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DO NOT USE UNAPPROVED ABBREVIATIONS PATIENT IDENTIFICATION LABEL ELIZABETH, NJ AUTHORIZATION IS HEREBY GIVEN TO DISPENSE THE GENERIC OR APPROVED THERAPEUTIC EQUIVALENT UNLESS OTEHRWISE SPECIFIED. THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST: Maintenance Orders PAGE 1 DATE: _______________ PHONE ORDER ORDER READ BACK AND VERIFIED WITH VERBAL ORDER ORDERING PHYSICIAN FOR T.O./V.O. MD NAME:________________/ _____________ R.N. TIME: _______________ ORDERED 1. Maintenance/ICU Phase/Nursing orders: Surface cooling pads with cooling device set to automatic mode with goal temperature of 33°C. Goal temperature is 33°C for 24 hours from initiation of cooling protocol. Replace electrolytes as needed every 6 hours. See pharmacy PRN orders: Monitor for shivering and document Bedside Shivering Assessment Scale (BSAS) every hour. Medicate as necessary. Monitor skin condition; reposition every 2 hours. If the patient awakens and follows commands at any time, DISCONTINUE the Hypothermia Protocol and allow the patient to passively warm. 2. Pharmacy Orders: IV fluids: □ 1000 mL NS at ______ mL/hour. Infuse NS at 4°C until target temperature is reached. Avoid subclavian and jugular lines. Analgesia/Sedation: Fentanyl 50 mcg IV bolus followed by Fentanyl 500mcg/100mL D5W IV infusion at 50 mcg/hr. Titrate to pain scale ≤3. Increase by 10 mcg/hr every 15 minutes until pain goal met. Lorazepam (Ativan®) 20mg/100mL D5W IV infusion at 2mg/hr. Increase by 1 mg/hr every 30 minutes to maintain BIS score 40-60. Midazolam (Versed®) 50 mg/100ml D5W IV infusion at 1mg/hr. Increase by 1 mg/hr every 30 minutes to maintain BIS score 40-60. Propofol (Diprivan®) 1000mg/100mL IV infusion at 5 mcg/kg/min. Increase by 5 mcg/kg/min every 5 minutes to maintain BIS score 40-60. Shivering protocol during cooling and re-warming period (48 hours): Acetaminophen (Tylenol®) 650mg oral solution every 6 hours via OGT for 24 hours; then q6h PRN T≥38.3°C Acetaminophen (Tylenol®) 650 mg suppository every 6 hours rectally for 24 hours, then Q6h PRN T T≥38.3 °C Magnesium sulfate 2 gm/50mL Sterile Water IVPB PRN shivering once. Meperidine (Demerol®) 50 mg IV Push slowly over 10 minutes every 1 hour PRN shivering not responsive to magnesium sulfate. May repeat once. Vecuronium 0.1mg/kg IVP over 1 to 2 minutes once PRN shivering unresponsive to magnesium sulfate or meperidine Start Vecuronium 100mg/100mL D5W IV infusion at 1mcg/kg/min. Increase by 1mcg/kg/min every hour to maintain 1 to 2 twitches with TOF monitor. PRN orders during cooling period (24 hours): KCl 10meq/100mL IVPB every 6 hours PRN for Potassium <3.4 mmol/L Magnesium sulfate 2gm/50mLSterile Water IVPB every 6 hours PRN for Magnesium <1.8 mg/dL Calcium Chloride 1 gm IV push every 6 hours PRN for serum Calcium <6 mg/dL Unit Secretary/RN: _____________________________________ Date&Time:___________________ PHYSICIAN SIGNATURE________________________________ DATE/TIME: ____________________________ ORDER NOTED BY: _____________________________________ Date&Time:___________________ RN’s Full Signature USE BALL POINT PEN ONLY Revised 10/25/12 DO NOT USE UNAPPROVED ABBREVIATIONS PATIENT IDENTIFICATION LABEL ELIZABETH, NJ AUTHORIZATION IS HEREBY GIVEN TO DISPENSE THE GENERIC OR APPROVED THERAPEUTIC EQUIVALENT UNLESS OTEHRWISE SPECIFIED. THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST: Maintenance Orders PAGE 2 DATE: _______________ PHONE ORDER ORDER READ BACK AND VERIFIED WITH VERBAL ORDER ORDERING PHYSICIAN FOR T.O./V.O. MD NAME:________________/ _____________ R.N. TIME: _______________ ORDERED DVT prophylaxis: Complete the VTE risk assessment in SCM. GI Prophylaxis: Famotidine (Pepcid ® ) 20 mg via OG tube every 12 hours Lansoprazole (Prevacid®) 30 mg via OG tube daily. Opthalmic lubricant: Lanolin/Mineral Oil/Petrolatum ophthalmic (Lacrilube®) apply 1” to each eye every 6 hours 3. Lab orders BMP, Magnesium, Calcium, Phosphorus, lactate, CBC, PT, PTT and ABG every 6 hours until normo-thermic. CKMB, CPK, Myoglobin, Troponin, q8h x 2. 4. Nutrition □ NPO for 48 hours except for medications through OGT. 5. Rewarming Phase/Nursing orders: At 24 hours, begin re-warming to 36.5°C over 12 hours (0.3°C/hr) using the surface cooling device at moderate setting. Keep temperature at 36.5 to 37°C with cooling device for next 24 hours. Continue sedation at current rate until normo-thermic; then titrate off as tolerated Discontinue vecuronium infusion, if still infusing. Monitor and record vital signs and temperature every 15-30 minutes until normo-thermic. 6. Other Orders: Unit Secretary/RN: _____________________________________ Date&Time:___________________ PHYSICIAN SIGNATURE________________________________ DATE/TIME: ____________________________ ORDER NOTED BY: _____________________________________ Date&Time:___________________ RN’s Full Signature USE BALL POINT PEN ONLY Revised 10/25/12