Intensive Care Electrolyte Replacement Orders for Hypothermia Therapy

736 Battlefield Blvd N, Chesapeake, VA 23320

THERAPEUTIC HYPOTHERMIA PROTOCOL
*****EMERGENCY DEPARTMENT/INTENSIVE CARE UNIT*****
Allergies: ______Ht: ______Wt: ______Kg
Date
Ordered / Time
Ordered / 1. Admit to Intensive Care Unit:
a. Time of Arrest: ______
b. Time of Return of Spontaneous Circulation______
c. Time Cooling Initiated: ______
2. INCLUSION CRITERIA:
Cardiac Arrest with initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia with
return of spontaneous circulation (ROSC). Initiate hypothermia therapy as soon as possible.
3. EXCLUSION CRITERIA:
a. DNR/DNI or severely impaired cognitive status prior to cardiac arrest
b. Glascow Motor Scale GREATER than 5 or patient is following commands
c. Pulseless GREATER than 60 minutes
d. GREATER than 12 hrs since return of Spontaneous Circulation (ROSC) Initiate hypothermia therapy as soon as possible.
e. Metastatic Cancer or other terminal illness
f. Comatose baseline due to CNS depressing drugs, ICH or SAH, or other possible causes (i.e. drug intoxication, pre-existing coma)
g. Sepsis as etiology for arrest
h. Uncontrollable bleeding
i. Significant trauma, especially intra-abdominal such as splenic or liver laceration (due to increased risk of bleeding)
4. CONSULTS:
a. Pulmonary / Critical Care Medicine MD______
b. Cardiology ______
c. Neurologist ______
d. OB/GYN consult if pregnant:______
e. Vascular Access Team for Central Line or PICC and Arterial line insertion
f. Rapid Response Team (CODE SILVER - ICE)
g. Notify Nursing Supervisor immediately for admission to ICU
h. Other: ______
5. EQUIPMENT LIST:
a. Arterial Line Kit (radial, ulnar, or femoral site)
b. Central Line Insertion Kit
c. Two 1 liter bags of 0.9% NaCL at 39.2˚F or 4˚C
d. Hypothermia Cooling System
e. Cooling Pads – Use sizing chart to determine size ( for torso and upper and lower limbs)
f. Foley Catheter Temperature probe (preferred monitoring route)
g. Esophageal Temperature probe (secondary route if patient anuric or unable to insert Foley catheter)
h. Rectal Temperature probe (use only if Foley catheter or Esophageal temperature inaccessible)
i. Neuromuscular Blockade Equipment (BARD Pump and Peripheral Nerve Stimulator)
j. Fluid Warmer (if needed)
k. CVP Monitoring Kit
l. NGT insert orally if not contraindicated
m. Forehead sensing / Ear sensing probes for oxygen saturation.
Date
Ordered / Time
Ordered / *****EMERGENCY DEPARTMENT/INTENSIVE CARE UNIT*****
6. INITIAL LABORATORY ORDERS: STAT
a. Urine HCG on all women of child bearing age (less than 55) Obtain serum if urine not available.
b. CBC/Platelets/ PT / PTT /INR / Fibrinogen
c. CMP / Magnesium / Ionized Calcium / Phosphorous
d. Amylase / Lipase / Lactic Acid
e. CPK MB / CK / Troponin
f. Pan Culture – Blood Culture ( 2 Sets), Urine Culture, Sputum Culture (if appropriate)
g. Urinalysis
h. ABG / ScvO2
□ Toxicology screen if appropriate MD must check √ box to order
7. DIAGNOSTIC TESTS:
a. 12 Lead EKG STAT, then Q 8 hrs X 2 Reason for test: post cardiac arrest or MI
b. Chest X Ray Portable STAT: Repeat in am and in 72 hrs.
c. Echocardiogram Routine unless specified below: to determine ejection fraction.
