PRETREATMENT

1. Fluid resuscitate to predefined endpoints (CVP > 7, SBP > 100)2. Give blood to achieve an H&H above 10 and 303. Correct electrolyte imbalances

PREREQUISITE

Patient is requiring a combined vasopressor need greater than 15 mcg (all VP added) to maintain a systolic pressure of 100 after the pre-treatment is completed or becomes hemodynamically unstable.

T-4 PROTOCOL

- Administer IV boluses of the following in rapid succession:
  - 1 Amp of 50% Dextrose
  - 2 gm of Solumedrol
  - 20 units regular insulin
  - 20 mcg Thyroxin (T-4)
- Start a drip of 200 mcg T-4 in 500cc Normal Saline (0.4mcg/cc). Administer at 25cc (10mcg) per hour initially. Reduce levels of other vasopressors as much as possible and then adjust T-4 as necessary to maintain desired pressure.
  - Donors > 100 lbs give above dose
  - Donors 50-75 lbs. give 13cc = 5.2 mcg/hr
  - Donors 75-100 lbs. give 19cc = 7.6 mcg/hr
- After 30 to 60 minutes, patients may become tachycardic with an increase in temperature and blood pressure.
- Monitor K+ levels carefully. The only perceived complication of T-4 identified to this point is an unusually high K+ requirement in some cases.