Adult Induced Hypothermia and/or Rewarming Post Cardiac ...



Post Cardiac Arrest Induced Hypothermia Protocol Orders

Orders preceeded by a “(” must be checked to be initiated.

Orders preceeded by a “(” will be initiated unless deleted by a single line and provider initials.

SICU/MICU Standard infusions to be used for all medications unless specified by order

|Date |Time of Return of Spontaneous Circulation (ROSC) : |

|Admit to |( MICU ( SICU Dr. ___________________________ Service |

|Diagnosis |S/P Cardiac Arrest Other: _________________________________ |

|Consults |Critical Care |

| |Cardiology __________________________________ |

| |Anesthesia __________________________________ |

| |Neurology consult at 48 hr post code_____________________________ |

| |Other: ______________________________________ |

|Invasive Monitoring |Continuous cardiac monitoring |

| |Arterial Line per protocol |

| |Two large bore peripheral lines for 1) NSS volume resuscitation, & 2) NSS KVO/ meds |

| |Temperature sensing urinary catheter to monitor temp |

| |NG/OGT to low continuous suction with Salem Sump tube; interrupt only for med administration per protocol. |

| |Central Line per protocol. CVP goal ___________ mmHg. |

| |Vigileo monitor |

| | |

| |(All fluids used during the cooling and re-warming phases should be dextrose free if possible) |

|Cooling Phase |Goal: reach target of 33o C in 4 hours |

| |If core temp is less than 33 o C, allow patient to warm to 33 o C |

| |Initiate cooling with ice packs to patient’s axilla and groin until cooling blanket in use. |

| |Insert rectal probe. Initiate cooling blanket using auto setting to reach target of 33 o C. Place blankets under and over |

| |patient. Correlate rectal and foley temp to insure accuracy. |

| |Iced Saline Administration: initiate within 5 minutes of ICU arrival: Select one |

|[pic] |No cardiac shock present |

| |Infuse 1500 ml iced NSS (4 o C) IV as fast as possible. |

| |If core temp remains greater than 34.5 o C, infuse an additional 500 ml iced NSS over 10 minutes. Repeat 500 ml infusions of iced|

| |NSS until core temp less than 34.5 o C to a max of 30 ml/kg total. |

| |Cardiac shock/LV failure/low EF |

| |Infuse 1500 ml iced NSS (4 o C) IV over 60 minutes. |

| |If core temp remains greater than 34.5 o C, infuse an additional 500 ml iced NSS over 30 minutes. Repeat 500 ml infusions iced |

| |NSS until core temp less than 34.5 o C to a max of 30 ml/kg total. |

| |If unable to obtain target core temperature within 5 hours, contact provider for further cooling orders. |

| |If patient awakens, discontinue active cooling & contact provider STAT. Begin active re-warming to reach temperature of 37 o C |

| |within 8 hours. |

|Maintenance Phase |Urinary output replacement will take place as designated below: |

| |Replace urine output every hour with NSS (room temp). Titrate to previous hour’s urine output. |

|BP & Volume Management|□ 0.5 ml/1 ml of IVF replacement to urine output |

| |□ 1 ml/ 1 ml of IVF replacement to urine output |

| | |

| |Observe closely for fluid overload. |

| | |

|GOAL: MAP greater than|If MAP remains less than 80 after initial cooling infusion, evaluate urine output. |

|80 mm Hg |If urine output is less than 0.5 ml/kg/hr, contact provider for additional volume replacement |

| |If urine output is greater than 0.5 ml/kg/hr, initiate pressor below to maintain |

|[pic] |MAP greater than 80 |

| |NOREPInephrine (Levophed) IV start at 2 mcg/min. Titrate up to 12 mcg/min. |

| |□ DOPamine (Inotropin) IV start at 2 mcg/kg/min. titrate up to 10 mcg/kg/min. |

| |□ EPINEPHrine (Adrenalin) IV start at 0.01 mcg/kg/min. Titrate up to 0.1 mcg/kg/min. |

