Download Saint John Regional Hospital CVS ICU Post

Saint John Regional Hospital CVS ICU Post-Op Order Set
Nutrition
 NPO
Activity
 Bedrest
 Elevate head of bed 30 degrees when hemodynamically stable
 Turn and position q2h
Vital Signs
 BP, MAP, P, R, PAS, PAD, PAM, CO, CI, SVR, PVR, CVP q15min until stable then q1h then q4h and
PRN
 Temperature q1h until 36 degrees Celsius, then q4h
 ETCO2 continuous until extubated
 Neuro checks q1h until awake then q4h
Labs
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CBC, electrolytes, urea, creatinine, glucose, PT-INR, PTT activated, magnesium, ionized calcium,
ABG, MVG immediately post-op and morning post-operative day one
Blood gas lytes arterial q1h x 4 then q2h x 4 then q4h and PRN
Troponin T 4 hours post-op
CBC 6 hours post-op
Diagnostic Imaging
 Chest x-ray immediately post-op
 Routine chest x-ray every morning while in ICU
Electrodiagnostic Testing
 ECG immediately post-op.
 ECG with every rhythm or ST change.
 Routine ECGs every morning while in ICU
IV Infusion
 Surgeon dependent
o 0.9% NaCl @ 50mls/hr
o D5W & 0.45% NaCl @ 50mls/hr
o D5W @ 50mls/hr
Analgesics
 Morphine Sulfate 2.5-5 mg IV q30min PRN while intubated
 For extubated patients under 80 kg: morphine sulfate 5 to 7.5 mg IM q3h PRN
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For extubated patients 80 kg or >: morphine sulfate 10 to 12.5 mg IM q3h PRN
For patients allergic to morphine or codeine
o Fentanyl 50 to 100 mcg IV q1h PRN
For one surgeon: ketorolac 30 mg IV when patient placed on PSV if creatinine is within normal
limits and chest tube drainage <100mls/hr
For minimally invasive approach and some Transapical Aortic Valve Implantation patients
o Ketorolac 15 mg IV q6h for 48 hours
o Acetaminophen 975 mg PO q6h
o Gabapentin 100 mg PO TID
Antiemetic
 Ondansetron 4 mg IV q6h PRN
Antipyretic
 Acetaminophen suppository 650 mg q4h PRN temperature > 38.5 degrees Celsius
Antibiotic
 Cefazolin 1000 mg q8h x 3 doses for three surgeons, x 4 doses for one surgeon. First dose in ICU
is given 3 hours after the last dose in the OR. For patients 100kg or > dose increases to 2000mg.
If bilateral thoracic arteries are utilized three of the surgeons will extend the number of doses to
9 or 10.
 If the patient has a true penicillin allergy, vancomycin is utilized.
Antiarrhytmic
 One surgeon will give 2 gm of magnesium sulfate immediately post-operatively
 Three surgeons give 2 gm of magnesium sulfate routinely the morning of post-op day one
Antiheparin
 Two surgeons give protamine 50 mg x 2 doses post-op
 One surgeon gives protamine 50 mg x 1 dose post-op
 One surgeon does not use any additional protamine in the ICU (the cell saver is used for all of his
patients)
Antihypertensive Agents
 Nitroprusside infusion (0.25 to 5 mcg/kg/min)
o For the first 1 to 2 hours SBP is maintained between 80 – 100 mmHg
o After this time if the patient is not bleeding the pressure is allowed to rise. Each
surgeon varies in parameters for pressure
 MAP less than 95
 SBP less than 110
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 SBP less than 120
 SBP less than 140
If nitroprusside infusion is at 1 mcg/kg/min nurses are able to utilize labetalol for hypertenision
PRN.
o Three surgeons will give 10 mg bolus doses q10min PRN
o One surgeon will give an infusion of 100 mg over 2 hours q8h PRN
o Hold parameters are for a heart rate less than 60 or a cardiac index less than 2.2
Coronary Perfusion/Spasm
 All patients who underwent bypass grafting surgery will be placed on a nitroglycerin drip at 0.25
mcg/kg/min for coronary perfusion and prevention of vasospasm
Volume Resuscitation
 Three surgeons will use volulyte, with different parameters and volume amounts.
o To maintain CVP 5-10 if MAP<65 (maximum of 750 mls)
o To maintain CVP 4-12 (maximum of 1000 mls)
o To maintain CVP 6-12 (maximum of 1000 mls)
 One surgeon will use voluven, to maintain a CVP 6-12 to a maximum of 1000 mls.
 Two surgeons will use crystalloid (0.9 % NaCl, D5W & 0.45% NaCl, or Ringer’s Lactate) if the
patient requires more volume
 If a patient has renal insufficiency or is bleeding 3 of the surgeons will use 5% albumin in place of
the volulyte or voluven. One surgeon will use crystalloid instead of volulyte.
Insulin Infusion
 Humulin R drip: titrate to maintain glucose 6-9 mmol/L @ nurse’s discretion. Maximum rate for
three surgeons is 15 units/hr. One surgeon has no maximum.
 ACCUs q1h. If no change in infusion after two serial checks may do ACCUs q2h.
 For glucose below 4 please give 25 mL of 50% dextrose. Please recheck glucose in 15 minutes.
Sedation
 Propofol infusion 5 to 75 mcg/kg/min as needed for sedation
 Midazolam 2 mg IV q30min PRN
Shivering
 Meperidine 25 mg q30min PRN. Stop after 2 doses. (Typically only used by one surgeon)
 Rocuronium 50 mg PRN
Thromboembolic Prophylaxis
 Three surgeons will give an ASA (325 mg) 7 hours post-op in patients who have had bypass
grafting.
 One surgeon will give an ASA (325 mg) 7 hours post-op in all of his patients
Chest Tubes
 Connect to under water seal drainage with suction at 20 cm
 Strip chest tubes q15min x 2 hours and then q1h (for two surgeons)
 Strip chest tubes lightly q1h (for two surgeons)
Nursing Fluid Balance
 Connect foley catheter to urometer
 Intake and output q1h
 Titrate total fluid intake to 50 mL/hr
 Suspend all PO medications
 Test ventricular pacemaker settings on arrival. Pacing wires are to be tested q12h while in ICU.
 Transfuse with red cell concentrates to maintain HGB greater than 70 (for most patients). In
older patients and patients with renal disease they will maintain a HGB greater than 80.
 Insert an oral gastric tube and connect to low suction. Flush OG with 10 mL of NaCl q4h.
Respiratory
 Ventilation:
o PRVC AC at RT’s discretion (for 3 surgeons)
o PRVC/SIMV respiratory rate 10; tidal volumes around 10 mls per kg; Peep 5; FiO2 0.6
o When stable awake and extubate at the discretion of RRT