Therapeutic Hypothermia Order Set after Cardiac Arrest



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(Circle items and complete check boxes where appropriate.

Strike through any undesired orders.)

Appropriate Exclusion and Inclusion check boxes must be completed prior to start of therapy:

Exclusion Criteria: Do NOT proceed with treatment orders if any of the following criteria are met:

___ Patient is within 72 hours of a major operative procedure

___ Uncontrolled bleeding

___ Shock (mean arterial pressure less than 75 despite interventions)

___ Known sepsis

___ More than12 hrs have elapsed since return of spontaneous circulation

___ Time to return of spontaneous circulation > 60 minutes

___ Not a primary cardiac arrest (ie., not ventricular tachycardia, ventricular fibrillation, asystole, or pulseless electrical activity)

___ Glasgow Coma Scale motor score greater than 5 (patient follows verbal commands)

___ Minimal pre-morbid cognitive state

___ DNAR level B or C

___ Temperature less than 32° C after arrest

Inclusion Criteria: Both criteria must be met:

___ Return of spontaneous circulation for at least 30 minutes since cardiac arrest

___ Patient is on mechanical ventilation

|Baseline procedures and |1. Consult (circle one): interventional radiology surgery critical care anesthesia for A-line placement |

|consults |2. Consult (circle one): interventional radiology surgery critical care anesthesia for central line placement |

|(Arterial line must be |3. Place temperature-sensing Foley to monitor temperature unless some contraindication |

|placed before the patient |4. If Foley not used for temperature sensing, place temperature-sensing esophageal probe for this purpose |

|is cooled) |5. Consult neurology |

| |6. Obtain baseline EEG as soon as possible upon transfer to the ICU |

|Vital signs |7. Transduce and record temperature every 15 minutes until 32°-34° C is achieved, then every 30 minutes |

| |8. Monitor other vital signs per ICU routine |

| |9. Monitor CVP every 2 hours |

|Sedation and Neuromuscular|10. Midazolam 0.1 mg per kg per hr or _____ rate; titrate up for unexplained tachycardia |

|blockade |11. Fentanyl 1.5 mcg per kg per hr or _____ rate |

| |12. Other sedation or analgesia (specify):___________________________________________________ |

| |13. Meperidine every 2 hrs prn shivering to a maximum of 2 doses (circle one below): |

| |a. 25-50 mg if normal renal function |

| |b. 12.5-25 mg if creatinine clearance is less than 30 ml per minute |

| |14. If shivering persists 30 minutes after meperidine dose: start cisatracurium 0.2 mg per kg IV bolus, followed by |

| |1 mcg per kg per minute continuous infusion (NOTE: cisatracurium cannot be started until patient has received |

| |more than 15 minutes of continuous IV sedation) |

| |a. Titrate cisatracurium to abolish shivering (maximum dose 3 mcg per kg per minute) |

| |b. keep train-of-four more than 0 |

|Cooling Phase |Goal is to achieve core temperature of 32°-34° C within 4 hrs of arrest |

| |15. If core temperature is more than 34° C at start of protocol: |

| |a. Infuse 2 liters of refrigerated 0.9% NS over 30 minutes if no evidence of pulmonary edema, then |

| |call MD for further fluid orders. |

| |b. Place ice packs around neck, in axillary areas, and in groin |

| |16. Set Gaymar machine on automatic rapid mode with set point 33° C. Remove ice packs when target temperature |

| |is achieved |

| |17. If unable to achieve target core temperature within 4 hrs, call MD for further orders |

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(Circle items and complete check boxes where appropriate.

Strike through any undesired orders.)

|Usual Hemodynamic Goals: |18. If CVP is less than 8 or _____, administer 500 mL 0.9% NS bolus, may repeat one time, then call MD |

|mean arterial pressure more |19. If mean arterial pressure is less than 75 or _____, select one: |

|than 75 and less than 120, |a. ____ dopamine continuous IV infusion: start at 3 mcg per kg per minute and titrate to |

|and CVP more than 8 |maximum of 20 mcg per kg per minute |

| |b. ____ norepinephrine continuous IV infusion: start at 2 mcg per minute and titrate to |

| |maximum of 30 mcg per minute |

| |Other:___________________________________________________ |

| |20. If mean arterial pressure is more than 120 or _____, select one: |

| |a. IV nitroprusside 0.3 mcg per kg per minute, increase at 5 minute intervals to maximum of 10 |

| |mcg per kg per minute (avoid in renal failure) |

| |b. IV nicardipine 5 mg per hr, increase at 5 minute intervals to maximum of 15 mg per hr |

| |(preferred in renal failure) |

|Laboratory Studies |21. At admission to ICU (if not sent at code): |

| |a. CBC, coagulation profile, BMP, ABG, lactate, troponin, phosphorous, magnesium |

