Download Orders: Post-Operative Cardiac Surgery 12/20/10

The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent practitioner
with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless otherwise specifically stated.
Change service to Dr. __________________________________ (surgeon)
Cardiologist: _________________________________
Procedure: _______________________________________________________
Critical Care Consult for: ____________________________________________
Code Status:  Full
If patient is DNR, complete DNR order form.
Weight: _______________ kg EF ____________%
Label chart ALLERGIC to: ____________________________________________________________________________________
AUTOMATIC STOP ORDERS INCLUDE: Narcotics – 7 days (Demerol 48 hrs) Antibiotics – 7 days
ROUTINES
Diet:  NPO
Advance diet to:
 Sodium 2 Gm (Cardiac)
 Diabetic (ADA) _____________________ calories
 Other: ____________________________________________________________________________________________
 Vital Signs: record BP, MAP, HR, CVP, PAP’s every 15 minutes until stable then every 1 hour until vasoactive infusions weaned per ICU
standard.
 Hemodynamic profile STAT on arrival then every 4 hours and as needed until vasoactive/inotropic infusions discontinued then per ICU
standard.







Temperature every hour until 98.6F (37C) then every 4 hours. Every 2 hours if temperature greater than 101.5F (38.6C).
Record hourly intake and output.
Record warmth color, pulses in feet and capillary refill in feet every 2 hours for 8 hours, then every 8 hours.
Weigh daily starting POD # 2 in AM.
IABP ratio: ______________
Pacemaker: initiate pacing support at 90 beats per minute for hemodynamically unstable bradycardia and notify intensivist.
Salem sump to low continuous suction, irrigate PRN, clamp after extubation, remove when tolerating liquids.
DRAINS/TUBES
 Closed chest drainage system to 20 cm suction, maintain patency, measure output every 1 hour for 24 hours, notify intensivist if output is
greater than 150 ml/hour.
 Blake drains to bulb suction. Measure output every 1 hour for first 12 hours. Call intensivist if output still greater than 100ml/hr after 12 hr. If
greater than 200 ml blood loss in first hour post-op connect to Pleurovac system with 20 cm suction. Call intensivist to inquire about
autotransfusion using Atrium closed system. Call intensivist if output is over 150 ml/hr.
 Indwelling urinary catheter to urimeter; call intensivist if urine output less than 0.5 ml/kg/hr for 2 consecutive hours.
 Telephone order:
________________________________________ MD / NP / PA_/________________________________ Date________ Time_________  RB&C
(circle one)
Provider Signature_______________________________________ ID #___________________ Date____________ Time______
RN Signature___________________________ Date_______ Time_______ USC Signature_______________________ Date________ Time________
ORDERS: POSTOPERATIVE
CARDIAC SURGERY
WAH 601-397 (12/20/10)
page 1 of 6
The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent practitioner
with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless otherwise specifically stated.
ACTIVITY/REHAB
 Bed rest: advance as tolerated
DRESSINGS/TREATMENTS
 Dressing change per incisional wound care protocol beginning 24 hours post-op for sternotomy and 48 hours for lower extremity incisions. No tape
on legs. May leave open to air if wounds clean, dry and intact.
 Surgical bra size: __________ or  abdominal binder
 SCD for all open heart surgery and Maze procedure patients.
TESTS
 Cancel all previously ordered daily lab
 STAT chest x-ray on arrival Indication: ET Tube placement and Atelectasis
 Chest x-ray Post-op day #1 and after pleural chest tube removed Indication: Volume Overload and Pneumothorax
 STAT EKG
 Basic Metabolic Panel, Magnesium and CBC Stat on arrival, in 4 hours and in AM on post op day # 1
 PT/INR, PTT, Fibrinogen, ACT if bleeding from the chest tubes exceeds 150 ml in first 30 min and over 200ml in first hour after arriving to ICU or
400 ml in first 4 hours.
 Lactic acid
 SVO2
AUTOMATIC STOP ORDERS INCLUDE: Narcotics – 7 days (Demerol 48 hrs) Antibiotics – 7 days
RESPIRATORY
Morbidly obese patients – please place in Reverse Trendelenberg position and HOB at 30 degrees if no
contraindications.
 Ventilator settings: Mode: _________ TV _________ Rate _______/minute FiO2_______ PEEP _______
PSV ______
 Initiate rapid vent weaning (extubate in less then 6 hours from arrival from the OR): minimize sedation, opiates . Once patient is arousable and SpO2
over____% and ETCO2 less than ____mm Hg start SBT’s . Accept RSBI less than ____ , SpO2 over ____%, FiO2 less than ________ and
ETCO2 less than ____mm Hg as indication of adequate ventilation and oxygenation, notify intensivist prior to extubation.
