PHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG

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1 DRUG AND TREATMENT Condition/Status This powerplan is only intended for use in those patients having symptoms related to alcohol withdrawal. See DSM-IV-TR criteria listed in the Alcohol Withdrawal ICU Reference Text.(NOTE)* Orders may be implemented only if patient is in ICU, or EDand is being transferred to ICU, or in an ICU setting.(note)* Communication Order Initiate PULM ICU Alcohol Withdrawal for patients with an for Alcohol Severity Assessment Scale Score of 6 or greater Alcohol Withdrawal ICU Reference Text Right click to view reference text for DSM-IV-TR, Severity Assessment Scale & Ativan Dosing Regimens Patient Status Patient Status: Inpatient, Level of Care Intensive Care (8) Vital Signs Vital Signs Q15MINS Int, Once Severity Score is 5 or Less, modify frequency to Every 2 Hours while awake and Every 4 Hours While Asleep Nursing Orders Alcohol Withdrawal Assessment Q15MINS Int, Once Severity Score is 5 or Less, modify frequency to Every 2 Hours while awake and Every 4 Hours Communication Order Continue to reassess severty score and vital signs every 15 minutes after each Lorazepam (Ativan) dose. Once score is 5 or less, resume monitoring severity score every 2 hours while awake and every 4 hours while asleep. Elevate Head of Bed 30 Degrees Communication Order Obtain ABG if Ramsay Sedation Score is greater than 3, respiratory rate is less than 12, or there is evidence of respiratory distress or depression Notify Provider Patient is experiencing seizures Notify Provider Patient has persistent alcohol severity score greater than or equal to 6 ( for a duration greater than 2 hours) Notify Provider Vital Signs HR > 120, SBP > 170, DBP > 100, RR < 12, SpO2 < 90 Notify Provider ABG Results PaO2 < 60, ph < 7.35 Medications Give all Lorazepam (Ativan) doses based on Alcohol Withdrawl Severity score. Give all doses IV if severity score is greater than or equal to 8. If severity score is less than 8, doses may be given IV if patient is unable to tolerate PO.(NOTE)* Page 1 of 6

2 DRUG AND TREATMENT Initial Alcohol Withdrawal Regimen Ativan initial range protocol 1-4mg IV PUSH, Q15MINS Int, PRN Other (see comment) (DEF)* doses may be given IV if patient is unable to tolerate PO. Dose based on Alcohol Withdrawal Assessment score. NOTIFY ORDERING PHYSICIAN IF PATIENT SWITCHED TO THE Ativan Escalated Alcohol Withdrawal Regimen * Reassess every 15 minutes and repeat dose based on the Ativan initial range protocol and all * Ramsay sedation score is less than 3 ** Hold for Ramsay sedation score greater than 3 and notify physician ** 1-4mg PO tab, Q15MINS Int, PRN Other (see comment) Comments: Titrate all Lorazepam (Ativan) doses based on Alcohol Withdrawl Severity score. doses may be given IV if patient is unable to tolerate PO. Dose based on Alcohol Withdrawal Assessment score. NOTIFY ORDERING PHYSICIAN IF PATIENT SWITCHED TO THE Ativan Escalated Alcohol Withdrawal Regimen * Reassess every 15 minutes and repeat dose based on the ativan initial range protocol and all ** Hold for ramsay sedation score greater than 3 and notify physician ** Page 2 of 6

