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 |

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| |36°C |

| | |

| |12 hrs to 14 hrs |

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| |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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