ICUCCU ADULT THERAPEUTIC HYPOTHERMIA ORDER SET PATIENT LABEL DRUG

ICU/CCU Adult Therapeutic Hypothermia Order Set

Patient Label

Drug Allergies:

Ht. ________ Wt. _______Kg.

Living Will:

 Yes  No

Durable Healthcare Power of Attorney:

 Yes  No

Code Status:

 Full Code

 Do Not Resuscitate (Tan Chart Required)

Limited Code to include:

 CPR

 Intubation

 Defibrillation

 Cardiac Drugs

 Pacemaker

DATE/TIME

ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated.

Noted by Date/Time

Diagnosis:

Inclusion and exclusion criteria are to serve as a guide for decision-making.

Inclusion Criteria: (requires all four components)

1. Nontraumatic cardiac arrest with return of spontaneous circulation (ROSC)

2. Core Temperature greater than 34º Celsius (94º F) at presentation.

3. Time to initiation of hypothermia is less than 6 hours from ROSC

4. Comatose after ROSC: GCS less than 8 AND No purposeful movement to pain

Exclusion Criteria: (any one of the following)

1. Conflict with advanced directives DNR/DNI status

2. Uncontrolled Gastrointestinal Bleeding

3. Patient requiring Mannitol therapy

4. Cardiovascular instability as evidenced by: uncontrollable arrhythmias, refractory

hypotension (unable to achieve target MAP 65 mmHg despite interventions)

5. Sepsis as suspected cause of cardiac arrest

6. Suspected intracranial hemorrhage

7. Major intracranial, intrathoracic, or intraabdominal surgery within 14 days

8. Gravid pregnancy

 Admit to ICU/CCU

Attending Physician responsible for hypothermia _____________________________

Time of Arrest:___________________________________________

Time of Return of Spontaneous Circulation:____________________

Time Cooling Initiated: ____________________________________

Time Target Temperature Obtained: _________________________

( Begin 24 hour cooling phase once target temperature obtained)

Consult:

 Pulmonary consult:_____________________________________________

 Cardiology consult: _____________________________________________

 ________________________________________ for arterial line placement

 _______________________________ for Hypothermia Catheter Placement

• _______________________________service for addition central venous catheter or PA catheter as needed

*2PO*

*2PO*

Physician’s Signature

Form No. P9900 (03/09) Medical Services Page 1 of 6

ICU/CCU Adult Therapeutic Hypothermia Order Set

Patient Label

DATE/TIME

ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated.

Noted by Date/Time

Patient Care Orders:

1. Initiate endovascular hypothermia system (preferred method) and cool for 24 hours

once target temperature has been obtained, set machine to 33 º Celsius (91º F).

2. If unable to use hypothermia catheter, initiate passive /active cooling methods.

3. No heated humidification on the ventilator.

4. Maintain PO₂ 90-100 millimeters Mercury and normal pH range.

(must be temperature corrected)

5. Notify Physician of any of the following:

A. MAP less than 60 despite use of vasopressors

B. Urine output greater than 300 milliliters per hour or less than 30 milliliters per hour

for two consecutive hours.

C. Temperature greater than 35º Celsius (95º F) during maintenance phase despite

implementation of all ordered interventions.

D. If patient has recurring arrhythmias, discontinue active cooling, begin re-warming

and call MD.

6. Maintain hypothermia for 24 hours once target temperature of 33º Celsius (91º F) has been obtained.

A. Temperature goal 33º Celsius (91º F).

B. Monitor primary continuous temperature with the Foley bladder probe

C. Obtain a secondary temperature source (Rectal or Esophageal or PA Catheter) at least every 2 hours to ensure accuracy of primary temperature source.

7. Do NOT bathe patient during hypothermic or re-warming period.

***** If Endovascular Cooling Catheter can not be obtained, the following cooling techniques will be implemented: *****

Passive Convective Cooling – check appropriate boxes

 Expose patient, dampen skin, cooling fan

 Cooling blanket set to 33º Celsius (91º F)

 Reduce temperature in patient’s room

 Ice packs applied to axilla / skin

 Naso-Gastric lavage with ice cold 0.9% Normal Saline repeat as needed

Physician’s Signature/Date/Time:

Form No. P9900 (03/09) Medical Services Page 2 of 6

ICU/CCU Adult Therapeutic Hypothermia Order Set

Patient Label

DATE/TIME

ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated.

