel* along with a clotted sample of the recipient’s blood. This should be sent by taxi not courier. Ensure the H&I lab / on-call tissue-typist is aware of the estimated time of arrival of specimens. Check where sample is to be sent, and that a sample has not already been sent from the donor hospital. If a vXM is taking place, and samples arrive after 3pm (Mon-Fri), then they should be kept in the ward fridge ready for collection the next working day. This is summarised in the flow chart in Appendix I. 
* Histocompatibility & Immunogenetics Service, Level 1, Laboratory Medicine Building, Gartnavel General Hospital, 21 Shelley Rd, Glasgow, G12 0ZD

The donor kidney will be taken out of ice, assessed by the operating surgeons to make sure that the kidney is suitable. This will take place before any immunosuppression has been given and before the patient is taken to theatre.

3.4 Medical Management

  • Document anonymised deceased donor details in casenotes (Age, gender, blood group, tissue type, date and cause of death, weight, virology and creatinine)
  • Fast for solids for 6 hours pre-operatively and for clear fluids as per anaesthetic plan (a cross match takes approximately 6 hours).
  • Document the following for the recipient: Weight, height, surface area and native urine output (mls/day) in the case notes (Information available on Transplant Plan in Clinical Portal)
  • Prescribe IV fluids once the child is fasting to cover measured urinary losses and insensible losses of 400ml/m2. Use Plasmalyte 140 unless otherwise indicated. Children should be well hydrated at the time of transplant. Discuss IV fluid choice with the consultant if in doubt.
  • Document BP.  Withhold long-acting anti-hypertensives. If BP elevated, discuss with consultant nephrologist.
  • Perform ischaemic pre-conditioning if appropriate (aged >5years, likely to tolerate procedure). Refer to Ischaemic pre-conditioning SOP (Appendix VIII)
  • Radiology. Order an ultrasound of the transplant kidney (to be performed during or just after surgery) and make radiology aware that a transplant is about to take place. The transplant surgeon may be happy to perform a point of care ultrasound in theatre or PICU and the formal ultrasound may therefore be deferred until the following morning but the nephrologist will check this with the surgeons. 
  • Calculate medication doses that will be necessary pre and post op. Discuss with renal pharmacist. Medication doses are provided in Appendix II.
    i. Prescribe immunosupression on HEPMA. The intended immunosuppressive regimen will be documented in the transplant plan. Most patients will receive the TWIST regimen: tacrolimus, MMF and short course steroids. Doses are given below and details of all medicines used post-transplant are available at the end of this protocol. Basiliximab is generally the only immunosuppressant given pre-operatively; methylprednisolone is given during surgery and the rest start after theatre.
    ii. Prescribe antibiotic cover. Give cefotaxime 50mg/kg at induction (maximum 5g bd). This is for surgical prophylaxis and should be for a minimum of 24 hours or longer if indicated. This can be changed to a prophylactic oral dose to prevent UTIs whilst catheters remain in situ. If co-trimoxazole has been started as PJP prophylaxis this will double as urinary prophylaxis.
    iii. Prescribe gastroprotection to start pre-op.
    iv. Check CMV status of recipient and donor. If the recipient is negative and donor is positive the patient will require valganciclovir. This is started post-op once the patient is taking oral medication.
    v. Aspirin is started on the day of transplant and is given prior to going to theatre. Any child deemed at increased risk of thrombosis will have a plan for low molecular weight heparin (LMWH) thromboprophylaxis outlined in their transplant plan.

    At the discretion of the operating surgeon, thromboprophylaxis may be administered intra-operatively or LMWH may be recommended post operatively (See appendix V).
  • Review blood results
  • Haemodialysis: children on haemodialysis will require dialysis pre-transplant unless they have had a satisfactory dialysis session within the previous 24 hours. Minimal anticoagulation should be used. Unfractionated heparin should be used during haemodialysis NOT tinzaparin.  The line should be capped with a heparin lock (not alteplase/urokinase) only (please document and label). Fluid removal should be minimal unless fluid overloaded. Discuss with consultant on call.
  • Peritoneal Dialysis: children should receive their usual overnight dialysis. Depending on the time of transplantation and biochemistry results, further cycles may be required. When going to theatre, the abdomen should be empty (no last fill), and the catheter capped prior to transfer to theatre. Fluid removal should be minimal unless fluid overloaded. Aim to leave child at or above their dry weight i.e. limit the UF or allow time to catch up with IV fluids if fluid removal greater than expected. Discuss with consultant on call.

3.5 Surgical Considerations

  • Consent will be obtained by the operating surgeons. Frequently consent will be taken by both transplant and paediatric surgeons.
  • Consideration should be given to the need for dialysis access (HD or PD) post operatively. Pre-emptive patients may need access inserted; for those with access in situ a decision needs to be made whether to keep the access or remove it (e.g. infected exit site or catheter). If dialysis is likely to be needed post op, replacement access may be necessary.

3.6 Deceased Donor Cross-Match results

The operation can go ahead if the cross-match result is negative. As soon as this result is known, the basiliximab can be given, and once the infusion is complete, the patient should go promptly to theatre. 

3.7 Living Donor Transplantation

The donor nephrectomy takes place in the adult operating theatre suite. As soon as the retrieving surgeon is happy that the kidney is suitable for use, they will phone ward 3C to say the transplant is going ahead. Nursing staff on Ward 3C will then phone theatre to inform them that the operation is proceeding. The basiliximab will be given promptly to the patient who will then go to theatre as soon as the infusion is complete.

4. Receipt of donor organ at recipient centre

The arrival of the donor organ needs to be recorded in the Transplant Log which is held in the ward and in theatre. See also NOP002 and NOP003 [External links]

See Appendix I for flowchart

5. Intra-operative management

See also NOP004 [External link]. The operating surgeon is responsible for the correct identification of the donor organ used.