MD must check √ box to order
□ ASAP per Cardiology request
□ Within 24 hours of initiation of protocol
□ Repeat in am
d. CT Scan of Head without contrast to r/o intracranial hemorrhage, or other causes of
coma STAT
e. EEG (routine)
8. VENTILATOR MANAGEMENT:
Mode: A/C Rate: 15 VTE: 6- 8 ml/kg of IBW PEEP: 5
FiO2 to maintain O2 saturation > 94%
ABG in 30 minutes (Temperature correct) If unable to temp correct subtract 10mm PCO2 and 20mm PO2.
Inline nebulizer with Albuterol 2.5 mg /Atrovent 0.5 mg Q 4 H PRN for wheezing
Ventilator Temperature – Respiratory Therapy to turn heater to non invasive setting
(89.6˚F or 32˚C) during cooling and maintenance phase.
9. LINE / TUBE PLACEMENT:
a. Place 2 large bore peripheral lines
b. Place arterial line (radial, ulnar, or femoral) for blood pressure monitoring prior to cooling.
c. Place central line or PICC line prior to initiation of hypothermia
d. If patient requires catherization, arterial sheath and central line can be placed in cath lab by Cardiologist.
e. Insert temperature sensing Foley Catheter prior to cooling
f. Insert oral gastric tube and connect to low intermittent suction. Clamp for meds.
Date
Ordered / Time
Ordered / *****EMERGENCY DEPARTMENT/INTENSIVE CARE UNIT*****
10. MONITORING: INDUCTION/COOLING AND REWARMING PHASES:
a. Vital Signs, Core Body Temperature, and Water Temperature of Cooling Unit
- every 15 minutes during induction, until less than 93.2 ˚ Fahrenheit (34 ˚ Celsius),
- then every 30 minutes times 2
- and then every 1 hour
b. MAP Overall Goal 70-100 (MAP 70-80 if ON Pressors; MAP 80-100 if NOT on Pressors)
c. ScVO2 Goal 65 % or greater
d. Notify MD if urine < 2ml/kg IBW q4H
e. Modified Ramsay Scale GOAL 2-3 (Achieve baseline then use during rewarming phase)
- Every 30 minutes till Ramsey Goal is achieved
- then every 1 hour
Light / Awake / Deep / Asleep
1 / Anxious, agitated or restless or both / 4 / Brisk response to light glabellar tap or loud auditory stimulus
2 / Cooperative, oriented and tranquil / 5 / Sluggish response to a light glabellar tap or loud auditory stimulus
3 / Responds to commands only / 6 / No response to a light glabellar tap or loud auditory stimulus
START PROPOFOL UNLESS OTHERWISE NOTED
PROPOFOL (DIPRIVAN) INFUSION (Concentration: 10 mg / ml)
(Agent of Choice unless specified by MD)
▪ Start Propofol IV Infusion at 50 mcg/kg/min
▪ Titrate by 5 – 10 mcg/kg/min every 5 minutes until sedation goal is achieved.
▪ Maximum infusion rate 100 mcg/kg/min
MD must check √ □ box to order
□ MIDAZOLAM (VERSED) INFUSION (Conc: 1 mg/ml) Start if Propofol is contraindicated
§ Bolus 1-2 mg IV
§ Start Midazolam Infusion at 1 – 3 mg/hr
▪ Titrate by 1 – 2 mg/hr until sedation goal is achieved
▪ Maximum infusion rate: 15 mg/hr
□ FENTANYL (SUBLIMAZE) INFUSION (1 mg/100 ml NS = 1000 mcg / 100 ml = 10mcg/ml )
▪ Start Fentanyl Infusion at 25 – 100 mcg/hr.
