DOCTOR’S ORDERS



ICU/CCU Adult Therapeutic Hypothermia Order Set |

Patient Label | |

|Drug Allergies: | Ht. ________ Wt. _______Kg. |

|Living Will: |( Yes ( No | |Durable Healthcare Power of Attorney: |( Yes ( No | | |

|Code Status: |( Full Code | |( Do Not Resuscitate (Tan Chart Required) | | |

|Limited Code to include: |( CPR |( Intubation |( Defibrillation |( Cardiac Drugs |( Pacemaker |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

| |Diagnosis: | |

| |Inclusion and exclusion criteria are to serve as a guide for decision-making. | |

| |Inclusion Criteria: (requires all four components) | |

| |1. Nontraumatic cardiac arrest with return of spontaneous circulation (ROSC) | |

| |2. Core Temperature greater than 34º Celsius (94º F) at presentation. | |

| |3. Time to initiation of hypothermia is less than 6 hours from ROSC | |

| |4. Comatose after ROSC: GCS less than 8 AND No purposeful movement to pain | |

| |Exclusion Criteria: (any one of the following) | |

| |1. Conflict with advanced directives DNR/DNI status | |

| |2. Uncontrolled Gastrointestinal Bleeding | |

| |3. Patient requiring Mannitol therapy | |

| |4. Cardiovascular instability as evidenced by: uncontrollable arrhythmias, refractory | |

| |hypotension (unable to achieve target MAP 65 mmHg despite interventions) | |

| |5. Sepsis as suspected cause of cardiac arrest | |

| |6. Suspected intracranial hemorrhage | |

| |7. Major intracranial, intrathoracic, or intraabdominal surgery within 14 days | |

| |8. Gravid pregnancy | |

| | | |

| |( Admit to ICU/CCU | |

| |Attending Physician responsible for hypothermia _____________________________ | |

| |Time of Arrest:___________________________________________ | |

| |Time of Return of Spontaneous Circulation:____________________ | |

| |Time Cooling Initiated: ____________________________________ | |

| |Time Target Temperature Obtained: _________________________ | |

| |( Begin 24 hour cooling phase once target temperature obtained) | |

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| |Consult: | |

| |( Pulmonary consult:_____________________________________________ | |

| |( Cardiology consult: _____________________________________________ | |

| |( ________________________________________ for arterial line placement | |

| |( _______________________________ for Hypothermia Catheter Placement | |

| |_______________________________service for addition central venous catheter or PA catheter as needed | |

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|*2PO* |Physician’s Signature |

|*2PO* | |

| | |Form No. P9900 (03/09) Medical Services Page 1 of 6|

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|ICU/CCU Adult Therapeutic Hypothermia Order Set | |

| |Patient Label |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

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| |Patient Care Orders: | |

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| |1. Initiate endovascular hypothermia system (preferred method) and cool for 24 hours | |

| |once target temperature has been obtained, set machine to 33 º Celsius (91º F). | |

| |2. If unable to use hypothermia catheter, initiate passive /active cooling methods. | |

| |3. No heated humidification on the ventilator. | |

| |4. Maintain PO2 90-100 millimeters Mercury and normal pH range. | |

| |(must be temperature corrected) | |

| |5. Notify Physician of any of the following: | |

| |A. MAP less than 60 despite use of vasopressors | |

| |B. Urine output greater than 300 milliliters per hour or less than 30 milliliters per hour | |

| |for two consecutive hours. | |

| |C. Temperature greater than 35º Celsius (95º F) during maintenance phase despite | |

| |implementation of all ordered interventions. | |

| |D. If patient has recurring arrhythmias, discontinue active cooling, begin re-warming | |

| |and call MD. | |

| |6. Maintain hypothermia for 24 hours once target temperature of 33º Celsius (91º F) has been obtained. | |

| |A. Temperature goal 33º Celsius (91º F). | |

| |B. Monitor primary continuous temperature with the Foley bladder probe | |

| |C. Obtain a secondary temperature source (Rectal or Esophageal or PA Catheter) at least every 2 hours to ensure accuracy of primary | |

| |temperature source. | |

| |7. Do NOT bathe patient during hypothermic or re-warming period. | |

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| |***** If Endovascular Cooling Catheter can not be obtained, the following cooling techniques will be implemented: ***** | |

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| |Passive Convective Cooling – check appropriate boxes | |