Human Tissue Authority Form B needs to be completed either electronically and e-mailed, or on paper and faxed to NSHBT.

ANAESTHETIC MANAGEMENT (J.Erskine/J. Skuratova)

Close communication with the nephrologist and surgeons is paramount. The following serves as a guide, developed after consultation with other UK and international centres. It is accepted that there will be variation in practice.

5.1 Preparation & Equipment

  • Ensure PICU bed available
  • Confirm cross-matched blood is in theatre fridge
  • Fluid warmer primed with Plasmalyte (if clinical indication for alternative fluids, the nephrologists will advise).
  • Arterial line
  • Central line if the patient does not already have a haemodialysis line. Consider a tunnelled line in children with sampling difficulties or other concerns.
  • Minimum of 2 drug infusion pumps (may be worth using PICU/cardiac stack).
  • Urinary catheter
  • 18G epidural catheter and local anaesthetic infusion device for surgically sited Transverse Abdominal Plane (TAP) block.
  • 2 temperature probes
  • Forced air warming device
  • Theatre temperature >23ºC
  • Gastrostomy extension (ask Ward 3C to bring down with patient)
  • Basiliximab will be given on the ward by the renal nurses prior to transfer to theatre.

5.2 Induction

  • Premedication as indicated
  • Aspirate gastrostomy
  • Any suitable induction technique. Atracurium NMB of choice.
  • Large bore IV access
  • Invasive monitoring. If patient has existing HD line ensure sterile access and dead space heparin is discarded.
  • Prophylactic antibiotics (often prescribed by nephrologists on HEPMA).

5.3 Maintenance

  • Remifentanil is useful in maintaining cardiovascular stability
  • Dopamine is usually required to optimise perfusion pressure. Start at 5µg/kg/min and titrate as necessary.
  • Consider additional boluses of phenylephrine or an infusion if indicated.
  • Goal directed fluid management. These patients can often require (and tolerate) intraoperative fluids of 60mls/kg and upwards. The author uses SPV (see below).
  • Regular blood gases (focusing on electrolytes, Hb, base excess, lactate)

5.4 Intraoperative goals

  • The transplanted kidney needs to be well perfused
  • Using systolic pressure variation (SPV) to direct fluid management is helpful. Maintain this parameter <10%. It can be selected on the GE monitor to be continually displayed in screen set up. Urine output is not measured during the majority of the case as the catheter is spigotted so SPV can provide valuable information and trends
  • Replace the recipients native urine output plus insensible losses
  • Use crystalloid/packed red cells/other blood products as clinically indicated
  • Maintain CVP 10-12 cmH2O
  • Target core-peripheral temperature gradient <2°C
  • Avoid hyperchloraemia. Plasmalyte® should be standard fluid unless directed by renal team.

5.5 Reperfusion

  • Give immunosuppression. Methylprenisolone will come with the patient prescribed by renal physicians. Administer 600mg/m2 (max 500mg) IV prior to release of vascular clamps
  • Prepare for potential cardiovascular instability – particularly for small children (<15kg) receiving adult kidneys.
  • Aim to match donor blood pressure or appropriate blood pressure for donor age. This information will be available in the patient’s casenotes.
  • Give a fluid bolus Initially 10mls/kg prior to release of vascular clamps but more may be required for large donor kidneys. 4.5% albumin is generally favoured however current evidence of clear advantage over crystalloids is lacking
  • Avoid packed red cells where possible. However intraoperative transfusion is preferable to postoperative from an immunological perspective

5.6 Analgesia

  • IV paracetamol, morphine or oxycodone bolus towards end of case.
  • Morphine, oxycodone, or fentanyl NCA/PCA as appropriate. See the Fentanyl SOP where this is used (Appendix X).
  • TAP block catheter and initial block by surgeons. Local anaesthetic infusion device (usually a Pajunk® elastomeric pump). A Lockit Plus® epidural securement device is useful in securing the catheter. Provide the surgeons with 10-20ml of local anaesthetic depending on patient weight to load the catheter.

5.7 Recovery/postoperative care

  • Decision to extubate is dependent on various factors including length of procedure, haemodynamics, intraoperative events, volume of fluid administered and patient specific factors. The majority of LRD recipients are extubated.
  • Avoid Sugammadex for reversal of rocuronium or vecuronium. There is evidence to suggest sugammadex encapsulates steroids (methylprednisolone given intraoperatively) and that the presence of methylprednisolone reduces the efficacy of reversal.
  • Extubated patients can be transferred to recovery or proceed directly to PICU. This is at the discretion of the anaesthetist but close communication with the entire team is essential to ensure the patient has the appropriate immediate postoperative management started.
  • If planning to transfer to recovery first, the anaesthetist should ensure the recovery staff are aware and have IV fluids prepared. Anaesthetist should also consider taking initial postoperative bloods.
  • IV fluids should replace both native and transplant urinary losses hourly until reaching PICU.
  • Ensure accurate documentation of all fluids given in theatre and recovery.
  • Handover to PICU consultant and team.

6. ITU management after return from theatre (Day 0)

The transplanted kidney needs to be well-perfused. Fluid management in the first 12 hours post operatively is critical and needs careful attention. 
Please discuss any concerns with the nephrologist on call.

6.1 MEDICATION 

The ward team will have prescribed relevant medication on HEPMA. Please transcribe onto the ITU prescription system. Appendix II contains all medications and doses needed.

6.1.1 Immunosuppression

The immunosuppression regimen will be documented on HEPMA. Typically this will be tacrolimus, MMF, and a short course of steroid.

6.1.2 CMV status

If the recipient is CMV negative and the donor CMV positive, then oral valganciclovir is given for at least the first 3 months, and consider treatment for 6 months total. This should be started when the patient is tolerating oral fluids (usually day 1 or 2 post transplant).

