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PLACE LABEL HERE ICD / PERMANENT PACEMAKER PRE-IMPLANTATION ORDERS The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modification and the bottom of each page indicated (multipage). 1. Diagnosis: ___________________________________________________________________________________ 2. Procedure scheduled Date: ________________ Procedure: Implantable Cardioverter/Defibrillator Device (ICD) Pacemaker BiVentricular Device Site of implant: RT Chest LT Chest 3. Diagnostics day of procedure: Chem 7 CBC PT/INR PTT Anti Xa (Heparin Level) ECG 12 lead, Reason: ______________ Group to Read: ____________ Chest X-ray, Reason: ________________ Quantitative hCG for any menustrating female ≥ 12 years of age 4. Insert 20 gauge or larger INT on side of implant 5. Instruct patient to shower using an antibacterial soap the night before and the morning of the procedure 6. Clip chest from neck to nipple line and bed line to bed line 7. Diet: Confirm NPO status after midnight (outpatient from home) NPO after midnight except medications OR NPO after clear liquid breakfast 8. Patient to void on call to cath lab 9. Pre-procedure antibiotic Ancef (cefazolin) 2 gm (or 3 gm if weight > 120 kg) IV over 20 min x 1 dose, immediately prior to procedure OR REQUIRED: Rationale for using Vancomycin as an antimicrobial prophylaxis History of MRSA/positive screen Betalactam Allergy (allergy to penicillin and cephalosporins) Vancomycin, immediately prior to procedure patient weight ________ kg If patient weight < 90 kg, 1 gm IV x 1 dose (infuse over 1 hr) If patient weight ≥ 90 kg, 1.5 gm IV x 1 dose (infuse over 90 mins) ADDITIONAL ORDERS: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________ Date __________ Time ____________________________ Physician Signature ___________ PID Number Copy to pharmacy *1-8211* FORM 1-8211 REV. 10/2015 Page 1 of 1