 Do not initiate rapid vent weaning
 Post extubation: turn, cough and deep breathe every 2 hours while awake and every 4 hours at night.
 Post extubation: incentive spirometer every 2 hours while awake and every 4 hours during night.
 Titrate FiO2 to keep O2 sat greater than ______ post extubation.
 Treatments on ventilator: _______________________________________________________________________________
 Post extubation: ______________________________________________________________________________________
 Telephone order:
________________________________________ MD / NP / PA_/________________________________ Date________ Time_________  RB&C
(circle one)
Provider Signature_______________________________________ ID #___________________ Date____________ Time______
RN Signature___________________________ Date_______ Time_______ USC Signature_______________________ Date________ Time________
Patient Identification
ORDERS: POST-OPERATIVE
CARDIAC SURGERY
WAH 601-397 (12/20/10)
page 2 of 6
The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent
practitioner with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless other wise specifically stated.
MEDICATIONS (Discontinue all previous orders): (Pharmacy Order Set: POSTOP CARDIAC)
ROUTINE
CABG/Valve patient:

Aspirin 81 mg PO daily; start 8 hours post-op if bleeding less than 100 ml/hour for 6 hours
 Aspirin suppository 300 mg per rectum daily if not able to give aspirin PO
 Clopidogrel (Plavix) 75 mg PO daily start ____hours post–op if bleeding less then 25 ml/hr for 6 hours
 Isosorbide (Imdur) for radial artery grafts patients Start on post operative Day one.
30 mg PO daily
60 mg PO daily
 Amiodarone (Cordarone) 200 mg PO/NG tube BID times five days, then 200 mg PO/NG tube daily times ten days
 Mupirocin (Bactroban) ointment apply to nares BID times 10 doses
 Chlorhexidine (Peridex) oral care swab and then suction every 4 hours while intubated
 Chlorhexidine (Peridex) 15 ml rinse for 30 seconds every 12 hours after extubation
Stress ulcer prophylaxis/VTE prophylaxis:
 Famotidine (Pepcid) 20 mg IV push every _________ hours
 Pantoprazole (Protonix) 40 mg IV every _________ hours
 Start VTE prophylaxis ________ hours post-op after assessing bleeding and verified with CCM
 Enoxaparin sodium (Lovenox) 40 mg SQ daily OR  Enoxaparin sodium (Lovenox) 30 mg SQ daily (if CrCl less than 30ml/min)
 Fondaparinux (Arixtra) 2.5 mg SQ daily, if patient HIT and SRA positive (contraindicated if CrCl less than 30ml/min)
 IF both of above contraindicated continue SCD with knee high TED hose until ambulating TID
Other:
 Docusate 50mg/sennosides 8.6mg (Senokot S) 2 tablets PO daily until BM, then change to 1 tablet PO daily
 Saline lock flush every 8 hours and PRN IV after medication administration
 Atorvastatin (Lipitor) 80 mg po/NGT at bedtime
ANTIBIOTIC PROPHYLAXIS (not to exceed 24 hours post-op): (choose one):
First (pre-op) dose given at: _____am/pm in surgery. If additional dose given in Surgery document the time given: _______am/pm.
 Cefazolin (Ancef, Kefzol)  1 Gm IV  2Gm IV (for patients over 80 kg) every ______ hours for total of 2 doses post-op.
 Vancomycin (Vancocin) 1 Gm IV every ______ hours for total of ____ doses post-op [if beta-lactam allergic patient].

 Telephone order:
________________________________________ MD / NP / PA_/________________________________ Date________ Time_________  RB&C
(circle one)
Provider Signature_______________________________________ ID #___________________ Date____________ Time______
RN Signature___________________________ Date_______ Time_______ USC Signature_______________________ Date________ Time________
Patient Identification
ORDERS: POSTOPERATIVE
CARDIAC SURGERY
WAH 601-397 (12/20/10)
page 3 of 6
The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent
practitioner with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless other wise specifically stated.
AUTOMATIC STOP ORDERS INCLUDE: Narcotics – 7 days (Demerol 48 hrs) Antibiotics – 7 days
Routine Infusions:
 Continue operating room IV fluid at KVO; mix all drugs in D5W if compatible.
 Nitroglycerin 50mg/250ml D5W infusion at 10-150 mcg/min for Map ____ to____ for 10 hours, then wean off. Radial artery grafts: maintain
nitroglycerin at 30 mcg/min.
PRN MEDICATIONS
 Meperidine (Demerol) IVP 12.5mg  25 mg; max ___ doses every 10 min PRN shivering during first 2 hours after arrival from operating room.
 Ondansetron (Zofran) 4 mg IV over 5 minutes every _______ hours PRN nausea for 24 hours only.
 Simethicone (Mylicon) 80 mg PO every 6 hours PRN gas
 Throat lozenges PRN sore throat
PAIN MANAGEMENT
Acetaminophen: NOT TO EXCEED 4 GRAMS ACETAMINOPHEN IN 24 HOURS!