6.1.3 Analgesia / Sedation

This will have been started in theatre and usually includes a TAP block, an opioid (or equivalent) PCA/NCA, and regular IV paracetamol. If further analgesia is required, consider additional morphine (doses in Appendix II)

6.2 Investigations

On admission measure FBC, coagulation, U&E, LFTs, Bone, glucose, magnesium, CRP and urinalysis. Thereafter measure U&E, LFTs, glucose and FBC 4-6 hourly.

Monitor serum Na on blood gas machine 3-4 hourly.

Renal USS and Doppler shortly after admission to ITU if not already performed in theatre and repeated if clinical situation changes.

Daily Investigations

6.2.1 Check Tacrolimus level at 0800 each day. For Tacrolimus level send 1 x 0.5 ml K-EDTA (pink) which must be filled accurately.

6.2.2 Send daily urine (boric acid container) for culture.

6.2.3 Consider daily renal USS and Doppler if concerns about renal blood flow.

6.3 Monitor CVP, urine output, BP and core-peripheral temperature gap

Aim to keep CVP at 8-10 cm H20

Aim to keep systolic BP > 50th centile for donor age. For donors aged 17 and over this is 120/70 mmHg. For younger donors age-specific centile charts are available. 

Aim to keep core-peripheral temperature gradient < 2o

Measure the urine output hourly 

6.4 Fluid and Electrolytes

Replace urine output ml for ml on an hourly basis with either Plasmalyte or 0.9% saline + 5% dextrose initially. This is the combined transplant and native urine output from the bladder.

6.4.1 If serum sodium rises change to 0.45% saline and 5% dextrose

6.4.2 Send a urinary sodium and dip urine for glucose

6.4.3 If combined urine output is >150 ml/hr, consider changing to 0.45% saline + 5% dextrose but be guided by urinary sodium losses.

6.4.4 Measure serum sodium frequently

6.4.5 If combined urine output is >200ml/hr, consider reducing the dextrose concentration. 

  • Insensible losses will generally be covered by infusions of inotropes, morphine, etc.
  • Document drain losses - only replace, with 0.9% saline or blood, if losses are >4-5 ml/kg/day (discuss with nephrologist or surgeon on-call).

6.4.6 Blood transfusion can result in sensitisation, therefore transfuse only if actively bleeding or Hb <80 g/l and falling, or if there are concerns regarding adequacy of tissue oxygen delivery. Do not administer blood without discussion with nephrologist.

6.4.7 If clinically underfilled (CVP or BP low, large core-peripheral temp gap) Give 5% Albumin or 0.9% Saline at 5-10 ml/kg to keep CVP in the required range 8-10 cmH20. Measure serum albumin 6-8 hourly

6.4.8 If urine output falls to less than 1.5ml/kg/hr

  • Check for a full bladder and flush urinary catheter (and stent if present).
  • Check for hypovolaemia and give 5% albumin or 0.9% saline 5-10ml/kg as appropriate
  • If well-filled then consider iv furosemide (initially 0.1- 0.25mg/kg). Start with a low dose as the response can be dramatic particularly with LD transplants. Discuss with renal consultant prior to first administration

6.5 Polyuria

Large urinary losses of sodium, calcium, magnesium and phosphate can occur with a high urine output. Monitor serum electrolytes closely. Check for glycosuria. SOPs are available for calcium, magnesium, and phosphate replacement.

6.6 Delayed Graft Function

If there is no urine output, mechanical or surgical causes should be discussed and ruled out. If there is no obstruction and no urine output despite adequate hydration and furosemide, then there is likely to be delayed graft function. Fluid replacement at this point should cover insensible losses, any other losses and any urine output that is present.

7. Transfer to ward 3C

Time of transfer to ward 3C will depend on the patient’s clinical condition but ideally should take place during working hours. The patient should be nursed in a cubicle. Patients should have a daily weight, accurate 24 hour fluid balance and 4 hourly blood pressure. Monitor peripheral temperature and aim to keep this at or above 35oC.

7.1 INVESTIGATIONS

On return to the ward, measure FBC, coagulation, U&E, LFTs, bone, glucose, magnesium, CRP, urinalysis and urine culture. Thereafter measure U&E and LFTs 12 hourly or more often if clinically indicated. Check that a renal USS and Doppler has been carried out within the previous 24 hours. Consider handheld USS to assess graft on the ward (if appropriate).

7.2 FLUID AND ELECTROLYTES

Measure urinary sodium losses to guide fluid prescription.

Replace transplant and native urine output ml for ml with either Plasmalyte 140, 0.9% saline + 5% dextrose or 0.45% saline + 5% dextrose on an hourly basis.
Insensible losses will generally be covered by infusions of morphine, antibiotics etc. and do not require a separate infusion.
Document drain losses only replace, with 0.9% saline or blood, if losses are greater than 4-5 ml/kg/day.

If clinically underfilled (BP low, large core-peripheral temp gap) Give 4.5% Albumin or 0.9% Saline at 5-10 ml/kg to maintain intravascular volume. Measure serum albumin and keep within the normal range.

If urine output falls <1.5ml/kg/hr, check for a full bladder and flush urinary catheter and stent. Check for hypovolaemia and give 5% albumin or 0.9% saline 5-10ml/kg as appropriate. If well-filled then consider iv furosemide (initially 0.1 - 0.25 mg/kg). Start with a low dose as the response can be dramatic particularly with LD transplants. Discuss with the consultant nephrologist on-call.

If the urine output is large, urinary losses of sodium, calcium, magnesium and phosphate can occur. Monitor serum electrolytes closely and dip urine for glucose.

If there is delayed graft function with no transplant urine output, mechanical or surgical causes should discussed and ruled out. If there is no obstruction and no urine output despite adequate hydration and furosemide, then there is likely to be delayed graft function. Fluid replacement should cover insensible losses, any other losses and any urine output that is present.

