Instructions for Use: Check the Box in Front of Each Applicable Order and Sign at The

Addressograph

La Crosse, WI 54601 EPIC ORDER # 1503 ADULT ICU POST CARDIAC ARREST HYPOTHERMIA ORDER

Instructions for use: Check the box in front of each applicable order and sign at the bottom of the order set. If a default order (box is checked) does not apply, draw a single line through the order and initial. Blank spaces within orders must be completed.

Code Status  Full Code (follow ACLS protocol.)  O – DNR  O – DNI/DNR  P – DNR

Nursing Communication – Cooling  Cooling: routine, continuous. Initiate Medi-Therm III, hypo/hyperthermia machine cooling settings for goal cooling temperature of 33 degrees Celsius. Once 33 degrees Celsius is reached, maintain set temperature for 24 hours. Then see rewarming instructions.

Nursing Communication – Rewarming  Moderate Rewarming (12 hours) A. Initiate “Moderate” rewarming option on cooling/warming machine 24 hours after cooling goal of 33 degrees Celsius has been reached. B. Discontinue paralytics once patient has been rewarmed to 36.5 degrees Celsius C. Titrate sedatives to a Ramsey scale of 2 – 3 once patient is rewarmed to 36.5 degrees Celsius and paralytics have been discontinued. D. Maintain patient at 37 degrees Celsius, notify pulmonary/attending if potassium is less than 2.5  Gradual Rewarming (24 hours) A. Initiate “Gradual” rewarming option on cooling/warming machine 24 hours after cooling goal of 33 degrees Celsius has been reached. B. Discontinue paralytics once patient has been rewarmed to 36.5 degrees Celsius and paralytics have been discontinued. C. Titrate sedatives to a Ramsey scale of two to three once patient is rewarmed to 36.5 degrees Celsius D. Maintain patient at 37 degrees Celsius, notify pulmonary/attending if potassium is less than 2.5

Nursing Interventions  Maintain mean Arterial Blood Pressure (ABP) greater than 80 – 100 mmHg, routine, continuous.  Assess for shivering every 15 minutes. If sedation at maximum, give bolus of Cicatriceum IV as ordered. If patient begins to shiver after two boluses of Cicatriceum contact Critical Care service to begin Neuromuscular Blockade protocol.  If Central Venous Pressure (CVP) less than 12 and mean ABP less than 80 give 500 mL of normal saline over 30 minutes: if means remains less than 80 call Critical Care Service.

 If CVP greater than 12 and mean ABP less than 80 start Norepinephrine at 0.05 mcg/kg/min and call the Critical Care service. If mean ABP greater than 100 start Nitroglycerin at 20 mcg / min and titrate to reduce mean ABP below 100.  Head of bed 30 degrees, routine, continuous  Maintain Arterial line, routine, continuous Page 1 of 3 Addressograph

 Apply cooling blanket, ASAP, continuous  Maintain Multi-Med Line, routine, continuous  Maintain Foley catheter to urometer with temperature probe, routine, continuous.  Place/maintain Nasogastric tube, routine, continuous. Suction setting:  No suction  low  medium  high Type of suction:  No suction  Intermittent  Continuous  Place foot pumps, routine, continuous  Intake and Output, routine, every hour  Daily weights, routine

Labs **Start six hours after labs were obtained in TEC** Blood Gases  Lab Calcium-Ionized, routine, every six hours for 48 hours. Lab collect. Chemistry  Electrolytes, routine, every six hours for 48 hours. Lab collect.  BUN, routine, every six hours for 48 hours. Lab collect.  Creatinine, routine, every six hours for 48 hours. Lab collect.  Magnesium, routine, every six hours for 48 hours. Lab collect.  Troponin T, routine, every eight hours times one (eight hours after troponin obtained in TEC) Hematology  CBC, routine, every six hours for 48 hours. Lab collect.

IV Fluids  sodium chloride at 125 mL/hour, IV, continuous. If any signs of pulmonary edema contact Critical Care service.  sodium chloride 500 mL bolus over 30 minutes if needed for two doses if CVP less than 12 and mean AVP less than 80 call Critical Care Service.

Medications ** Refer to Insulin Continuous Infusion Order Set**  acetaminophen (TYLENOL) 650 mg solution per nasogastric every six hours for 24 hours (start six hours after dose obtained in TEC)  buspirone (BUSPAR) 30 mg tablet per nasogastric every eight hours for 24 hours if not in MAO inhibitor (start eight hours after dose obtained in TEC)  famotidine (PEPCID) 20 mg IV every 12 hours, give over two minutes.  pantoprazole (PROTONIX) 40 mg IV, for two minutes, daily, first to be given today.  enoxaparin (LOVENOX) 40 mg subcutaneous, daily, first dose to be given today.  heparin 5,000 units subcutaneous every eight hours. Pressure Support  Norepinephrine (LEVOPHED) 4 mg in dextrose 5% water, 250 mL infusion, routine, continuous as needed. Initiate IV infusion at 0.01 mcg/kg/min and titrate every five minutes by increments of 0.01 – 0.05 mcg/kg/min (Maximum rate = 0.2 mcg/kg/min). To maintain: MAP greater than 80 *Start only if needed when MAP less than 80 AND CVP greater than 12*  Nitroglycerin in dextrose 5% water, 200 mcg/mL) infusion, routine, continuous as needed. Page 2 of 3 Addressograph

Initiate IV infusion at 5 mcg / min and titrate by increments of 5 – 10 mcg/min every five minutes (Maximum rate= 200 mcg / min) to maintain: MAP less than 100 *Start only if needed when MAP greater than 100 AND CVP greater than 12* Sedation ** Refer to Ventilator Order Set ** May consider dexmedetomidine (PRECEDEX) if sedation/shivering**  fentaNYL (SUBLIMAZE) IV infusion, 5 mcg/mL, routine, continuous. Initiate IV infusion at 10 mcg/hr and titrate in increments of 10 mcg / hour every 30 – 60 minutes to a maximum rate of 125 mcg/hour to appropriate pain scale rating goal.  cisatricurium (NIMBEX) 0.1 mg/kg every 30 – 60 minutes as needed for shivering while being cooled with sedation allowing no more than two doses. If shivering continues, contact Critical Care Service to initiate Neuromuscular Blockade protocol.

Therapies  Respiratory therapy communication: Hypothermia Protocol, routine, continuous. Hypothermia cooling protocol: Ventilator humidification temperature 32 degrees Celsius during cooling phase. Initiate heat humidification once patient has been rewarmed to 36.5 degrees Celsius.

Signature: ______Pager: ______Date: ______Time: ______July 2011