Noted by Date/Time

Labs:

Labs to be drawn NOW:

 Complete Blood Count (CBC), PT/PTT, INR ABG’s (temp corrected)

 Complete metabolic profile (CMP)

• Creatine phosphokinase (CPK), Troponin I, Creatine Kinase Myocardial Bands (CK- MB)

• Progressive Urinalysis

• Lactate

• MRSA Nasal Swab

• HCG if child bearing age female

Labs to be drawn every 6 hours x 24 hours:

 CMP, ABG’s (temp corrected), CBC, PT/PTT, Phosphorus

 CPK, Troponin I, CK-MB

Labs to be drawn 12 hours post arrest:

 Blood cultures X 2

Daily Diagnostic Testing:

 BMP

 CBC

 ABG’s

 PCXR (while intubated)

• EKG

Patient Care – Induction Phase:

 Administer sedation prior to initiation of neuromuscular blocking agents

 Obtain baseline data with Peripheral Nerve Stimulator prior to initiation of neuromuscular blocking agents and sedatives (Peripheral Nerve Stimulator baseline will be acquired using Train of Four)

 Baseline goal of Train of Four is 4 out of 4 twitches (not to exceed 40-50 milliamps)

 Train of Four will be performed every 15 minutes during initiation and titration of neuromuscular blocking agent until goal of 2 out of 4 twitches is achieved (do not exceed 40-50 Milliamps)

 Once goal of 2 out of 4 twitches is achieved, Train of Four will be performed every 2 hours during paralytic infusion

 Insert Naso-Gastric Tube or Oral-Gastric Tube and connect to intermittent low wall suction if not done in ED

 Follow Continuous IV Insulin Infusion Orders (Bayhealth Form P8728)

 Check Arterial Blood Gases (ABG) baseline and repeat at 33º Celsius (91º F).

***Be sure that all ABG results are temperature corrected***

 Hemoccult stool daily

 Monitor neurological status per Critical Care protocol. Notify physician for shivering myoclonus or seizure activity

Physician’s Signature/Date/Time:

Form No. P9900 (03/09) Medical Services Page 3 of 6

ICU/CCU Adult Therapeutic Hypothermia Order Set

Patient Label

DATE/TIME

ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated.

Noted by Date/Time

MEDICATION ORDERS:

Patient’s total body weight: ________ Kilograms

Sedation/Narcotics:

Administer the following medications prior to initiation of cooling:

Administer sedation prior to initiation of neuromuscular blocking agents

 1. Fentanyl ________ micrograms per hour intravenous continuous infusion (suggested initial rate: 2 micrograms per kilogram per hour- not to exceed 150 micrograms in an hour)

 2. Fentanyl _________ micrograms intravenously PRN every 4 hours for agitation or breakthrough pain (suggested: 25 – 50 micrograms)

 3. Propofol___________ micrograms per kilogram per minute continuous intravenous infusion while receiving chemical paralysis (suggested initial rate: 5 micrograms per kilogram per minute). Increase rate in 5 – 10 microgram per kilogram per minute increments every 5 minutes until goal Ramsey Sedation Scale less than 3 achieved

 4. Vecuronium Bolus: 0.1 milligrams per kilogram intravenous bolus

Continuous Infusion: Start continuous infusion 20-40 minutes after initial bolus dose at 1 microgram per kilogram per minute

• 5. Vecuronium 0.1 milligrams per kilogram intravenously every 1 hour as needed for shivering

Vasopressors:

 6. Norepinephrine (Levophed) IV-start at 0.5 micrograms per minute and titrate as needed to keep MAP greater than 65

 7. Other pressor agent: ______________________________________________

Vasodilators:

 8. Nitroglycerin IV-start if systolic blood pressure over ____________________

Start at 5 micrograms per minute and titrate until systolic blood pressure is less than _____________

Intravenous Fluids:

 9. Infuse 2 liters of 4º Celsius (39.2º F) of 0.9% normal saline solution IV over 30 minutes if not already administered in ED.

 10. Maintenance IV of 0.9% normal sodium chloride at _____________ milliliters per hour

Physician’s Signature/Date/Time:

Form No. P9900 (03/09) Medical Services Page 4 of 6

ICU/CCU Adult Therapeutic Hypothermia Order Set

Patient Label

DATE/TIME

ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated.