7.3  MEDICATION

For all medication, doses are in Appendix II.

Immunosuppression
The immunosuppression regimen will be documented on HEPMA from pre-transplant and should be reactivated.

Analgesia / Sedation
Most children will have a NCA/PCA in situ and a local TAP block around the wound site. If additional pain relief is required, consult with the pain service. For those not on a PCA, morphine can be given as per appendix II. Close liaison with the pain service is recommended. Avoid non-steroidal analgesics.

Gastroprotection
Prescribe IV esomeprazole until tolerating oral medications, then switch to oral omeprazole.

Antibiotics
Prescribe IV cefotaxime or oral co-trimoxazole. Cefotaxime is usually given for the first 48 hours post-op, then oral co-trimoxazole thereafter. Co-trimoxazole is given for Pneumocystis prophylaxis and can double as urinary prophylaxis for patients at risk for UTI. This is given for 6 months. If urinary prophylaxis is required thereafter, change to an appropriate antibiotic.

CMV Status
If the recipient is CMV negative and the donor CMV positive, then oral valganciclovir is given for at least the first 3 months, and preferably 6. This should be started when the patient is tolerating oral fluids (usually day 1 or 2 post transplant). 

Aspirin
Aspirin should be given as thromboprophylaxis for the first 3 months post transplant. For patients deemed to be at increased risk of clotting low molecular heparin may be used.

8. Daily management on ward 3C

8.1 Daily Investigations

Check U+E, LFTs, Bone, Glu, CRP, Mag and FBC each day. Blood tests should be sent by 0800 so that results are available by midday at the latest.

Check tacrolimus level at 0800 each day initially. For tacrolimus levels send 0.5 ml pink K-EDTA which must be filled accurately. Samples need to reach the lab by 10:00. Assays on public holidays may need to be arranged by communication with the laboratory beforehand. If there has been a dose change, do not check tacrolimus level the following morning unless specifically requested by consultant.

Send daily urine for culture (boric acid container)

Consider daily renal USS if concerns about renal blood flow.

If the creatinine is elevated, it should be repeated (results to be back before 5pm) and the following considered:-

  1. Tacrolimus toxicity
  2. Urinary tract infection
  3. Obstruction to urine outflow
  4. Dehydration
  5. Rejection

Serum levels of phosphate, magnesium and potassium can fall post transplant and should be supplemented when below the normal range (See separate electrolyte replacement SOPs).

8.2 Other tests 

Weekly (Monday)

  • EBV / CMV /BK and adenovirus PCR (3-5 ml blood in EDTA tube to virology at South Sector Microbiology laboratory).
  • Urine protein/creatinine ratio

Post Transplant HLA antibody Monitoring
HLA antibody levels should be measured if there is suspected rejection, when performing a renal biopsy or if there is declining renal function. They should be checked 3 monthly until one year post-transplant and then yearly thereafter. If they need to be processed more urgently then the H&I lab needs to be contacted by phone or by email using ggc.histocompatibilityandimmunogenetics@nhs.scot

8.3 SURGICAL ISSUES 

The following apply to routine (extraperitoneal) procedures. Always check operative notes and discuss with surgeons involved in all cases. The surgical team will review the morning after surgery. As both local paediatric surgeons and the transplant surgeons are involved, decisions may require a discussion. Unless by prior agreement, any deterioration or concern should be passed on to both operating surgeons to ensure a coordinated plan can be made.

In principal:

NG Tube / Gastrostomy

  • If minimal and improving drainage over the first 24hrs with a soft flat abdomen and normal bowel sounds, then spigot the NG tube.
  • Sips to drink initially building up as tolerated
  • If there is any abdominal distension or vomiting, then stop fluids, place NG on free drainage and discuss with surgeons
  • Aim for fluids, light diet and all medication taken orally by 24-48 hours or earlier if tolerated
  • Remove NG tube when tolerating fluids and drugs

Wound Drain

  • If drainage minimal then consider removal at 48-72 hours
  • If drainage volumes change dramatically then discuss with surgeon

Urethral catheter

  • Should remain in situ until days 6-7 (remove after wound drain and external stent if present)

Ureteric Stent

  • These will mainly be internal JJ stents which will be removed surgically after approximately 4-8 weeks. Theatre date to be arranged with the urologist prior to discharge. Often patients will be booked onto beginning of next LD transplant list if possible. Patients may also need lines removed at that time.
  • Occasionally external transplant ureteric stents are used which are usually of small calibre (4-6Fr) and therefore prone to blockage. Flush these 6 hourly with 5ml of 0.9% Sodium Chloride for first 24 hours, or longer, if not draining well. Aim to remove this on day 5.

HD or PD catheters, Internal JJ Stents

  • Where PD or HD catheters remain in situ or an internal (JJ type) stent has been used patients should be booked for removal at about 4-6 weeks. This should be on the elective list of the operating paediatric surgeon or utilising the first hour of the LD transplant Wednesday list. A booking should be made early to ensure patients are not delayed through waiting list pressures.

8.4 RADIOLOGY

  • Renal USS as clinically indicated
  • Use portable handheld Clarius USS (available on Ward 3C) if appropriate
  • Consider USS pre and post catheter removal
  • Consider MAG3 scan if there is concern re graft function or perfusion.

9. Discharge planning

9.1 The discharge planning summary sheet is held within the nursing documentation and should be reviewed to ensure all aspects of transplant care for discharge have been considered.

