PRE-PRINTED PHYSICIAN S ORDERS

Transcription

1 PREPRINTED ORDERS FOR: CARDIAC SURGERY IMMEDIATE POST-OPERATIVE CVT POST OP (Page 1 of 6) Services of Diagnosis 1. Discontinue all previous orders. NOTE: Orders with option indicator ( ) are to be carried out only if checked ( ) Weight kg BSA M 2 Vital Signs and PAP, SVR, SaO 2, PCWP, CVP, C.O., U.O. Chest Tube drainage every 15 minutes x 4, then every 1 hour while on vasoactive drips. Do not wedge swan for Dr. Edgerton or Dr. Ellman patients. 2. NPO: Nasogastric tube to low continuous suction, clamp for 30 minutes after meds. 3. Elevate head of bed to degrees if Blood Pressure OK. 4. Chest tube to 20 cm suction 5. Initial Ventilator Setting: (8-10ml/kg) VT ml cm H 2 O FIO 2 100% SIMV 10 bpm Pressure Support 10 cmh 2 O May increase the SIMV rate to maintain an ETCO2 of less than 55 mm Hg Respiratory Care Adult Cardiothoracic Patient Ventilator Management Protocol **If Patient not extubated within 24 hours of surgery then nursing to perform wake up assessment once every 24 hours unless contraindicated. 18. ETS prn 7. Capnography monitoring 8. ABG with co-oximetry within 30 minutes of admission. 9. All ABG s to be done with co-oximetry. 10. Turn patient every 2 hours when stable, pillow under head 11. Temporary pacemaker settings: PRN Mode: Rate: Atrial ma: Ventricular ma 12. STAT on admission: Portable Chest x-ray and ECG on arrival Hematocrit, platelet count Renal panel PT, PTT Page 1 of 6

2 PREPRINTED ORDERS FOR: CARDIAC SURGERY IMMEDIATE POST-OPERATIVE CVT POST-OP (Page 2 of 6) 13. i-stat, every 4 hours and prn and until first post-op a.m. 14. Post-op Day #1 AM Labs. On chart by 0600: CBC without diff, Renal Panel, and portable CXR 15. MEDICATIONS: Perform oral care every 12 hours with Chlorahexidine 0.12% and perform mouth care at least every 4 hours. Cefuroxime (Zinacef) 1.5 grams IV every 8 hours x 2 doses Vancomycin 1 Gm every 12 hours x 2 doses, first dose at.reason: Famotidine (Pepcid) 20 mg IV 12 hours Esomperazole 40mg IV daily (Nexium). Mylanta II 30 ml every 6 hour per NG 16. Blood sugars every 2 hours until stable. Sliding scale will be utilized when insulin drip is not in use units regular insulin IV units regular insulin IV units regular insulin IV units regular insulin IV units regular insulin IV Greater than 450, call Physician units regular insulin IV Start insulin infusion for blood sugar greater than 150 after 4 hours. Continue Insulin infusion (Regular Insulin 100 units/ 100 ml Normal Saline) started in OR or initiate insulin IV infusion if blood sugar checks are greater than 150 on two consecutive readings (see Insulin IV Infusion Cardiothoracic Hyperglycemic Control preprinted orders for target Blood Glucose Range and starting Algorithm) Inotropic and Vasoactive Medications All Inotropic and vasoactive drips should be through a Central line. May double concentrate for fluid restriction. Sodium Nitroprusside 50 mg/250 ml D 5 W to maintain systolic Blood Pressure less than and greater than. Nitroglycerin 100mg/250 ml D 5 W to maintain systolic Blood Pressure less than and greater than. Not to exceed 1.5 mcg. Dopamine 400 mg/250 ml D 5 W at mcg/kg/min Dobutamine 500 mg/250 ml D 5 W at mcg/kg/min Epinephrine 4 mg/250 ml D 5 W at mcg/kg/min Milrinone 20 mg/100 ml D 5 W at mcg/kg/min Vasopressin 100 units in 250 ml Normal Saline at units/hr. Page 2 of 6

3 PREPRINTED ORDERS FOR: CARDIAC SURGERY IMMEDIATE POST-OPERATIVE CVT POST OP (Page 3 of 6) Phenylephrine (Neo-Synephrine) 25 mg/250 ml D 5 W at mcg/kg/min titrate to maintain systolic Blood Pressure less than and greater than. Norepinephrine (Levophed) 8 mg/250 ml D 5 W at mcg/kg/min Esmolol 2.5 Gms/250 ml D 5 W at mcg/kg/min Lidocane Drip 2 grams/250ml D 5 15ml/hr (2ml/min) 17. Sliding Scale KCL: Administer via Central Line ONLY using premixed mini bags. K + less than or equal to 3.7, give 30 meq KCL IV in 100 ml sterile water for Injection over 2 hours x 1 (total supplement 30 meq) K , give 20 meq KCL IV in 100 ml sterile water for Injection over 1 hour x 1 (total supplement 20 meq) K + less than or equal to 3.7, give 20 meq KCL IV in 100 ml sterile water for Injection over 2 hours x 1 K , give 10 meq KCL IV in 50 ml sterile water for Injection over 1 hour x 1 PRN DRUGS / FLUID Sodium Bicarbonate 50 meq IV for Base excess greater than 5. May repeat x3 Call if base excess remains greater than -5 Mepridine (Demerol) 12.5 mg IV prn every 30 minutes for shakes, not to exceed 50 mg in 1 hr. If exceeds Meperidine 50 mg., and if patient continues to shake, then give Rocuronium (Zemuron) 0.6 mg/kg IV every 30 minutes for shakes, not to exceed 100 mg. For persistent shakes after IV Meperidine and/or IV Rocuronium, call surgeon Morphine Sulfate 5 mg IV every 1-hour prn pain/agitation. May repeat to total no more than 10 mg in one hour for unrelieved pain/agitation/uncontrolled Blood Pressure. Ondansetron 4mg IV every 6 hours prn for nausea/vomiting. Systolic MAP Blood Pressure less than and PCWP/CVP less than. Give Albumin 1 bottle (5% gm /250 ml) IV prn fluid. Total Systolic MAP Blood Pressure less than and PCWP/CVP less than. Give Albumin (25% gm /50 ml) Total Systolic MAP Blood Pressure less than and PCWP/CVP less than. Give Normal Saline Lacated Ringers ml/hour prn fluid. Total ml Revised: 12/06/2010 Page 3 of 6

