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Bar Code Place Patient ID Label Here All Entries must have Date and Time Albert Einstein Healthcare Network Physician’s Orders ALLERGIES: Date/Time Press firmly-Use ball point pen only-Make sure there is a copy behind part one before writing 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