Before the child is ready for discharge, ensure the following have been completed:

  • Discharge summary to GP and other medical personnel involved in the child’s care. The aim is for this to be received within 2-5 days of discharge. Refer to Discharge Summary Guideline for the information that needs to be included.  Copy the Trakcare IDL onto SERPR, and e-mail a copy (where relevant) to the local paediatrician on day of discharge.
  • Supply of medications including where appropriate either
    • 0.5 and 1.0 mg of Tacrolimus (Prograf®) capsules OR
    • 0.2 and 1.0 mg Tacrolimus (Modigraf®) sachets
  • Renal Medication Information Bookwith up to date medication, and update ALL medications are put on SERPR.
  • Ensure booking confirmed for removal of PD or HD catheters and internal JJ stent.
  • Consider dietary advice, sun protection advice (leaflet available), advice re vaccination etc.
  • Co-trimoxazole should be used for the first 6 months post transplant.
  • Prednisolone reducing schedule if appropriate (Avoid enteric coated prednisolone)
  • Aspirin should be continued for the first 3 months
  • Valganciclovir should be continued for the first 3-6 months (depending on CMV status).

 

9.2 Review after Discharge

The following is a rough guide.

Weeks 1 and 2 Daily
Weeks 3 and 4 Alternate days (but depends upon clinical status)
Weeks 5 and 6 3 times per week
Weeks 7 and 8 Twice weekly
3rd-4th months Weekly
5th month Every 2 weeks
6th-8th months Every 3 weeks
9th month onwards Monthly
  • If rejection episodes occur then visits will need to be more frequent.
  • At each visit, check: weight, BP, bloods, urinalysis +/- urine culture as required.
  • Virology: If EBV, CMV, varicella IgG negative – repeat serology 6 monthly during first year (clotted blood).
  • Virology: If Hep BSAg and Hep C screen negative – repeat serology yearly unless indicated more frequently
  • If creatinine elevated, measure viral PCRs and anti- HLA antibodies

 

9.3 Viral Screening

EBV, CMV, BK, and adenovirus PCR - 3-5 ml EDTA blood sample
0 - 6 months post transplant: - monitor weekly or at each visit if seen less often
6- 12 months: monitor monthly to every 6 weeks
Then only at annual transplant assessment unless there is clinical concern

Clinical concern of BK (polyoma virus) – send urine in a plain universal

10. RHC Renal Transplant Review

Tests Required

 

Routine Review

UE / LFT / Bone / Mag / Glu / CRP / Tacrolimus / FBC (EBV, CMV, BK and adenovirus PCRs if <1 yr post tx)

 

3 monthly

UE / LFT / Bone / Mag / Glu / CRP / Tacrolimus / urate / FBC / PTH, Ur Pro/Cr, Ferritin

(EBV, CMV, BK and adenovirus PCRs and PRA if <1 yr post tx)

6 monthly

UE / LFT / Bone / Mag / Glu / CRP / Tacrolimus / urate / FBC / PTH, Ur Pro/Cr, Ferritin, TG and Cholesterol

CMV IgG if seronegative EBV IgG if seronegative Varicella IgG if seronegative

(EBV, CMV, BK and adenovirus PCRs and PRA if <1 yr post tx)

 

Annual review

UE / LFT / Bone / Mag / Glu / CRP / Tacrolimus / urate / FBC PTH, Ur Pro/Cr, Ferritin

Triglycerides and Cholesterol (no need to fast unless 1st set abnormal) – HDL and LDL

CMV IgG if seronegative

EBV IgG if seronegative

Varicella IgG if seronegative

Hep B and C IgG if seronegative

EBV, CMV, BK and Adenovirus PCRs

Anti-HLA Antibodies

HBA1c

25 OH Vit D level

Cystatin C

Investigations

Renal USS

Review rejection episodes

Review medication -RE, anaemia, renal bone disease

ABPM +/- ECHO

Assess growth, nutrition & bone health

Review education

Review sun awareness

Review sexual health

Dental review

Calculated GFR

This is only a guide. If results are abnormal then they may need to be checked more frequently.

Appendix I: Organ arrival flowchart

Appendix II: Medication including electrolyte supplements

Medication

Dosage

Prednisolone

 

 

Day  0: 600mg/m2 (max 500mg) in theatre prior to the release of vascular clamps as IV Methylprednisolone

Day 1: 60mg/m2 (max 60mg) PO

Day 2: 40mg/m2 PO

Day 3: 30mg/m2 PO

Day 4: 20mg/m2 PO then STOP

Tacrolimus

0.15mg/kg PO BD (max 5mg BD initially) at 08:00 and 20:00

Check pre-dose level at 08:00 but do not wait for result – trough and give

Prescribe brand – Prograf/Modigraf/Adoport

Mycophenolate mofetil (MMF)

600mg/m2 PO BD (max 1g BD) then reduce to

300mg/m2 PO BD from day 14.

Basiliximab

<35kg    10mg each dose IV

≥35kg    20mg each dose IV

Dose 1 on day 0 – made up and administered in ward prior to transfer to theatre

Dose 2 on day 4

Cefotaxime

50mg/kg IV BD (max 1.5g BD) 10:00 & 22:00

Adjust dose for GFR

Esomeprazole

1-11y: 10mg daily IV

12-17y: 20mg daily IV

Change to omeprazole when tolerating oral

Omeprazole

10-20kg: 10mg daily PO

>20kg: 20mg daily PO

Valganciclovir

520mg/m2 PO daily  once tolerating oral

Only if recipient CMV negative, donor CMV positive

Adjust dose for GFR            For 3-6 months post-Tx

Aspirin

 

<25kg 37.5mg PO daily AM

≥25kg 75mg PO daily AM

Continue for 3 months post-Tx

Morphine

Infusion: 20micrograms/kg/hr IV (max weight 50kg)

Bolus: Up to 12y: 100 micrograms/kg every 4 hours

12-18y: 5mg every 4 hours

Co-trimoxazole

12mg/kg PO at night (max 480mg)       

Adjust dose for GFR         For 6 months post-Tx

Tinzaparin

50 units/kg/dose s/c daily

Measure anti-Xa levels 4 hours after 2nd dose

Aim for levels 0.2 – 0.4 (usually)

Additional Notes

Tacrolimus: IV tacrolimus treatment (0.06mg/kg/day continuous infusion) is associated with hypertension - where possible start with oral therapy. Can give NG by opening the capsules and dissolving the contents in at least 10 ml water. Flush with at least 10 ml water and clamp NG tube for 45 - 60 minutes.

