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Albert Einstein Healthcare Network
Physician’s Orders
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Date/Time
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Physician order sheet: Therapeutic Hypothermia Post Cardiac Arrest
1. Initiate Clinical Practice Guideline (CPG): Induced Hypothermia Post Cardiac Arrest
2. Pregnancy test for all women of childbearing age. If positive pregnancy test, consult perinatology.
A positive pregnancy test should not impede initiation of therapy.
Pregnancy test (HCG) blood STAT (all Intensive Care Units and Cath lab)
Pregnancy test (HCG) urine (in Emergency Department only)
3. Verify admission weight for drug dosing: ________kg
4. Prior to cooling, Sedative, Analgesia and Neuromuscular Blocking Agent must be started as clinically appropriate.
(Desired level of sedation is non-applicable secondary to neuromuscular blocking agent. No drug holiday during 24 hour cooling)

Initiate bispectral index monitoring as quickly as possible for patients receiving
sedation/analgesia alone as well as patients receiving sedation/analgesia with
neuromuscular blockade.

Titrate sedation/analgesia to maintain BIS value between 50 and 60 on linear scale.
If BIS value sustained above 60 for greater than 15 minutes re-bolus with sedative agent
at dose equal to infusion rate. If BIS value remains greater than 60, administer
additional bolus and increase infusion rate.
A) Sedation infusion management: Utilize sedation/analgesia order sheet.
B) For propofol utilization as sedative agent: Utilize propofol infusion order set.
C) Analgesia infusion management: Utilize sedation/analgesia order sheet.
D) Neuromuscular Blockade: Utilize neuromuscular blockade order sheet.
Neuromuscular Blocking Agent must not be initiated without Sedation and Analgesia.
5. Insert Foley with temperature probe or esophageal temperature probe
for continuous monitoring of core temperature.
6. Iced normal saline infusion:
A). Infuse 4ºC Normal Saline over 30 minutes. (2 large bore IVs or Central Line recommended)
If patient admission weight greater than 60 kg, infuse 2 liters (2000 mL) of normal saline
B). If patient admission weight less than or equal to 60 kg, infuse 1.5 liters (1500 mL) of
normal saline.
7. External conductive cooling device:
A). Initiate external cooling measures.
B). Place cooling device surface pads on patient and set machine temperature to 4ºC.
C). Therapeutic hypothermia goal is core temperature of: 32-34ºC
D). Remove cooling device if patient temperature drops less than 32°C until temperature returns to 33°C
E. Notify physician if target patient temperature of 32-34°C has not been achieved within 2 hours of
initiation of cooling measures
8. Temperature documentation
A). Every 30 minutes during initial cooling and then every hour
B). Every hour during passive rewarming until patient temperature reaches 36°C
9. Passive Rewarming
A). Discontinue Induced Hypothermia Post Cardiac Arrest Order Set 24 hours after initial placement of
patient on cooling device in the following sequence;
B). Discontinue Cooling device and neuromuscular blocking agent.
C). Notify the physician and obtain order for external warmer (e.g. Bair hugger) if patient temperature
less than 36°C after 12 hours of passive rewarming
10 Neurological evaluation:
A) Allow recovery of neuromuscular function as documented by recovery of skeletal muscle
movement (movement of extremities, reflex movements such as cough, gad reflexes) and return to
baseline train-of-four as measured by peripheral nerve stimulator and assessment of evoked response.
B. As clinically indicated, wean off sedation/analgesia for optimal neurological assessment.
C. Diagnostic EEG
D. Neurology consultation.
11. If sedation and analgesia still indicated utilize sedation/analgesia order sheet, titrate therapy to
appropriate clinical goals using Sedation/Agitation Scale.
12. Laboratory studies:
At initiation of hypothermia:
Type and screen for blood products.
CBC/platelets/PT/PTT
Serum electrolytes, magnesium and phosphorus.
CPK-MB
Troponin
Lactate
Fibrinogen
D-Dimer
Arterial Blood Gases (Notify respiratory of patient temperature)
At 6 hours following initiation of cooling:
CPK-MB
Troponin
Serum electrolytes, magnesium and phosphorus.
Arterial Blood Gases (Notify respiratory of patient temperature)
At 12 hours following initiation of cooling:
CPK-MB
Troponin
Serum electrolytes, magnesium and phosphorus
CBC
Arterial Blood Gases (Notify respiratory of patient temperature).
At 18 hours following initiation of cooling:
CPK-MB
Troponin
Serum electrolytes, magnesium and phosphorus.
ABG (Notify respiratory of patient temperature)
At 24 hours following initiation of cooling:
CBC/Platelets/PT/PTT
Serum electrolytes, magnesium and phosphorus.
Serum phosphorus
Liver function tests
Serum lactate level
Surveillance blood cultures X 1
ABG (Notify respiratory of patient temperature)
13. Hemodynamic support: Maintain MAP at 90 mmHg.
A). If MAP is less than 90 mm Hg:
M Dopamine 400mg in 250mL D5W. Continuous IV infusion to maintain MAP greater than
90 mm Hg to a maximum of 20 mcg/kg/min
Other_____________________________________________________________________
B). If MAP is less than 90 mm Hg on maximum dose of first pressor add
M Norepinephrine 4mg in 250mL D5W. Continuous IV infusion to maintain MAP greater than 90
mm Hg. Maximum dose 30 mcg/min.
Other:_______________________________________________________________________
C). If Refractory hypotension on 2 vasoactive agents, unstable cardiac rhythm, re-evaluate therapy and
consider rewarming.
14. Ventilator Support:
A). Titrate FiO2 to maintain O2 saturations greater than 92%
B). Ventilator Settings:
Mode ________________ Rate__________________ TV____________________
F
FiO2 ________________ Peep _________________
515. ECG every 6 hours.
116. Consults:
Cardiology
Nutrition
Pulmonary/Critical Care
jPhysician’s Signature
Printed Name
Beeper number
Date
Time