PHYSICIAN ORDERS / PROGRESS NOTES

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1 PHYSICIAN / PROGRESS NOTES Drs Joseph Thibodeau and Louis Violi Created: 4/10 - Next Review: 4/10 Page 1 of 5 Initiation Phase: Emergency Department Notify Interventional Cardiology and Cath Lab immediately to prepare for emergent cath regardless of ECG findings. Enter order for Cardiac Cath into computer. Notify ICU. (ICU to notify E Focus ). Record height, weight, allergies (especially contrast material), and medications into the electronic record. Insert two large bore peripheral IVs (18 gauge or larger). Remove all clothing (gown only). Insert Foley catheter with temperature probe and connect it to the monitor system. Infuse 2 liters of 4 C 0.9% NaCl over 30 minutes if no evidence of pulmonary edema. Apply ice to axillae and groin. Prepare informed consent for heart catheterization with coronary angiogram and percutaneous coronary intervention. Use EBC Ventilator Management Protocol (Doc #87018) with these alterations: Immediately titrate FiO2 to keep SpO %. Do NOT wait for initial ABGs. Turn off the vent heater. Hypothermia protocol should continue uninterrupted during any procedures. IV Fluid: 0.9% NaCl at 125/hour following cold saline. Aspirin 300 mg PR x1. Stat Diagnostic Panel 12-lead ECG. CXR indication: Post cardiac arrest/post intubation. CBC with differential. (Continued on page 2) v1 Patient weight Time of collapse Time CPR initiated (including effective CPR) Time of return of spontaneous circulation Time cooling initiated Time cooling machine applied Time target temperature of 33 reached Time rewarming phase initiated _ Time normothermia (36 ) reached Inclusion Criteria: Postcardiac arrest with VIT/VF. <15 minutes from collapse to CPR. Arrest to return of spontaneous circulation time <1 hour. Cardiac arrest within the past six hours. Intubated, requiring mechanical ventilation. Unresponsive to pain. Systolic blood pressure >90 mmhg with our without pressors or MAP >60 mmhg on no more than one pressor. Temperature >30 C (86 F) before cooling efforts. Age 18 or over. Exclusion Criteria: Do Not Resuscitate/Do Not Intubate status. Postrespiratory arrest. Active severe bleeding or known bleeding diathesis. Impaired cognitive/neurological status precardiac arrest (could not perform ADLs independently). Known systemic infection or sepsis. Uncontrolled, unstable cardiac dysrhythmia. History of cryoglobulinemia. Coma clearly unrelated to arrest (overdose, intoxication, seizure, head trauma, stroke, hypoglycemia, electrolyte abnormality). Relative Exclusionary Criteria: Prolonged arrest time (>1 hour). Known systolic HF with NYHA Functional Class III or IV/Stage C or D. Trauma or major intracranial, intrathoracic, or intra-abdominal operation within seven days. Normal saline should be given for all patients except in refractory hypoxemia In a 70 kg patient, 1 liter of - 4 C chilled saline induces about C of cooling. Excess oxygenation early postcardiac arrest contributes to cerebral oxidative stress and poor outcomes.

2 PHYSICIAN / PROGRESS NOTES Page 2 of 5 Stat Diagnostic Pane (continued) Blood Gas Arterial, temperature corrected. aptt PT (protime/inr) Fibrinogen HCG Qualitative (serum) for women <55 years old Lipase Complete Metabolic Profile (CMP) Magnesium Phosphorus Ionized Calcium CK-MB (Includes CPK). Troponin I Initiation Phase: Cath Lab Insert femoral or radial arterial line or leave arterial sheath in place. Cath Lab: Insert IJ, subclavian or femoral triple lumen venous catheter. If temperature rises above 34.5 C, infuse 250 ml bolus of 4 C 0.9% NaCl q 10 minutes until <34. Initiation Phase: ICU (to be managed by E Focus MD) Admit to ICU inpatient status. Notify Pulmonology Consults to Nephrology Neurology Palliative Care Insert rectal temperature probe, attach to cooling machine. Apply cooling blankets or wraps, attach the patient to the cooling unit, and set the target temperature at 33 C. Begin cooling. (Continued on page 3) v1

