Tumescent Interventional Radiology Orders

PLACE LABEL HERE TUMESCENT INTERVENTIONAL RADIOLOGY ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

SCHEDULED MEDICATIONS:

Tumescent cocktail, using one of the below, to be injected per interventional radiologist during procedure.

 EVLT: Lidocaine 2% inj 30 ml Sodium bicarbonate 8.4% 30 ml In Normal Saline 500 ml or

 Phlebectomy: Lidocaine 2% inj 30 ml Sodium bicarbonate 8.4% 30 ml In Normal Saline 250 ml

ADDITIONAL ORDERS: ______

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______Date Time Physician Signature PID Number

Copy to pharmacy

*1-39374* FORM 1-39374 INITIATED 03/2016 Page 1 of 1