| |b. Repeat ABG 10 minutes after paralysis achieved (if applicable) |

| |c. EKG |

| |d. CXR |

| |22. Follow-up studies (until patient completes the re-warming process): |

| |a. Every 4 hours: ABG, BMP, lactate, magnesium, phosphorous (or as dictated by |

| |electrolyte replacement schedule – see below) |

| |b. Every 8 hours: CBC, coagulation profile, EKG (two times only), troponin (two times only) |

| |c. Obtain 2 sets of blood cultures (each from a distinct site if possible) 12 hrs after initiation of |

| |hypothermia |

|Electrolyte replacement |Check all that apply (recommend custom electrolyte orders in renal failure patients): |

|schedule |23. ____Administer magnesium sulfate on arrival to ICU as follows: |

| |a. ____ less than 60 kg: 2 gm per 50 mL over 15-30 minutes, repeat once in 1 hr |

| |b. ____ more than or equal to 60 kg: 2 gm per 50 mL over 15-30 minutes, repeat twice at 1 hr intervals |

| |24. ____Two hrs after completing initial magnesium replacement, obtain magnesium level. If magnesium is |

| |less than 2 mg per dl: |

| |a. Give magnesium sulfate 2 gm IV in 100 ml NS over 1 hr |

| |b. Repeat magnesium level 2 hrs after replacement is completed |

| |c. Repeat IV magnesium sulfate replacement and serum magnesium levels every 2 hrs until magnesium |

| |is more than or equal to 2 mg per dl |

| |25. ____If K is less than 3.2 mEq per L: |

| |a. give KCl 20 mEq IV in 100 ml sterile water (premix) over 1 hour |

| |b. repeat K level 2 hrs after replacement is completed |

| |c. repeat IV KCl replacement and K levels every 2 hrs until K is greater than or equal to 3.2 mEq per L |

| |26. ____If phosphorous is less than 2.5 mg per dl: |

| |a. Give sodium phosphate 20 mEq IV in 250 ml NS over 4 hrs |

| |b. Repeat phosphorous level 2 hrs after replacement is completed |

| |c. Repeat IV sodium phosphate replacement and phosphorous levels every 2 hrs until phosphorous is |

| |more than or equal to 2.5 mg per dl |

| |27. Discontinue all potassium-containing solutions 6 hrs prior to warming |

| |28. ____Customized electrolyte replacement orders (recommended for renal failure): |

| |__________________________________________________ |

| |b. __________________________________________________ |

| |c. __________________________________________________ |

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(Circle items and complete check boxes where appropriate.

Strike through any undesired orders.)

|Nursing Care |29. Do not bathe patient during hypothermic or rewarming period |

| |30. No subcutaneous medications other than prophylactic anticoagulants during protocol, until rewarmed |

| |31. Maximum enteral tube feed rate is 10 ml per hr |

|Glucose Control |32. ICU glycemic protocol (use intravenous insulin only, not subcutaneous sliding scale) |

|Re-Warming Phase - to begin 24 |Goal is to achieve core temperature of 36.1°-37° C within 6-10 hrs of re-warming start time |

|hrs after goal hypothermia |33. Empty Foley at start of re-warming |

|temperature is reached |34. Set Gaymar machine on automatic moderate mode with set point 36.1° C |

| |35. If external cooling devices still in place, remove cool packs, wet linens, cooling blanket |

| |36. Stop re-warming once temperature is 36.1° C |

| |37. Discontinue cisatracurium once temperature reaches 35° C |

| |38. If shivering occurs after neuromuscular blockade has been discontinued, administer meperidine |

| |(see #13 above) |

| |39. Obtain repeat EEG as soon as possible after rewarming commenced |

|After target temperature of 36.1°|40. Monitor temperature every hour for 12 hours, then per ICU routine |

|C is reached |a. Acetaminophen 650 mg pr every 4 hrs prn temperature greater than 37° C |

|(do not allow temperature to |b. Use cooling blankets prn temperature greater than 37° C |

|exceed 37° C for the next 48 hrs)|41. Titrate midazolam to Ramsay score of 3 or _____ |

|Co-ordination with Standardized |42. For any orders that conflict between this protocol and the standardized ICU order set, these orders take |

|ICU Order Set |precedence |

| |43. If therapeutic anticoagulation is necessary, the anticoagulant dose should be decreased by 50% with further |

| |adjustments based on PT/PTT monitoring |

| |44. During therapeutic hypothermia, do not use the standardized electrolyte replacement schedule found in the |

| |ICU order set |

| |45. This protocol is concluded once normothermia is maintained for 48 hrs after target temperature achieved |

For any protocol questions: contact ICU attending for clarification

Physician signature: ______________________________________ Date and time: _____________________

Physician name (print): ____________________________________

Checked by (nurse): ______________________________________

Transcribed by: __________________________________________

Approved: (date to be entered)

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Addressograph only

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