Microsoft word - hypothermia induction orders.doc

STAT MEDICATION ORDER
PLEASE INCLUDE: PHYSICIAN NAME, NUMBER AND SIGNATURE 9 DATE TIME Hypothermia Induction Order Set Page 1 of 2
Patient must meet inclusion criteria on reverse PRIOR to inducing hypothermia Indication: Patient weight: kg
6 NS - 30 mL/kg IV of cold injection at a target of 4° Celsius STAT
6 Initiate cooling with the appropriate hypothermia induction device according to Hypothermia Induction policy 6 Apply pads appropriate for patient weight(Apply Universal pads if Wt>= 220 LBs) 6 The Arctic Sun is preset to 33° Celsius 6 Start Magnesium Sulphate 4 Gm IV (in 100 ml injectable water ) over 4 hours 6 Continuous cardiac monitoring with pulse oximetry - monitor vital signs and record every hour 6 Consider target MAP ≥ 90mmHg or mmHg to maintain Cerebral Perfusion Pressure (CPP) of 6 Maintain ScvO2 > 70%.(if available) 6 Obtain bedside glucose every 1 hour. (See Adult Insulin order sheet if already initiated.)Maintain Accuchecks q 1 Hr until T=37° Celsius.(maintain BS=110-150) 6 CBC, BMP, Magnesium, Phosphorus, PT/PTT every 6 hours 6 Consider blood cultures 12 hours after initiation of cooling 6 Initiate VAP Bundle Order Set, if not already begun 6 No sedation vacation if patient is receiving neuromuscular blockade infusion or in cooling phase 6 Consider Empiric Antimicrobial therapy if sepsis or immunosuppression is suspected(ex: neutropenia.) Activity
6 Skin assessment should be performed and documented every 4 hours 6 Turn patient every two hours unless contraindicated and ordered 6 PT/OT consults and treatment if not already ordered Sedation/Analgesia/Control of Shivering
† Propofol (DIPRIVAN) drip initiated at 10mcg/kg/min. - titrate by 5mcg/kg/min for RASS of _____ to a
† Midazolam (VERSED) drip initiated at mg/hour - titrate by 1mg/hr for RASS of _____ † Fentanyl infusion at mcg/hour - titrate to mcg/hour † Morphine infusion at mg/hour - titrate to mg/hour If still shivering (physical assessment or trend indicator) give:
PHYSICIAN ORDERS
STAT MEDICATION ORDER
PLEASE INCLUDE: PHYSICIAN NAME, NUMBER AND SIGNATURE 9 DATE TIME Hypothermia Induction Order Set Page 2 of 2
If still shivering, consider neuromuscular blockade:
6 Start with PRN dosing as ordered for shivering 6 If patient still shivering, consider continuous infusion. 6 Place “Neuromuscular Blockade in use” sign at head of bed. † Intermittent dosing__________________________(dose/route/interval) † Loading dose (0.5 mg/kg) = ________ mg IV x one dose now † Infusion – begin at 4 mcg/kg/min IV to a max. of 12 mcg/kg/min † Intermittent dosing__________________________(dose/route/interval) † Loading dose (0.1 mg/kg) = ________ mg IV x one dose now † Infusion – begin at 1 mcg/kg/min IV to a max. of 2 mcg/kg/min Paralytic Titration
6 Monitor patient for ventilator compliance and shivering * Neither the Train of Four (TOF) or Bispectral Index Monitor (BIS) monitor has evidence for use in cooling and are not recommended
Continuous EEG(please choose one of the following):
† Start now and D/C when patient is rewarmed to 37° Celsius - page EEG tech-consult Dr. Kos † Start in am and D/C when patient is rewarmed to 37° Celsius - page EEG tech- consult Dr. Kos in am. Respiratory:
6 Maintain O2 Sats=95%
6 Maintain pCO2=40mmHg
Medications
6 Artificial tears ophthalmic ointment (LACRILUBE or equivalent) – one ribbon in each eye every 12
6 Maintenance IV Fluids: at ml/hr.-Titrate to maintain equal to UO.
Rewarming - To start 24 hours after temperature of 33° Celsius is attained
6 Stop all potassium infusions 6 Rewarm at 0.25° Celsius to 0.33° Celsius per hour - 6 Keep patient in goal temperature range of 36° Celsius to 37° Celsius for next 48 hours 6 May discontinue paralytic(if used) once goal temperature is obtained 6 Begin daily sedation vacation once paralytic has been discontinued Once rewarmed, please maintain EUTHERMIA(~37° Celsius).
PHYSICIAN ORDERS
Hypothermia Induction Criteria

Patients who have been shown to benefit from induced hypothermia include:
1. Those comatose post cardiac arrest – Start as soon as possible(earlier start=Better outcome-”Time is Brain”) 2. Those able to maintain a blood pressure, with or without vasopressors, after CPR. 3. Those in coma at the time of cooling. (Coma is defined as: not responding to verbal commands.(Brainstem reflexes and pathological/posturing movements are permissible.) 4. Patients may be and should be cooled and undergo Cardiac Cath/PCI simultaneously if indicated.
Facts:( NOT contraindications)
Patients in whom hypothermia may come with increased risk include those with:
1. Major head trauma – if clinical suspicion for possible head injury with arrest, a non-contrast head CT must be performed to rule out intracerebral hemorrhage prior to cooling. 2. Recent major surgery within 14 days - hypothermia may increase the risk of infection and bleeding 3. Systemic infection/sepsis- hypothermia alters immune function and is associated with an increased risk of 4. Patients in coma from other causes (drug intoxication, pre-existing coma prior to arrest) should not be cooled. 5. Patients with a known bleeding diathesis, or with active ongoing bleeding - hypothermia may impair the clotting system. Check PT/PTT, fibrinogen, D-dimer at admission. 6. Induced hypothermia after PEA, asystolic, or in-hospital arrest may be applied at the discretion of the treating
Note: patients may receive chemical thrombolysis, antiplatelet agents, or anticoagulants if necessary for
treatment of the primary cardiac condition.

Source: http://www.stlcriticalcare.net/Lectures/Therapeutic%20Hypothermia/Therapeutic%20Hypothermia%20Order%20Set.pdf