 

  • Aim for 12 hour trough levels of:
    1st 2 months
    3 to 6 months
    6 months to 1 year
    After 1 year
    8 - 12 ng/ml
    5 - 10 ng/ml
    4 - 8 ng/ml
    3 - 6 ng/ml
     
  • Trough level measured at 12 One 0.5 ml EDTA is sufficient.
  • Interaction can occur with erythromycin, fluconazole and other imidazoles, Do not administer with grapefruit or cranberry juice.
  • Prescribe as  brand  (Prograf®  /  Modigraf®)  as  other  preparations  are available
  • Modigraf® sachets can be used for those who have difficulty swallowing

MMF: Dose reductions will be needed if there are low platelets, low WCC or low haemoglobin. Available as 250mg capsule and 500mg tablet. Use liquid preparation rather than splitting capsules for doses in between. Side effects can be lessened by splitting the same daily dose tds or qid. If side effects are problematic, drug levels can be measured as an MPA trough.

If used in combination with ciclosporin continue on 600mg/m2 bd after 2 weeks. Ciclosporin interacts with MMF and reduces the AUC.

Basiliximab: An IL-2 receptor blocking antibody used at induction. It is generally well tolerated. Only 2 doses are needed causing IL-2 receptor blockade for up to 4-6 weeks.

The infusion: reconstitute with 5ml of water provided and then further dilute to a volume of 50 ml with 5% Glucose or 0.9% Sodium Chloride. Give over 20-30 minutes.

Electrolyte replacements

Phosphate  Supplement if serum phosphate is below 0.7 mmol/l

*SOP available – use to calculate infusion rate*

infusion:

0.4 mmol/kg           adjust as necessary (See BNFc)

Add 15 mmols Na Phosphate to 50 ml N saline (0.3 mmol/ml) and run at 0.5-3 ml/hr

po:

< 5yrs 2 -3 Phosphate sandoz tablets per day

> 5yrs           4 - 6 Phosphate Sandoz tablets per day

Phosphate Sandoz tablet contains:

Phosphate           16.1 mmol

Na                      20.4 mmol

K                        3.1 mmol

 

Magnesium Supplement if serum Magnesium is below 0.45 mmol/l or patient symptomatic

*SOP available – use to calculate infusion rate*

IV:

1-12yrs: 0.2 mmol/kg Mg++ bd see BNFc

12-18 yrs 4mmol Mg++ bd see BNFc

Magnesium Sulphate 1g equivalent to ~4mmol Mg++

PO:

0.2 mmol/kg initially once daily increasing to 3 times daily if required

One tablet of Magnesium Citrate contains 6 mmol magnesium

Magnaspartate sachets contain 10mmol magnesium per sachet

 

Calcium Supplement if calcium is below 2.00 mmol/l or patient symptomatic

*SOP available – use to calculate infusion rate*

IV:

Calcium gluconate 10% 0.5 ml (0.113 mmol)/kg with ECG monitoring as a slow injection through a central line if possible (max 4.5 mmols)

infusion:

1 mmol/kg/day added to maintenance through central line (max 8.8mmols in 24 hrs)

po:

< 5 yrs             0.25 mmol/kg qid

5-11 yrs           0.2 mmol/kg qid

12-18 yrs         10 mmols qid

Appendix III: CMV post renal transplantation

PROPHYLAXIS

Patients who are CMV seronegative at the time of transplantation, should receive oral valganciclovir after transplantation if the donor is CMV seropositive. Valganciclovir should be started when the patient is tolerating oral fluids and continued for a duration of at least 3 and preferably six months.

Valganciclovir

Note:

The dose needs to be adjusted for renal function. After oral administration valganciclovir is rapidly metabolised to ganciclovir which is renally excreted.

Dose:

All ages for GFR > 80 ml/min/1.73m2

520 mg/m2 po daily to a maximum of 900mg daily. 

All ages for GFR < 80 ml/min/1.73m2

The dose (mg) = 7 x BSA x CrCl (ml/min). Maximum dose is 900mg daily.

Side effects:

leucopenia, thrombocytopenia, anaemia, rash, abnormal LFTs

Monitor CMV infection as required by CMV PCR: send 3-5 ml EDTA blood and urine (plain universal) for CMV PCR.

TREATMENT OF CMV DISEASE

CMV disease is diagnosed by evidence of CMV in the blood by PCR and systemic symptoms: fever, abnormal LFTs, anaemia etc. Treatment is with oral valganciclovir

Valganciclovir

Dose:

All ages for GFR > 80 ml/min/1.73m2

520 mg/m2 po twice daily for a minimum of 14 days (maximum dose 900mg twice daily). 

All ages for GFR < 80 ml/min/1.73m2

The dose (mg) = 7 x BSA x CrCl (ml/min) twice daily for at least 14 days (maximum dose is 900mg daily). 

Side effects:

leucopenia, thrombocytopenia, anaemia, rash, abnormal LFTs

The length of treatment will depend on the severity of the illness.

Longer treatment may be required for gastrointestinal disease

Appendix IV: Pneumocytis Jirovecci prophylaxis

Immunosuppressed patients are at risk of pneumocystis jirovecii pneumonia. This is particularly true for patients receiving augmented immunosuppression. Patients who develop CMV disease are susceptible to PJP.

