Hello all -
I can't seem to upload my Word document here (if someone knows how, please let me know!) so here is the protocol I use. I'd rather upload that because it's much easier to read:
SCLS Protocol for Jeffrey Zielinski
Jeffrey is a good judge of his symptoms and is educated about his disease.
Plasma Volume (at 45ml/kg body weight) = 4500ml
DX OF IMPENDING SHOCK OR SHOCK
Elevated BP = impending shock
HCT: usually >50
PULSE: 110-140, persistently. Also decreased UOP, despite approx 1L of PO fluids at home.
Low or absent BP=shock
PULSE: >130 and thready
Initially Jeff may be alert, anxious, may have cold, clammy extremities. He will often complain of arm/leg fatigue, lower lumbar pain, increased nasal congestion and facial/neck fullness. May lead to progressive anxiety, leading to confusion, and livido reticularis (mottling) of his skin in severe leaks only.
1. Establish secure IV lines in EACH arm. Use a #18 or larger angiocath. Secure with armbands and tape.
2. DO NOT use CVP lines unless you suspect volume overload. Otherwise, it is inaccurate.
3. If pt confused and unable to use urinal, place Foley catheter (ask patient first).
4. Obtain blood samples PRIOR to administration of albumin.
- PT/PTT (blue top)
- Electrolytes, BUN, Cr, CPK, LDH, LFT's (red top)
- Venous hematocrit STAT (purple top), first calculated, then manual.
- CBC, albumin level. Albumin will trend downwards during leak; will slowly normalize after administration of albumin.
5. Keep IVF (NS) at 150-200cc/hr ONLY UNTIL ALBUMIN IS AVAILABLE. Excessive fluid administration with saline will lead to muscle engorgement and possible compartment syndrome.
6. Increase rate of IVF (wide open) if pt with SBP <80 only if mental status changes are present and no albumin available.
7. He should be placed on telemetry for his entire length of stay.
SPECIFIC TREATMENT: RE-EXPANSION OF INTRAVASCULAR VOLUME WITH COLLOID OF HIGH ONCOTIC PRESSURE
Initial Phase: Rapid restoration of normal plasma volume
Total Time: approx 2 hrs for total infusion
DO NOT leave patient if pt in shock
1. Re-expand blood volume with albumin only - discontinue saline.
- 2 units (1000 ml total, 1 unit = 500 ml) 5% albumin in one arm
- 4 units (200 ml total, 1 unit = 50 ml) of 25% albumin (SPA) in the other arm.
-The RATE should be approx 1 UNIT/HR for 5% albumin and 2 UNITS/HR for 25% albumin in each arm SIMULTANEOUSLY (approx 500cc/hr into one arm and 100cc/hr into the other arm)
2. Warm IV bottles if possible to prevent hypothermia and chilling from rapid infusion. Albumin can be infused at room temperature.
3. Monitor serial response by SERIAL VENOUS HEMATOCRITS.
- send first post-Rx sample immediately after combined albumin infusion (6 total units).
4. Excessive re-hdyration may lead to pulmonary edema. Follow O2 saturation closely. Jeff has normal EF by ECHO on 12/19/01.
Hematocrit post-treatment therapy recommendations:
If HCT 20-50 then DISCONTINUE ALBUMIN and recheck serial hct, albumin q4hrs and supportive mgmt
IF HCT 50-60, speak to patient about condition, status of his UOP and back pain then recheck HCT ONE HOUR later. If >55, and SBP <90, administer: 1 unit of 5% (500 ml) and 2 units of 25% (100 ml total) over one hour. If <55, may consider following clinically.
IF HCT >60 then repeat initial mgmt: 2 units (1000ml) 5% and 4 units (200ml) 25% in each arm over 2 hrs. Recheck labs as per protocol after combined infusion of albumin.