| | |

| |For MAP over 100, initiate |

| |NITROglycerin IV start at 5 mcg/min. Titrate to maintain MAP 70 to 100. |

| |Other _____________________________________________________________ |

|Ventilator Management |Settings: |

| |Mode: (SIMV (PRVC (P/S (OTHER _______________ |

| |Vt _________ RR ______ FiO2__________ PEEP _______cm H20 |

| |Continuous ETCO2 monitoring. Maintain ETCO2 at 35 to 45 |

| |O2 Weaning Protocol - maintain O2 sat. greater than 92% |

| |No weaning parameters, vent weaning or wake-ups until core temp is 37˚C. |

| |Follow VAP Bundle otherwise. |

|Analgesia |Use Faces, Numeric Scale or FLACC to assess pain |

| |Goal for analgesia: less than 3 or minimal pain behaviors |

| |FentaNYL (Sublimaze): Bolus with 25 mcg IV. Follow with continuous infusion at 25 mcg/hr. Titrate up to150 mcg/hr. |

|Sedation |Use Richard Agitation-Sedation Scale (RASS) to assess sedation |

|Goal for sedation:|Discontinue after patient is warmer than 36 o C and after NMBA discontinued. |

|RASS (-3). |Propofol (Diprivan): Begin at 10 mcg/kg/min IV. Titrate up to 50 mcg/kg/min for RASS -3. |

| |DEXMEDetomidine (Precedex): Begin at 0.3 mcg/kg/hr IV. Titrate up to 0.7 mcg/kg/hr |

|Prevention of |Use Bedside Shivering Assessment Scale (BSAS) to assess shivering. |

|Shivering |Basic Anti-Shivering Meds (NOT PRN): |

|Goal: BSAS of 0 |BusPIRone (Buspar): 30 mg per NG/OG every 8 hours x 3 doses. Start now. |

| |Acetaminophen (Tylenol): 650 mg per NG/OG every 6 hours x 4 doses. Start now. |

| | |

| |If BSAS is not 0 within 30 minutes after the administration of Acetaminophen and/or Buspirone, consider |

| |□ Meperidine (Demerol): 50 mg IVP every 30 minutes PRN x 2 doses within 24 hrs. For patient with CrCL less than 30, decrease |

| |dose to 25 mg IVP every 30 minutes PRN x 2 doses within 24 hrs. |

| |Consider the use of Midazolam (Versed) if above medications not effective to control shivering. |

| | |

| |If BSAS continues above 0 after the administration of the above meds, |

| |begin a Neuro Muscular Blocking Agent (NMBA). |

| |Before starting, verify that the patient is adequately medicated with analgesia and sedative agents at goal and receiving |

| |mechanical ventilation. |

| |Vecuronium (Norcuron): Bolus with 0.1mg / kg IV. Begin infusion at 1 mcg /kg /min. Titrate to maintain BSAS of 0. |

| |If significant renal or hepatic dysfunction, consider: |

| |Cisatracurium (Nimbex): Bolus with 0.2 mg/kg IV. Begin infusion at 2.5 mg /kg /min. Titrate to BSAS “0”. |

| |Petrolatum ophthalamic ointment (Lacrilube) to each eye every 4 hours while on NMBA |

| | |

| |***Discontinue paralytics after patient is rewarmed to greater than 36 o C |

|DVT Prophylaxis |Sequential compression devices (SCDs) |

| |Anti-embolism stocking: Knee-length |

| |Enoxaparin (Lovenox) 40 mg SC daily (unless on Heparin), start now. |

| |For CrCl less than 30, decrease to 30 mg SC daily, start now. |

|Other Medications |Famotidine (Pepcid) 20 mg IV q12h, start now. |

| |For CrCL less than 50, decrease to 20 mg IV daily, start now. |

| |Call physician if Blood Sugar greater than 150 to obtain insulin protocol orders. |

| |Acetaminophen (Tylenol) 650 mg NG/OG/PR every 4 hours PRN for a temp |

| |greater than 37 o C for total of no more than 4 gm per 24 hrs including doses for shivering. |

|Nursing |Critical care bed with rotational therapy |

| |Daily weight |

| |Diet: NPO |

| |Elevate head of bed 30 degrees when stable |

| |Apply hands free defibrillator pads |

| |Document intake and output monitoring every hour. Contact Provider for urine output less than 0.5 ml/kg/hr despite replacement |

| |volume |

| |Document vital signs and pain every hour and as needed. |

| |Monitor rectal temp, foley temp and water temp closely. Document per protocol: every 15 minutes during cooling until core temp |

| |has been reached, then every 30 minutes. |

| |Document RASS and BSAS every 30 minutes until goal is reached and then every hour. |

| |Perform neuro check using Glasgow Coma scale and document. |

| |Assess skin for breakdown every hour |

| |Do not bathe patient during cooling, maintenance, or warming phase |

|Electrolyte |Hold Electrolytes for Serum Creatinine greater than 2 mg/dl and contact physician |

