Download ICD/Permanent Pacemaker Pre-Implantation Orders

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
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