3 PHYSICIAN / PROGRESS NOTES Page 3 of 5 Initiation Phase: ICU (continued) Continuous core temperature, arterial BP, cardiac monitoring, CVP, and SaO2 monitoring during hypothermia protocol. Record vital signs (including temperature) q 15 minutes during initiation phase. 1:1 nursing during hypothermia protocol. Accu-Cheks q.2h. during hypothermia protocol. Hourly urinary output (UOP). Notify MD if SBP <90 MAP <80 or >100 (<65 if patient had PCI) CVP <8 or >15 UOP >300/hour or <.5 ml/kg/hour Skin checks q.2h. during protocol. Insert OG tube and place on low intermittent suction. Analgesia: FentaNYL (1000 mcg/0.9% NaCl 100 ml) by continuous IV infusion at 50 mcg/hour. Sedation: Use order set Sedation for Mechanically Ventilated Patients (Doc #87017) using the LORazepam (Ativan) regimen with a loading dose of 1 mg and initial infusion rate of 1 mg/hour. Titrate up to a maximum of 10 mg/hour. Acetaminophen 1 gm per OG tube now, then 650 mg per OG tube q.6h. x12 doses through rewarming. BusPIRone 30 mg OG q.8h. throughout cooling and rewarming (clamp OG tube for 60 minutes). Magnesium sulfate 4 gm IV/Sterile water 50 ml to be given over 5 hours unless dialysis dependent. If moderate or severe shivering occurs 30 minutes after initiation of cooling, call E Focus for possible neuromuscular blockade orders. Initiate EBC Neuromuscular blockade Mechanically Ventilated Patients Order Set (Doc #87014). If target temperature is not achieved within 4 hours, give 500 ml 0.9% NaCl at 4 C and place ice packs on the groin, axillae, and neck. Repeat until target temperature is achieved. Blood Gas Arterial 30 minutes after 33 is reached. No sedation vacation during this hypothermia protocol. -Acetaminophen is an antipyretic which can assist in efforts to maintain hypothermia and assist with normothermia in the first 48 hours after rewarming. -BusPIRone is a novel agent which reduces shivering during hypothermia. -Magnesium sulfate is capable of reducing shivering and can assist with hypothermia. Bedside Shivering Assessment Scale (BSAS): 0 - None: No shivering noted on palpation of the masseter, neck, or chest wall. 1 Mild: Shivering localized to the neck and/or thorax only. 2 Moderate: Shivering involves gross movement of the upper extremities (in addition to neck and thorax). 3 Severe: Shivering involves gross movements of the trunk and upper and lower extremities. If the temperature drops to <31 degrees, consider infusing 250 ml boluses of % NaCl or LR until temperature reaches >32. (<32 increases the incidence of dysrhythmias). Early warming should be done only with the approval of two physicians. (Continued on page 4) v1

4 PHYSICIAN / PROGRESS NOTES Page 4 of 5 Maintenance Phase Continue maintenance phase, sedation, and analgesia for 24 hours from the time of reaching the target temperature, even if the patient becomes hemodynamically unstable. Record vital signs (including temperature) q.1h. 12-lead ECG q.8h. x2 and p.r.n. for dysrhythmia or morphology change on cardiac monitoring. CXR q a.m. Limited echocardiogram for EF, wall motion, and rapid gross overview (can be done in a.m.). NPO except medications. If temperature rises above 34.5 C, infuse 250 ml bolus of 4 0.9% NaCl q 10 minutes until <34. Notify MD if temperature >35 C or >31 C during maintenance phase despite interventions. Labs q.6h. throughout cooling, maintenance, and rewarming phases. CBC without differential Basic Metabolic Panel (BMP) Magnesium Ionized Calcium PTT Blood Gas Arterial (temperature corrected) Lactic Acid Arterial CK-MB Troponin I If serum K + is <4 mmnol/l, call MD. All potassium replacement or IV fluids with potassium should be completed or stopped 6 hours prior to rewarming if the serum K + is 3.5 or greater. (Continued on Page 5) v1 Potassium replacement is not to be done during rewarming phase. Anticipate vasodilatation, hypotension, hypoglycemia, and rapid electrolyte shifts during the warming phase. Aggressive IV fluid resuscitation may be necessary.

5 PHYSICIAN / PROGRESS NOTES Page 5 of 5 Calcium Replacement If ionized calcium is <1.0, then give calcium gluconate 1 gm IV. Magnesium Replacement: To be used following the magnesium sulfate IV infusion. If serum magnesium is <1.8 mg/dl, call MD. Phosphate Replacement: Call MD for phosphate <2. Rewarming Phase Initiate rewarming 24 hours after the target temperature of 33 C was achieved. Record vital signs (including temperature) q 15 minutes during rewarming phase. Rewarm at a rate of 0.5 C/hour. Rewarming to 36 C should take 6-8 hours. Resume ventilator circuit heating. If neuromuscular blockade is being utilized, stop it when the patient s temperature reaches 36 C. Stop sedation and IV fentanyl 2 hours after neuromuscular blockade has stopped. Post-Rewarming Phase Maintain normothermia (<38 C) for hours after warming was initiated. Continue scheduled acetaminophen for 72 hours from the time the target temperature was reached during the cooling phase. Dr Date Time v1

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