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| |( Expose patient, dampen skin, cooling fan | |

| |( Cooling blanket set to 33º Celsius (91º F) | |

| |( Reduce temperature in patient’s room | |

| |( Ice packs applied to axilla / skin | |

| |( Naso-Gastric lavage with ice cold 0.9% Normal Saline repeat as needed | |

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| |Physician’s Signature/Date/Time: |

| | |Form No. P9900 (03/09) Medical Services Page 2 of 6 |

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|ICU/CCU Adult Therapeutic Hypothermia Order Set |Patient Label |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

| |Labs: | |

| |Labs to be drawn NOW: | |

| |( Complete Blood Count (CBC), PT/PTT, INR ABG’s (temp corrected) | |

| |( Complete metabolic profile (CMP) | |

| |Creatine phosphokinase (CPK), Troponin I, Creatine Kinase Myocardial Bands (CK- MB) | |

| |Progressive Urinalysis | |

| |Lactate | |

| |MRSA Nasal Swab | |

| |HCG if child bearing age female | |

| |Labs to be drawn every 6 hours x 24 hours: | |

| |( CMP, ABG’s (temp corrected), CBC, PT/PTT, Phosphorus | |

| |( CPK, Troponin I, CK-MB | |

| |Labs to be drawn 12 hours post arrest: | |

| |( Blood cultures X 2 | |

| |Daily Diagnostic Testing: | |

| |( BMP | |

| |( CBC | |

| |( ABG’s | |

| |( PCXR (while intubated) | |

| |EKG | |

| | | |

| |Patient Care – Induction Phase: | |

| |( Administer sedation prior to initiation of neuromuscular blocking agents | |

| |( Obtain baseline data with Peripheral Nerve Stimulator prior to initiation of neuromuscular blocking agents and sedatives (Peripheral | |

| |Nerve Stimulator baseline will be acquired using Train of Four) | |

| |( Baseline goal of Train of Four is 4 out of 4 twitches (not to exceed 40-50 milliamps) | |

| |( Train of Four will be performed every 15 minutes during initiation and titration of neuromuscular blocking agent until goal of 2 out of | |

| |4 twitches is achieved (do not exceed 40-50 Milliamps) | |

| |( Once goal of 2 out of 4 twitches is achieved, Train of Four will be performed every 2 hours during paralytic infusion | |

| |( Insert Naso-Gastric Tube or Oral-Gastric Tube and connect to intermittent low wall suction if not done in ED | |

| |( Follow Continuous IV Insulin Infusion Orders (Bayhealth Form P8728) | |

| |( Check Arterial Blood Gases (ABG) baseline and repeat at 33º Celsius (91º F). | |

| |***Be sure that all ABG results are temperature corrected*** | |

| |( Hemoccult stool daily | |

| |( Monitor neurological status per Critical Care protocol. Notify physician for shivering myoclonus or seizure activity | |

| |Physician’s Signature/Date/Time: |

| | |Form No. P9900 (03/09) Medical Services Page 3 of 6 |

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| |Patient Label |

|ICU/CCU Adult Therapeutic Hypothermia Order Set | |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

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| |MEDICATION ORDERS: | |

| |Patient’s total body weight: ________ Kilograms | |

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| |Sedation/Narcotics: | |

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| |Administer the following medications prior to initiation of cooling: | |

| |Administer sedation prior to initiation of neuromuscular blocking agents | |

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| |( 1. Fentanyl ________ micrograms per hour intravenous continuous infusion (suggested initial rate: 2 micrograms per kilogram per hour-| |

| |not to exceed 150 micrograms in an hour) | |

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| |( 2. Fentanyl _________ micrograms intravenously PRN every 4 hours for agitation or breakthrough pain (suggested: 25 – 50 micrograms) | |

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| |( 3. Propofol___________ micrograms per kilogram per minute continuous intravenous infusion while receiving chemical paralysis (suggested | |

| |initial rate: 5 micrograms per kilogram per minute). Increase rate in 5 – 10 microgram per kilogram per minute increments every 5 minutes | |

| |until goal Ramsey Sedation Scale less than 3 achieved | |

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| |( 4. Vecuronium Bolus: 0.1 milligrams per kilogram intravenous bolus | |

| |Continuous Infusion: Start continuous infusion 20-40 minutes after initial bolus dose at 1 microgram per kilogram per minute | |

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| |5. Vecuronium 0.1 milligrams per kilogram intravenously every 1 hour as needed for shivering | |

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| |Vasopressors: | |

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| |( 6. Norepinephrine (Levophed) IV-start at 0.5 micrograms per minute and titrate as needed to keep MAP greater than 65 | |

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| |( 7. Other pressor agent: ______________________________________________ | |

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| |Vasodilators: | |

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| |( 8. Nitroglycerin IV-start if systolic blood pressure over ____________________ | |

| |Start at 5 micrograms per minute and titrate until systolic blood pressure is less than _____________ | |

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| |Intravenous Fluids: | |

| |( 9. Infuse 2 liters of 4º Celsius (39.2º F) of 0.9% normal saline solution IV over 30 minutes if not already administered in ED. | |

| |( 10. Maintenance IV of 0.9% normal sodium chloride at _____________ milliliters per hour | |