650 mg tab PO every 4 hours PRN pain rated 2 or less or temperature greater than 101.5F (38.6C) for first 24 hours post-op
 650 mg liquid NG every 4 hours PRN pain rated 2 or less or temperature greater than 101.5F (38.6C) for first 24 hours post-op
 650 mg suppository PR every 4 hours PRN pain rated 2 or less or temperature greater than 101.5F (38.6C) for first 24 hours post-op
 300 mg with codeine 30 mg (Tylenol # 3) 1 tablet PO every 4 hours PRN for pain scale rated 1 to 3.
 300 mg with codeine 30 mg (Tylenol # 3) 2 tablet PO every 4 hours PRN for pain scale rated 4 or greater.
 Fentanyl (Sublimaze)  25 mcg  50 mcg IV every 15 minutes PRN pain rated over 4. Do not exceed _______ mcg every hour
after weaning from ventilator. Discontinue after 48 hours
 Continue On-Q Pain Pump: bupivacaine (Marcaine) 0.2% at 4 ml/hour for post-op pain control x 72 hours
SEDATION (Check desired sedation scale)
 Midazolam (Versed)  0.5mg  1 mg IVP every 5-10 min for RASS score 0 to -1 for total up to max of____ doses.
 Lorazepam (Ativan)  0.5mg  1 mg IVP every 10 min for RASS score 0 to -1 for total up to max of____ doses.
 Propofol (Diprivan) 500 mg/ 50 ml infusion at 10 microgram/kg/min; titrate to RASS score 0 to -1 up to 50 mcg/kg/hr. Call MD if 50 mcg/kg/hr required
 Dexmedetomidine (Precedex) 200 mcg/50 ml NS infusion at 0.1 microgram/kg/hour titrate for RASS score 0 to -1 up to 1.5 mcg/kg/hour.
 Telephone order:
________________________________________ MD / NP / PA_/________________________________ Date________ Time_________  RB&C
(circle one)
Provider Signature_______________________________________ ID #___________________ Date____________ Time______
RN Signature___________________________ Date_______ Time_______ USC Signature_______________________ Date________ Time________
Patient Identification
ORDERS: POSTOPERATIVE
CARDIAC SURGERY
WAH 601-397 (12/20/10)
page 4 of 6
The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent
practitioner with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless other wise specifically stated.

TREATMENT OF HYPERTENSION
 Nicardipine (Cardene) 20 mg/ 200 ml D5W infusion at 1.25 mg/hr up to 15 mg/hr titrate to maintain MAP _____ and/or SBP less than _____
 Labetalol (Trandate)  2.5 mg  5 mg IVP every 5 min for total up to max of___doses for MAP over ___and SBP over___ if HR over ___and CI
over___
 Metoprolol (Lopressor)  1.25mg  2.5 mg IVP every 5 min up to 7.5 mg for MAP over____ and SBP over____if HR over___ and CI over___
 Hydralazine (Apresoline)  5mg  10 mg IVP every 10-60 min for MAP over____and SBP over ____ as long as HR less than _____
 Other ______________________________________________________________________________________
TREATMENT OF HYPOVOLEMIA RELATED HYPOTENSION ( LOW CVP/PAOP AND HYPOTENSION)
 Infuse Albumin 5% bolus: 500 ml if PAWP or CVP less than _______or SVV over ______mmHg and MAP is less than ______ . Call Intensivist if
PAWPor CVP less than _____ [1000 ml total OR/ICU Albumin 5% given].
 Infuse Normal Saline bolus: 500 ml if PAWP or CVP less than _______SVV over ______mm Hg and MAP is less than _______. Can repeat bolus
up to total of __________________________.
 If HCT less than _____% call Intensivist
DYSRHYTHMIAS MANAGEMENT
 Ventricular tachycardia/ ventricular fibrillation: Amiodarone (Cordarone) 75 mg bolus IV over 10 minutes then continuous infusion at 1 mg/min.
May repeat bolus times 4 (total 300 mg loading dose). Call Intensivist.
 Atrial fibrillation with rapid ventricular response i.e., HR over ______: Amiodarone (Cordarone) 75 mg bolus IV over 10 minutes then
continuous infusion at 1 mg/min. May repeat bolus times 4 (total 300 mg loading dose). Call Intensivist.
 Prophylaxis of ventricular tachycardia, ventricular fibrillation and atrial fibrillation: Amiodarone (Cordarone) 75 mg bolus IV over 10 minutes
then continuous infusion at 1 mg/min.
ELECTROLYTE REPLACEMENT
 Magnesium 2 Gm/ 100 ml NS over 30 minutes PRN urine output greater than 200 mL/hour or serum magnesium less than 1.8 mEq/liter.