If clinically indicated send a bronchial alveolar lavage (BAL) to Virology for CMV PCR and to confirm the diagnosis of PJP by direct immunofluorescence and PCR.

Prophylaxis

Co-trimoxazole 12 mg/kg nocte (max. 480 mg) to be given for a minimum of 6 months.

Half normal dose if GFR < 30ml/min/1.73m2.

Can ‘double’ as urinary prophylaxis.

Treatment

Co-trimoxazole

Dose:

60mg/kg bd orally or intravenously for 10-14 days. When given intravenously give diluted via a central line. See BNFc for administration information.

Reduce the dose in renal failure:

15-30 ml/min/1.73m2: Use half normal dose bd

<15 ml/min/1.73m2: Avoid unless receiving haemodialysis, when 50% of the dose can be given.

Side effects:

Rash, agranulocytosis

Appendix V: Thromboprophylaxis

If the patient is deemed to be at increased risk of clotting then low molecular heparin may be used instead of aspirin. This is given as Tinzaparin 50 units/kg daily by subcutaneous injection, starting within 2-4 hours post surgery. An anti-Xa level is measured 4 hours after the second (usually morning) dose.. Remember levels are only measured within working hours, but samples can be spun down and frozen.

Check  an  Anti-Xa  level  at  1000  each  day  (Purple  Sodium  Citrate  tube). Withhold next dose until this result is available.

Aim for Anti-Xa levels of between 0.2 - 0.4 iu/dl. Patients with a pro-coagulant tendency may require a different therapeutic range.

Once patients are ambulant (approx day 5) or as directed by the medical team, tinzaparin can be discontinued and aspirin commenced.

Thromboprophylaxis

Tinzaparin

Subcut:

50units/kg daily subcut– measure anti-Xa level 4 hours after 2nd dose

Aspirin

PO:

<25kg 37.5 mg PO in the morning

>25kg 75 mg PO in the morning Continue for 3 months

 

Appendix VI: Anti Thymocyte Globulin (ATG)

WIG Protocol for Use of ATG ( Rabbit Anti T-lymphocyte Globulin/ Thymoglobuline)

Updated by Heather Black, Renal Pharmacist 6.2.12   Reviewed by Neal Padmanabhan

Uses

Steroid resistant rejection in renal transplant patients. Use of ATG should only be on the instruction of the Consultant looking after the patient.

Supply Dosage

The aim is to suppress absolute CD3 count to <0.05 x109/L  (50,000 cells/ml) for 14 days.  On day 0 a test dose is administered, followed on day 1 by the first full dose of 1.5mg/kg. CD3 counts are monitored daily and further doses of 1.5mg/Kg are administered if the CD3 count is≥0.05 x109/L. Usually 3 doses will be required over a 10-14 day period.  Length of treatment will be decided based on clinical status and laboratory results (approx 10-14 days) and may be suspended if total WCC falls to <2 x109/L, platelet count < 50 x109/L, or if unacceptable side effects intervene. To avoid over-immunosuppression,  tacrolimus dose is reduced to quarter dose and MMF is stopped during treatment.  Cumulative doses between 10.5-21mg/kg may be required. Use ideal weight not actual weight and round the dose to nearest 25mg.

Presentation and Administration

  • Thymoglobuline is presented in vials of 25mg freeze dried purified immunoglobulin + 5ml vial of diluent. The vials should be stored in the fridge.
  • Although not essential, many units give a test dose due to infusion related symptoms including anaphylaxis.
  • Test dose: no test dose is generally required
  • Full dose:
    Premedicate with hydrocortisone 100mg IV and chlorphenamine 10mg IV.
    Reconstitute vials as above.
    Administer in NaCl 0.9%, allowing 50mls for every 25mg vial (total volume 250-500mls).
    Administer via a central line over at least 6 hours (preferably 8-12 hours if infusion related reactions are an issue). Observe the patient checking BP, pulse and temperature frequently during the infusion.

Time after dose

Frequency of observations

0-2hrs

15mins

2-4hrs

30mins

4+ hrs

hourly

Stability

Once reconstituted, the infusion is only stable for a maximum of 24 hours but should be used as soon as possible.

Contraindications

  • Allergy to rabbit protein
  • Acute viral illness
  • Full anaphylactic reaction to test dose

Side Effects

Severe acute infusion associated reactions associated cytokine release and rarely anaphylaxis can occur. Symptoms include headache, fever, arthralgia, rigors and hypotension. Pulmonary oedema may occur in severe cases. Reducing infusion rate and pre med with paracetamol, hydrocortisone and chlorpheniramine can reduce incidence and severity of these reactions.

Caution if platelet count falls <50 or WBC<2- consider interrupting treatment.

Interactions

There is a risk of over-immunosuppression- review tacrolimus/ ciclosporin dose and stop MMF.

Continue co-trimoxazole and valganciclovir prophylaxis for 3 months after treatment with ATG.

Dosing schedule

Drug  
  1 2-7 7-14 14+

ATG

Full

*CD3 Count

*CD3 Count  

Tacrolimus

0.025mg/kg/day as 2 doses

0.025mg/kg/day as 2 doses

0.025mg/kg/day as 2 doses

0.05mg/kg bd

MMF

Stop

Stop

Stop

Full

Prednisolone 

Normal

Normal

Normal

Normal

*CD3 Count 

Daily CD3 count. Further full dose if CD3 Count ≥0.05 x109/L (50,000 cells/ml). No dose if total WCC <2 x109/L or platelet count<50 x109/L.