4 PREPRINTED ORDERS FOR: CARDIAC SURGERY IMMEDIATE POST-OPERATIVE CVT POST OP (Page 4 of 6) 18. All pressure lines to Normal Saline flush except IABP pressure line. Use Heparin flush for IABP (500 ml Normal Saline with 1000 units Heparin) 19. Call for the following parameters: Systolic Blood Pressure greater than or less than Urine output less than 50 ml/hour for 2 hours. Heart rate greater than or less than bpm Chest Tube drainage greater than 200 ml/hr for the first 4 hours greater than 100 ml/hr thereafter CI less than 2.0 L/min/M 2 PO 2 less than 60 mm Hg; pco 2 greater than 50 mm Hg Arterial ph greater than 7.55 or less than 7.30 Serum K + greater than 5.7 Hct less than 25% Blood Pressure less than 90 mm Hg Systolic Serum Creatinine greater than or equal to 2. Unrelieved pain/agitation 20. Notify for temp greater than 38.5 o C Acetaminophen (Tylenol) 650 mg per rectum or by mouth every 4 hours prn Cooling blanket prn If temp remains greater than 38.5 o C after Acetaminophen and cooling blanket Hydrocortisone 100 mg IV x 1 for temperature greater than 21. Discontinue NG prior to extubation 22. Please check if patient remains on medical doctor s computer list 23. Safety Protocol Off Pump Post-Op Care Protocol a. Sequential Compression Device (Thrombogards). b. Heparin 5000 units subcutaneous every hour(s) Start on. Page 4 of 6

5 PREPRINTED ORDERS FOR: CARDIAC SURGERY IMMEDIATE POST-OPERATIVE CVT POST OP (Page 5 of 6) 24. Radial Artery Harvest Site Post-Op Care Protocol a. IV Nitroglycerin 100 mg/250 ml D 5 W at 50 mcg/min IV Diltiazem (125 mg/125 ml D 5 W) at 5 mg/hr. b. Keep affected arm elevated Do not turn drip off unless ordered by physician. May titrate drip to assist with hypertension control. (minimum rate 25 mcg/min). c. Check palmar pulse every 15 min x 4 then every 1 hour d. No Blood Pressure measurement or ABG blood samples to be drawn from affected arm. e. If patient extubated before 0530, give 30 mg Imdur PO or 5mg Norvasc PO and discontinue IV Nitroglycerin 4 hours after dose. 25. Ventricular Arrhythmia Protocol 1. For PVC greater than 6/minute, multifocal, QRS on T wave, runs of bigeminy V-tach with a pulse: a. Lidocaine 1 mg/kg IV stat and 0.5 mg/kg in 5-10 minutes b. Lidocaine Drip 2 Grams /250 ml D 5 W at 15 ml/hr (2mg/min) c. Magnesium Sulfate 2 Grams/100 ml D 5 W IV over 1 hour d. Call physician: 2. For pulseless Ventricular Tachycardia or Ventricular Fibrillation: a. Defibrillate 200 joules (watts/sec) STAT For repeat, defibrillate at joules if unsuccessful b. Repeat at 360 joules if unsuccessful c. CPR and intubate d..epinephrine 1 mg IV push e. Amiodarone 300 mg mixed with 30 ml Normal Saline in syringe IV push may repeat Amiodarone 150 mg IV mixed with 30 ml Normal Saline in syringe IV push x 1 if unsuccessful 3. Start maintenance infusion of Amiodarone 900 mg in D 5 W 500 ml GLASS BOTTLE ONLY (1.8 mg/ml) a. Infuse at 1 mg/min (33ml/hr) x 6 hours only (deliver 360 mg in 6 hours) b. Infuse first 6 hours, reduce rate to 0.5 mg/min (17 ml/hr). Maximum dose 2.2 grams over 24 hours c. For breakthrough episodes of ventricular fibrillation or ventricular tachycardia, give Amiodarone 150 mg in 100 ml D 5 W IV over 1 minutes x 1 and call physician Page 5 of 6

6 PREPRINTED ORDERS FOR: CARDIAC SURGERY IMMEDIATE POST-OPERATIVE CVT POST OP (Page 6 of 6) 4. Call for stat ECG and Chest x-ray 5. Send stat K +, ABG, and Digoxin level if on Digoxin Contact pacer representative to reactivate internal defibrillator. V.O. Dr. Date/Time PA-C Date/Time Page 6 of 6