 Potassium Chloride replacement FOR FIRST 24 HOURS ONLY, if creatinine level is less than 1.8 and urine output over 50 ml/hr and no history of
ESRD.
Central line: 20 mEq/ 100ml H2O over 1 hour if serum K+ is 3.9 – 4.1 mEq/liter
40 mEq/ 100 ml H2O over 2 hours for serum K+ less than 3.9 mEq/liter
If no central line give potassium chloride (elixir or tablet) PO/NG:
20 mEq if serum K+ is 3.9 – 4.1 mEq/liter
40 mEq if serum K+ is less than 3.9 mEq/liter
 Telephone order:
________________________________________ MD / NP / PA_/________________________________ Date________ Time_________  RB&C
(circle one)
Provider Signature_______________________________________ ID #___________________ Date____________ Time______
RN Signature___________________________ Date_______ Time_______ USC Signature_______________________ Date________ Time________
Patient Identification
ORDERS: POSTOPERATIVE
CARDIAC SURGERY
WAH 601-397 (12/20/10)
page 5 of 6
The licensed independent practitioner must check () the desired boxes. All order sheets must be signed with date/time by the licensed independent
practitioner with ID #. A generic or therapeutically equivalent drug as approved by the P&T Committee may be dispensed unless other wise specifically stated.

BLOOD GLUCOSE CONTROL/HYPERGLYCEMIA MANAGEMENT
INSULIN IV DRIP
 Insulin, regular 100 units / 100ml NS (1 unit/ml). Start insulin drip at _____ units/hour. Titrate to achieve glucose of 100-120 mg/dl. May titrate 1 to 4
units/hour. Glucose monitoring every hour using glucometer. Notify intensivist if more than 25 units insulin per hour required to control blood
sugar or blood sugar is less than 80 mg/dl. May monitor glucose level every two hours if blood glucose level at goal and no changes made to
insulin infusion rate for 2 consecutive hours.
CONVERSION TO SUBCUTANEOUS INSULIN
 DISCONTINUE Insulin drip at _____(time), obtain glucometer reading and cover with insulin aspart (Novolog) according to the scale on attached
“SUBCUTANEOUS INSULIN ORDER FORM” (601-491) if pt ready to transfer.
Coronary Endarterectomy
 Dextran 40 infusion total dose of 500 ml IV over 24 hours for coronary artery endartarectomy. Start 4 hours post-op if no signs of bleeding
 Clopidogrel(Plavix ) 75 mg po daily starting on ______(date) _____time
VASOACTIVE/INOTROPIC INFUSIONS
Accept following variations for titration: MAP or SBP +/- ____mm Hg CI +/- ____L/m2 Mean PAP +/- ____mm Hg HR +/- ____ BPM
 Epinephrine 4 mg/ 250 ml D5W infusion at 0.5 mcg/min to ____ mcg/min titrate to MAP _______and/or CI______ as long as HR is less
than______.
Once epinephrine drip is infusing check glucometer a minimum of every 2 hours. Once blood glucose over ____ refer to
Hyperglycemia Management Section orders.
 Dobutamine (Dobutrex) 500 mg/ 250 ml D5W infusion at 1mcg/kg/min to _____ mcg/kg/min; titrate to CI _____ as long as HR is less than_____
 Norepinephrine (Levophed) 4 mg/250 ml D5W infusion at 0.5 mcg/min to _____mcg/min; titrate to MAP____ and/or SBP _____
 Vasopressin (Pitressin) 200 units/ 200 ml D5W infusion at 0.02 units/min to ______units/min; titrate to maintain MAP ______ and/or SBP _____
While on vasopressin infusion obtain lactic acid level 1 hour into infusion and then every 4 hours – call MD if over 2.5mg/dl
 Dopamine (Intropin) 200 mg/ 250 ml D5W infusion at 1mcg/kg/min to ____mcg/kg/min; titrate to maintain MAP____ and/or CI ___ or  HR____
 Milrinone (Primacor) bolus ______mcg/kg over _____ min.
 Milrinone (Primacor) 40 mg/ 200 ml D5W infusion at _____ mcg/kg/min to _____mcg/kg/min to maintain  CI____ or  mean PAP less than ____
Vasoactive drugs weaning orders:
_______________________________________________________________________________________________________________________
__________________________________________________________________________________________
Other orders:
______________________________________________________________________________________________________________________
 Telephone order:
________________________________________ MD / NP / PA_/________________________________ Date________ Time_________  RB&C
(circle one)
Provider Signature_______________________________________ ID #___________________ Date____________ Time______
RN Signature___________________________ Date_______ Time_______ USC Signature_______________________ Date________ Time________
Patient Identification
ORDERS: POSTOPERATIVE
CARDIAC SURGERY
WAH 601-397 (12/20/10)
page 6 of 6