Tacrolimus/MMF

Reduce Tacrolimus to 0.025mg/Kg as 2 doses until day 14, then increase to 0.05mg/Kg bd (Target level 8-12)

Stop MMF during treatment then reintroduce at full dose  from day 14.

ihttp://www.dh.gov.uk/health/2012/03/sabto/

Appendix VII: Ischemic Pre-conditioning

Introduction

The potential for an ischaemic injury to reduce the impact of a subsequent ischaemic injury has been demonstrated in animal models since the 1990s.  This can occur directly (direct) or following an injury to a different part of the body (remote).   The effect also appears to occur if the ischaemic injury is applied before (pre-), at the same time (per-) or after (post-) the main injury.

A conditioning injury can be caused by inflation of a BP cuff impeding blood flow to the distal end of a limb.  Studies suggest that 3-4 cycles are sufficient to have a conditioning effect.  The exact timing of conditioning and whether it should be applied to donor, recipient or both remains under investigation.

Who it applies to
Paediatric patients due to receive a living related donor transplant
Paediatric patients due to receive a deceased donor transplant where there is sufficient time
Paediatric patients old enough to tolerate the procedure (practically, this has been >5 years)

Equipment required
‘Green light’ sphygmomanometer
Appropriate blood pressure cuff size
Stethoscope

Procedure

On morning of LRD transplant approx 0900 (or 2-3 hours pre-procedure for DD)

  • Check blood pressure with manual (‘green light’) sphyg.
  • Document blood pressure and note systolic
  • Manually inflate cuff to 40mmHg above systolic BP and keep inflated for 5 minutes
  • Deflate cuff and leave for 5 minutes
  • Repeat 3) + 4 above for a total of FOUR inflations and deflations
  • Document completion of procedure and time in notes.

Adverse Effects

Some pins and needles and discomfort in the arm is expected.  Mild bruising over the cuff area is frequently seen. 

Procedure must be completed 1-2 hours before called for theatre.

Appendix VIII: Bedside management of Renal Transplantation (Paediatrics)

Appendix IX: Post-Transplant Medications (PICU Checklist)

Appendix X: Fentanyl NCA/PCA Guidance

IMPORTANT

  • If function post-transplant is not immediate and eGFR remains <10 –fentanyl PCA/NCA  capped at 1ml/hr (=0.5micrograms/kg/hr) and 1ml (0.5micrograms/kg) bolus.

PCA/NCA PRESCRIPTION

  • 25micrograms per kg of FENTANYL made up to 50ml with 0.9% Saline (gives strength of 0.5micrograms/kg/ml) – for children under 50kg

OR

  • 1250micrograms made up to 50ml with 0.9% Saline – for children 50kg and over. 
  • As with other opiate infusions, the prescription bundle should include a prescription for naloxone (respiratory depression and itch doses), oxygen and multi-modal analgesia.
  • Regular clinical review by both pain and nephrology teams, particularly where kidney function is rapidly changing.  Consider both potential for insufficient analgesia where function improving or excessive analgesia where function either deteriorating or not improving as expected'

ADJUVANT PRESCRIPTIONS

  • All patients prescribed PCA/NCA opiates should have at least PRN anti-emetics prescribed.  As per APRS protocol, first line anti-emetic is Ondansetron 0.15milligrams/kg up to 8 hourly. 
  • Oxygen may be prescribed as required
  • Naloxone – as per APRS, recommendations are :
  • If a child on an opiate infusion is excessively sleepy, or with a RR <10 (<20 for infants), the infusion should be stopped and the ward/parent team should be called to review. 
  • As part of the standard ABC assessment of an unwell child, naloxone should be administered.
    • For Severe (life threatening) respiratory depression = 400micrograms
    • For sedation/mild respiratory depression/itch = 1microgram/kg
    • This can be repeated at 5 minute intervals for 5 doses, maximum dose 2mg.  Ideally given IV but can be given IM or SC if these routes are available.  By IM and SC routes, both the dose and the frequency are the same as above. 
    • Consider smaller dosing initially in children at risk of withdrawal, or in children who will continue to need opiates (post-operative care, palliative care, mucositis, sickle cell crisis).

PCA/NCA INITIAL SETTINGS

PCA  Dose Range  Suggested Initial Dose/Dose range
Background 0-0.2ml/hr (0-0.1micrograms/kg/hr) 0ml/hr
Bolus  0.5-2ml (0.25-1micrograms/kg)  1ml (0.5micrograms/kg)
Lockout 5-10mins   5mins

 

NCA Dose Range  Suggested Initial Dose/Dose range
Background 0-1ml/hr (0-0.5micrograms/kg/hr) 1ml/hr (0.5micrograms/kg/hr) 
Bolus  0.5-1ml (0.25-1micrograms/kg)   1ml
Lockout 20-30mins  20mins

                                                                                                            

LOADING DOSE or EXTRA BOLUS (clinician or APRS only)

0.5-2ml (0.25-1micrograms/kg).  Max 1microgram/kg up to 50mcg

 

NURSING CARE AND GUIDANCE

Patients on NCA/PCA Fentanyl should:

  • Be attached with an anti-siphon (non-return) valve
  • Be nursed in a central location within 3C
  • Be centrally monitored, or as a minimum hourly Observations with continuous Saturation monitoring
  • Nursed for their initial post- operative period with a nursing ratio of at least 1:2.  This is already in place both on PICU (day 0 post op for renal transplant patients) and on 3C where they have 1:1 nursing care for 4 days/nights thereafter. 
  • Be reviewed at least daily by the APRS
  • Have syringe changes by APRS (in-hours, 84319) or Anaesthetics on call (84342/3) only

AUTHOR:

Dr Alana Kirkwood, Consultant Paediatric Anaesthetist and Lead for Acute Pain Service, RHC

Correspondence to: alana.kirkwood@ggc.scot.nhs.uk

Editorial Information

Last reviewed: 08/01/2025

Next review date: 31/10/2026

Author(s): Dr B Reynolds.

Version: 2.1.2

Approved By: Renal Transplant Group

Document Id: YOR-REN-037