3 DRUG AND TREATMENT 1-4mg PO tab, Q15MINS Int, PRN Other (see comment) Comments: Titrate all Lorazepam (Ativan) doses based on Alcohol Withdrawl Severity score. Give all doses IV if severity score is greater than or equal to 8. If severity score is less than 8, doses may be given IV if patient is unable to tolerate PO. Dose based on Alcohol Withdrawal Assessment score. NOTIFY ORDERING PHYSICIAN IF PATIENT SWITCHED TO THE Ativan Escalated Alcohol Withdrawal Regimen * Reassess every 15 minutes and repeat dose based on the Ativan initial range protocol and all ** Hold for ramsay sedation score greater than 3 and notify physician ** 1-4mg PO tab, Q15MINS Int, PRN Other (see comment) Give all doses IV if severity score is greater than or equal to 8. If severity score is less than 8, doses may be given IV if patient is unable to tolerate PO. Dose based on Alcohol Withdrawal Assessment score. NOTIFY ORDERING PHYSICIAN IF PATIENT SWITCHED TO THE Ativan Escalated Alcohol Withdrawal Regimen * Reassess every 15 minutes and repeat dose based on the ativan initial range protocol and all ** Hold for ramsay sedation score greater than 3 and notify physician ** Page 3 of 6

4 DRUG AND TREATMENT Escalated Alcohol Withdrawal Regimen Ativan escalated range protocol 3-6mg IV PUSH inj, Q15MINS Int, PRN Other (see comment) (DEF)* doses may be given IV if patient is unable to tolerate PO..After 3 consecutive doses on the Ativan Initial Alcohol Withdrawal Regimen, and the patient severity score is not changed SEVERITY SCORE ATIVAN DOSE 12 or greater 6 mg 10 to 11 5 mg 8 to 9 4 mg 6 to 7 3 mg * Give the first dose based on the Ativan Escalated Alcohol Withdrawal Regimen. * Reassess every 15 minutes and repeat dose based on the Ativan Escalated Alcohol Withdrawal Regimen and if all mmhg ** Hold for Ramsay sedation score greater than 3 and notify physician ** 3-6mg PO tab, Q15MINS Int, PRN Other (see comment) doses may be given IV if patient is unable to tolerate PO. After 3 consecutive doses on the Ativan Initial Alcohol Withdrawal Regimen, and the patient severity score is not change. Vitamin Supplement Vitamin B1 100 mg inj IVPB DAILY SEVERITY SCORE ATIVAN DOSE 12 or greater 6 mg 10 to 11 5 mg 8 to 9 4 mg 6 to 7 3 mg * Give the first dose based on the Ativan Escalated Alcohol Withdrawal Regimen. * Reassess every 15 minutes and repeat dose based on the Ativan Escalated Alcohol Withdrawal Regimen and if all mmhg ** Hold for Ramsay sedation score greater than 3 and notify physician ** Page 4 of 6

5 DRUG AND TREATMENT Antihypertensives Catapres 0.1 mg tab PO Q8H, PRN Other (see comment) Comments: For systolic blood pressure GREATER than 140 mmhg or diastolic blood pressure GREATER than 95 mmhg Antipsychotic Haldol 5 mg inj IV PUSH Q4H, PRN Other (see comment) Comments: For hallucinations and/or agitation not relieved by Lorazepam (Ativan). Total daily dose should not be greater than 20 mg. ** Hold for Ramsay sedation score greater than 3 and notify physician ** IV Solutions Banana Bag IV Set (IVS)* Sodium Chloride 0.9% IV bag Rate: 100 ml/hour thiamine IV drip 100 mg folic acid IV drip 1 mg MVI ml Laboratory Comprehensive Metabolic Panel Complete Blood Count. Prothrombin INR Partial Thromboplast Time Phosphorus Magnesium Level Liver Profile Toxicology Screen 12 - Urine, If not previously done Alcohol Serum, If not previously done Respiratory Pulse Oximetry (Continuous) Special Instructions: Monitor continuously. If O2 sat less than 90% draw ABG ABG/VBG Notification Timed Study, PRN, if Ramsay Sedation Score is greater than 3, respiratory rate is less than 12, or there is evidence of respiratory distress or depression Consults Page 5 of 6

6 DRUG AND TREATMENT Social Work Consult Other - See Special Instructions, Discharge Pending, Screen for Alcohol Withdrawal Orderset initiation Consult Pharmacy Stat, Kinetics Dosing, Review medication profile for previously sedating medications and contact physician to hold once clarified Page 6 of 6