COMMUNITY MEMORIAL HOSPITAL OF VENTURA
COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders Page 1 of 4
|DATE & |Admitting Physician: ________________________________________________________ |
|TIME | |
| |ALLERGIES: _____________________________________________________________ |
| |Goal Temperature: 33°C or 91.4°F as quickly as possible |
| |Maintain patient temperature at 33° C for 24 hrs from the time < 34°C is achieved. |
| |Initial labs: |
| |( CBC ( TPN Panel ( Liver Panel ( PTT/PT ( CPK |
| |( Troponin ( BNP ( ABG ( Art Lactate ( Cortisol level |
| |( BHCG (If female of child bearing age) ( Fibrinogen |
| |( Ca ++ Ionized ( Amylase ( Lipase |
| |Non-Contrast Head CT to R/O Bleed (Pt not a candidate for hypothermia if bleed present) |
| |Apply continuous temperature monitoring: (Required for operation of the cooling machine) |
| |Insert esophageal temperature probe |
| |Insert Urinary/Bladder temperature probe |
| |Set up for cuff or arterial blood pressure monitoring per physician' s orders |
| |VS every 15 minutes, with particular attention to arrhythmia detection until goal temperature obtained, then every 1 hr |
| |Notify Physician if temperature < 32° C (89.6° F) or > 34° C (93.2° F) |
| |Urine output every hour |
| |Assess skin for burns caused by ice/cooling blankets every two hours |
| |Keep Head of Bed (HOB) greater than 30 degrees at all times |
| |Turn off ventilator heating unit |
| |Pain, Shivering, & Sedation (See: Shiver score below; RASS score on pg 2 of orders) |
| |Fentanyl loading dose 50 mcg slow IV push over 2 min |
| |Fentanyl IV Drip (Concentration: 4mcg/ml) titrate from 0.5 to 1.0 mcg/kg/hr to maintain a shivering score ≤ 1 |
| |Midazolam IV Drip (Concentration: 1mg/1ml) titrate from 0.02 to 0.1 mg/kg/hr to maintain a RASS score of -4 (Deep sedation) |
| |Propofol IV Drip Titrate up to 75 mcg/kg/min to maintain a RASS score of -4 (Deep sedation) |
| |Assess for shivering and document hourly |
| |0= no shivering |
| |1= one or more of the following: piloerection, peripheral cyanosis without other cause; without visible muscular activity |
| |2= visible muscular activity confined to one muscle group |
| |3= visible muscular activity in more than one muscle group |
| |4= gross muscular activity involving the entire body |
| |Call physician for a score of 2 or more for greater than 5 minutes despite deep sedation |
| |Continued on page 2 |[pic] |
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| |Date/Time: _____________________________ | |
| |MD Signature: __________________________ | |
| |MD#: _________________________________ | |
COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders Page 2 of 4
|DATE & | |
|TIME | |
| |Richmond Agitation Sedation Scale (RASS) every 1 hr & PRN during sedation &/ or paralysis |
| |Richmond Agitation Sedation Scale (RASS) |
| | |
| |Target |
| |Description |
| | |
| |+ 4 |
| |Combative, violent, danger to staff |
| | |
| |+ 3 |
| |Pulls or removes tube(s) or catheters; aggressive |
| | |
| |+ 2 |
| |Frequent nonpurposeful movement, fights ventilator |
| | |
| |+ 1 |
| |Anxious, apprehensive , but not aggressive |
| | |
| |0 |
| |Alert and calm |
| | |
| |- 1 |
| |Awakens to voice (eye opening/contact) >10 sec |
| | |
| |- 2 |
| |Light sedation, briefly awakens to voice (eye opening/contact) 180) |
| |Initiate Insulin Infusion Protocol for two consecutive blood glucoses > 180 mg/dL |
| |Glucose goal on infusion protocol is 140 mg/dL - 180 mg/dL |
| |Potassium & Magnesium recheck every 4 hr and PRN |
| |Potassium Chloride 40 mEq IV at 20 mEq/hour every 6 hours PRN Hypokalemia < 3.4 |
| |Prior to rewarming, measure serum K+ |
| |Hold all K+ containing fluids if K+ > 3.5 immediately before and during rewarming |
| |Magnesium 2 gm IV PRN Hypomagnesemia levels less than 1.8 |
| |Rewarming Phase |
| |Repeat lab every 6 hours & PRN until temperature ≥ 36.5°C (Begin when target temperature reached): |
| |( CBC ( TPN Panel ( CPK ( Troponin ( ABG |
| |Notify physician when 24 hrs of therapeutic hypothermia is reached (Temp maintained < 34°C) |
| |Rewarming Schedule (No more than 0.5°C/hr until target temperature of 36.5°C): |
| |Minimal Hours |
| |Time |
| |(Round to nearest hr) |
| |Target Temp. |
| | |
| |Begin to 2 hrs |
| | |
| |33.5°C |
| | |
| |2 hrs to 4 hrs |
| | |
| |34°C |
| | |
| |4 hrs to 6 hrs |
| | |
| |34.5°C |
| | |
| |6 hrs to 8 hrs |
| | |
| |35°C |
| | |
| |8 hrs to 10 hrs |
| | |
| |35.5°C |
| | |
| |10 hrs to 12 hrs |
| | |
| |36°C |
| | |
| |12 hrs to 14 hrs |
| | |
| |36.5°C |
| | |
| |Begin = 24 hrs at temp maintained < 34°C |
| |Physician will determine the rewarming times |
| |Recommended rewarming is 0.25 °C/hr |
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| |Continued on page 4 |[pic] |
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| | | |
| |Date/Time: _____________________________ | |
| |MD Signature: __________________________ | |
| |MD#: _________________________________ | |
COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders Page 4 of 4
|DATE & | |
|TIME | |
| |When 24 hours of therapeutic hypothermia have been reached initiate rewarming with the aid of the Blanketrol III |
| |When patient rewarmed to ≥ 36.5°C (97.7° F) thermal blankets can be removed |
| |Turn on ventilator heating unit after the patient reaches ≥ 36.5°C (97.7° F) |
| |Monitor temperature and vital signs every 15 min during rewarming procedure |
| |Stop NMB infusion after core temperature reaches 36° C (96.8° F) |
| |Notify M.D. of temperature > 38°C (100.5° F) |
| |Additional Orders: |
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| |Date/Time: __________________________ | |
| |MD Signature: _______________________ | |
| |MD#: ______________________________ | |
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