Noted by Date/Time

Other Medications:

 11. Pantoprazole 40 milligrams intravenously daily

 12. Ophthalmic lubricant oint to both eyes every four hours and as needed while on neuromuscular blocking agents

*** Do not replace potassium during the Cooling Phase unless it is less than 3.5 mEq/L.***

Call MD for specific replacement dose

*** All intravenous solutions should be Dextrose free during cooling and re-warming phase***

***** Do not administer any medication to the hypothermic patient if medication is labeled “Do not refrigerate.”**** (Example: Mannitol)

DVT Prophylaxis Choose one of the following:

 1. Sequential compression devices (SCD)

 2. Enoxaparin 40 milligrams subcutaneously every day

 3. Enoxaparin 30 milligrams subcutaneously every day for creatinine clearance less than 30

 4. Heparin 5000 units subcutaneously every 8 hours

Blood Glucose Control:

 Blood Sugar to be regulated as per Continuous IV Insulin Infusion Orders

(See Bayhealth form P8728)

 Continue Insulin drip until patient is able to eat

• Consult Physician for new glucose management orders

Patient Care – Re-warming Phase:

 24 hours following achievement of target temperature, initiate re-warming

 Time re-warming started:________________________________________________________

 Time target temperature of 36.1º Celsius (96.9 º F) met: __________________

 Notify physician of Central Venous Pressure (CVP) less than 4

 Empty Foley at start of re-warming. Strict I&O

 Continue sedation, analgesics and neuromuscular blocking agents until temperature is equal to or greater than 36.1º Celsius (96.9º F) (discontinue neuromuscular blocking agents first, then wean sedation and analgesic infusions)

 Acetaminophen 650mg via NGT or rectally every 4 hours PRN, if temperature spikes greater than 37 º Celsius (98.6ºF) during re-warming phase

 Do not permit hyperthermia (37º Celsius/98.6º F) in the first 24 hours after cooling phase

 Remove femoral line when patient has been 36.1º Celsius (96.9º F) for 48 hours

Physician’s Signature/Date/Time:

Form No. P9900 (03/09) Medical Services Page 5 of 6

ICU/CCU Adult Therapeutic Hypothermia Order Set

Patient Label

DATE/TIME

ORDERS- Another generic/drug product identical in dosage and content of active ingredients may be dispensed unless otherwise indicated.

Noted by Date/Time

Endovascular Temperature Management System Re-Warming:

• Activate re-warming program on the machine for 0.5 º Celsius / hour for target temperature of 36.1º Celsius (96.9º F)

• May place warm blankets (Do not use Bair Hugger)

• Target temperature - 36.1-37º Celsius (96.9-98.6º F) to be obtained in 6-8 hours; STOP re-warming once 36.1º Celsius (96.9º F) is reached to prevent overshoot

• Maintain the machine at 36.1º Celsius (96.9º F) for 18 hours once target temperature has been achieved

Passive Cooling Therapeutic Hypothermia Re-Warming:

• Remove Cooling Blanket and cover patient with dry sheets

• Resume passive cooling methods if temperature increases more than 1º Celsius per hour or exceeds 37º Celsius (98.6º F)

Labs:

 BMP, ABG’s, Lactate every 6 hours until temperature 36.1º Celsius (96.9º F)

Medications:

 Meperidine (Demerol) 12.5 milligrams intravenous may repeat in 5 minutes times one dose for shivering during re-warming phase only

**** If above methods are ineffective call physician for further orders (may need to restart neuromuscular blocking agents and sedation)***

Potassium Replacement to be used ONLY in Re-warming Phase:

 If at start of re-warming phase, serum Potassium level is 3.5mEq/L or below, give Potassium Chloride 10 mEq’s in 100 milliliters sterile water IVPB through central line

over 1 hour

• Obtain serum Potassium level 1 hour post infusion of each Potassium piggyback. If serum Potassium level is 3.5 mEq/L or below, repeat infusion of Potassium 10 mEq’s IVPB until it reaches 3.6 or above. Serum Potassium level must be checked after each Potassium piggyback administration.

**Potassium replacement will only be used during re-warming phase as needed**

Physician’s Signature/Date/Time:

Form No. P9900 (03/09) Medical Services Page 6 of 6