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| |Physician’s Signature/Date/Time: |

| | |Form No. P9900 (03/09) Medical Services Page 4 of 6 |

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|ICU/CCU Adult Therapeutic Hypothermia Order Set | |

| |Patient Label |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

| | | |

| |Other Medications: | |

| | | |

| |( 11. Pantoprazole 40 milligrams intravenously daily | |

| |( 12. Ophthalmic lubricant oint to both eyes every four hours and as needed while on neuromuscular blocking agents | |

| |*** Do not replace potassium during the Cooling Phase unless it is less than 3.5 mEq/L.*** | |

| |Call MD for specific replacement dose | |

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| |*** All intravenous solutions should be Dextrose free during cooling and re-warming phase*** | |

| |***** Do not administer any medication to the hypothermic patient if medication is labeled “Do not refrigerate.”**** (Example: Mannitol) | |

| | | |

| |DVT Prophylaxis Choose one of the following: | |

| |( 1. Sequential compression devices (SCD) | |

| |( 2. Enoxaparin 40 milligrams subcutaneously every day | |

| |( 3. Enoxaparin 30 milligrams subcutaneously every day for creatinine clearance less than 30 | |

| |( 4. Heparin 5000 units subcutaneously every 8 hours | |

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| |Blood Glucose Control: | |

| |( Blood Sugar to be regulated as per Continuous IV Insulin Infusion Orders | |

| |(See Bayhealth form P8728) | |

| |( Continue Insulin drip until patient is able to eat | |

| |Consult Physician for new glucose management orders | |

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| |Patient Care – Re-warming Phase: | |

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| |( 24 hours following achievement of target temperature, initiate re-warming | |

| |( Time re-warming started:________________________________________________________ | |

| |( Time target temperature of 36.1º Celsius (96.9 º F) met: __________________ | |

| |( Notify physician of Central Venous Pressure (CVP) less than 4 | |

| |( Empty Foley at start of re-warming. Strict I&O | |

| |( Continue sedation, analgesics and neuromuscular blocking agents until temperature is equal to or greater than 36.1º Celsius (96.9º F) | |

| |(discontinue neuromuscular blocking agents first, then wean sedation and analgesic infusions) | |

| |( Acetaminophen 650mg via NGT or rectally every 4 hours PRN, if temperature spikes greater than 37 º Celsius (98.6ºF) during re-warming | |

| |phase | |

| |( Do not permit hyperthermia (37º Celsius/98.6º F) in the first 24 hours after cooling phase | |

| |( Remove femoral line when patient has been 36.1º Celsius (96.9º F) for 48 hours | |

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| |Physician’s Signature/Date/Time: |

| | |Form No. P9900 (03/09) Medical Services Page 5 of 6 |

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| |Patient Label |

|ICU/CCU Adult Therapeutic Hypothermia Order Set | |

|DATE/TIME |ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated. |Noted by |

| | |Date/Time |

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| |Endovascular Temperature Management System Re-Warming: | |

| |Activate re-warming program on the machine for 0.5 º Celsius / hour for target temperature of 36.1º Celsius (96.9º F) | |

| |May place warm blankets (Do not use Bair Hugger) | |

| |Target temperature - 36.1-37º Celsius (96.9-98.6º F) to be obtained in 6-8 hours; STOP re-warming once 36.1º Celsius (96.9º F) is reached | |

| |to prevent overshoot | |

| |Maintain the machine at 36.1º Celsius (96.9º F) for 18 hours once target temperature has been achieved | |

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| |Passive Cooling Therapeutic Hypothermia Re-Warming: | |

| |Remove Cooling Blanket and cover patient with dry sheets | |

| |Resume passive cooling methods if temperature increases more than 1º Celsius per hour or exceeds 37º Celsius (98.6º F) | |

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| |Labs: | |

| |( BMP, ABG’s, Lactate every 6 hours until temperature 36.1º Celsius (96.9º F) | |

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| |Medications: | |

| |( Meperidine (Demerol) 12.5 milligrams intravenous may repeat in 5 minutes times one dose for shivering during re-warming phase only | |

| |**** If above methods are ineffective call physician for further orders (may need to restart neuromuscular blocking agents and sedation)***| |

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| |Potassium Replacement to be used ONLY in Re-warming Phase: | |

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| |( If at start of re-warming phase, serum Potassium level is 3.5mEq/L or below, give Potassium Chloride 10 mEq’s in 100 milliliters sterile| |

| |water IVPB through central line | |

| |over 1 hour | |

| |Obtain serum Potassium level 1 hour post infusion of each Potassium piggyback. If serum Potassium level is 3.5 mEq/L or below, repeat | |

| |infusion of Potassium 10 mEq’s IVPB until it reaches 3.6 or above. Serum Potassium level must be checked after each Potassium piggyback | |

| |administration. | |

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| |**Potassium replacement will only be used during re-warming phase as needed** | |

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| |Physician’s Signature/Date/Time: |

| | |Form No. P9900 (03/09) Medical Services Page 6 of 6 |

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