|Replacement |Send STAT K+ and Mg++ level for any arrhythmia |

| | |

| |Anticipated Re-warming Time _____________ |

| | |

| |POTASSIUM: |

| | |

| |Cooling and Maintenance Phase. DISCONTINUE 8 HRS PRIOR TO REWARMING. |

| |Potassium: Repeat K+ level 1 hour after infusion |

| |K+ less than 3: give 10 mEq KCl/100 ml IVPB over 1 hour x 4 doses |

| |K+ 3-3.5: give 10 mEq KCl/100 ml IVPB over 1 hour x 2 doses |

| |K+ greater than 3.5: repeat K+ in two hours |

| | |

| |8 HOURS PRIOR TO REWARMING, DISCONTINUE ABOVE K+ ORDERS AND BEGIN |

| |ORDERS BELOW: |

| | |

| |Potassium: DO NOT treat 3 or greater within 8 hours PRIOR to warming. |

| |K+ less than 3: give 10 mEq KCl/100 ml IVPB over 1 hour x 2 doses |

| |Repeat K+ level 1 hr after infusion |

| | |

| |MAGNESIUM: Cooling and Maintenance Phase. |

| |DO NOT REPLACE after re-warming has begun. |

| | |

| |Magnesium: Repeat Mg++ level 1 hour after infusion |

| |Mg++ 1.6 to 2: give 1 gram Magnesium Sulfate/50 ml IVPB over 30 min x 1 dose |

| |Mg++ less than 1.6: give 1 gram Magnesium Sulfate /50 ml IVPB over 30 min. x 2 doses |

| | |

| |CALCIUM: Cooling and Maintenance Phase. |

| |DO NOT REPLACE after re-warming has begun. |

| | |

| |Calcium: Repeat Ca++ level 1 hour after infusion |

| |Ca++ less than 7.5 (or ionized Ca less than 1): give 1 gram Calcium Gluconate |

| |IV push over 10 minutes x 1 dose |

|Rewarming Phase |Target Temperature: 36.5 to 37˚C. |

| |Begin re-warming 24 hours from time cooling was started. Rewarm passively to 36.5 o C by changing cooling machine controls to |

| |Manual mode. Increase target temperature 1 o C every 3 hours. |

| |Empty urinary collection device at start of rewarming. Follow strict I&O. |

| |Remove cool packs if present |

| |Monitor temp/VS/ rhythm every 15 minutes until target temp is reached. Then monitor every 30 minutes. |

| |Continue sedation and NMBA until temperature is greater than 36 o C. If on NMBA, discontinue NMBA first. Wait one hour and then |

| |discontinue sedation. |

| |After target temperature is reached, assess for shivering every 30 minutes x 2 then every hour. Contact provider for orders if |

| |shivering persists after re-warming target temperature has been reached. |

| |Do Not permit Hyperthermia for 72 hours after the start of Hypothermia. Treat with Acetaminophen (Tylenol) NG/OG/PR every 4 hours|

| |PRN Temp greater than 37o C. |

| |Remove cooling blanket from under patient after goal temp of 37o C achieved. Continue to use blanket over patient to maintain |

| |temperature at 37o C |

Lab Tests

ICD9 |Test |STAT |Every 4 hrs |Every 8 hrs |At 12 hrs |At 24 hrs |At 37 degrees | | |CXR |( | | | |( | | | |EKG |( | | | | | | | |Bedside glucose unless on IV Insulin Protocol | |( | | | | | | |Potassium, Magnesium | |( | | | | | | |ABG/ionized calcium |( | | |( |( | | | |BMP |( | | |( |( |( | | |CBC with Diff |( | | |( |( |( | | |Hepatic Function Panel: TP, Alb, Bili, Alk phos, ALT, AST | | | | | | | | |Coagulation Profile |( | | | |( |( | | |Lactate |( | | |( |( |( | | |Troponin I |( | |( | | | | | |Blood Cultures x 2 | | | | |( | | | |Amylase, Lipase |( | | | |( | | | |Repeat serum Ca, K, or Mg 1 hr after replacement |( | | | | | | | | Infusion. | | | | | | | | |Stat K and Mg for any arrhythmia |( | | | | | | |Draft 1-5-2011-ddb

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Time Cooling Started:

___________

Alert pharmacy that infusion is to begin

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Please COPY or FAX

to Pharmacy

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