▪ Maximum infusion rate: 300 mcg/hr
f. Train of Four (TOF) per Neuromuscular Blockade Protocol GOAL 2 – 3 (See attached)
- Every 1 hour till TOF is at Goal
g. Central Venous Pressure Monitoring
- Every 1 hr GOAL CVP 8 mmHg- 20 mmHg during cooling /induction phase
- then q4 hours during maintenance phase
h. Assess skin
- Every 4 hours (pull pads back to fully assess skin)
i. Do not treat for Bradycardia if BP and urinary output acceptable.
j. Hypothermia therapy increases risk for bleeding. Notify MD for significant bleeding - may consider
terminating hypothermia therapy
Date
Ordered / Time
Ordered / *****EMERGENCY DEPARTMENT / INTENSIVE CARE UNIT*****
11. COOLING: INDUCTION PHASE - GOAL Temperature 89.6 – 93.2 ˚ F (32 – 34˚C) Target temperature 91.4˚F or 33˚C within 4 hours of ROSC. ***DO NOT COOL TO <32˚C (89.6˚F)***
a. Infuse 2 liters 0.9 % NaCL (1L per site concurrently) at 39.2˚F (4˚C) over 30 minutes or ASAP (PER
PERIPHERAL LINE ONLY) if no evidence of Pulmonary Edema or if not already done.
b. Obtain access (arterial line and central line)
c. Assess patient for baseline Ramsay Scale Score and Train of Four (TOF)
d. Initiate sedation and paralytic. All patients are to be paralyzed prior to hypothermia therapy
e. Attach Hypothermia Cooling Unit. Cooling pads to cover 40 % of total body surface
area (TBSA). Set Target Temperature at 91.4˚F (33˚C) DO NOT CUT PADS for any reason.
(Reference Hypothermia Cooling Unit Competency)
f. If UNABLE to achieve target core temperature WITHIN 4 HOURS, notify MD for further orders.
Consider ice packs to neck, groin, and axilla.
g. Room Temperature – Turn room thermostat to lowest setting during cooling and
maintenance phase
h. If patient requires Cardiac catherization procedure continue hypothermia therapy while in cath lab.
GUIDELINES FOR INFUSION OF VECURONIUM STANDING ORDERS
NO WAKE UP ASSESSMENT DURING COOLING PHASE
A. Patient MUST be on ventilator before this drug is administered.
B. Patient requires paralysis. If patient is not already paralyzed, administer a bolus of 100 mcg/kg Vecuronium IV. Patient weight ______kg.
C. Vecuronium infusion (20mg/20ml NS syringe via Bard Infusion Pump) to run at 1 mcg/kg/min
D. Perform and document initial current (mA’s) and Train of Four (TOF) prior to drug therapy.
Evaluate and chart “train of four” (TOF) q 1hr x 4hr, then q 4h x continuously.
GOAL = Maintain TOF between 2 and 3
E. If TOF < 2, decrease infusion by next increment using Bard infusion pump and check
TOF q 15min until desired range.
F. If TOF > 3, increase infusion by next increment using BARD infusion pump and check
TOF q 15 min until in desired range.
G. Eye care is to be provided q 24 hr with Lacrilube.
H. Patient positioning: Reposition patient q2hr to include passive ROM and other appropriate decubitus prevention measures as otherwise ordered.
I. If patient exhibits signs or symptoms of any adverse reaction to Vecuronium, notify MD immediately. Order required to discontinue infusion and for reversal agents.
Reversal Agents: Choose A or B to reverse Vecuronium MD must check √ box to order
□ A. 1. Neostigmine (Prostigmine) 0.5-2 mg IV. TOTAL not to exceed 5 mg.
2. Glycopyrrolate (Robinul) 0.2 mg IV for each 1mg of Neostigmine.
May be mixed in same syringe as Neostigmine.
3. Atropine 0.6 – 1.2 mg for each 0.5 – 2.5 mg of Neostigmine. Give 30 seconds
before Neostigmine.
□ B. 1. Endrophonium Chloride (Tensilon) 10 mg IV every 5 -10 minutes up to 40 mg.
To be given in conjunction with Atropine
2. Atropine 0.01 – 0.02 mg/kg (give before Tensilon)
Physician Signature: ______Date:______
Date
Ordered / Time
Ordered / ***** INTENSIVE CARE UNIT*****
12. SERIAL LABORATORY ORDERS:
NOTE: For ABG and Central Venous Blood – Use temperature correction when analyzing
ABGs and Central Venous Blood. The temperature should be written on a bright sticker
and attached to the syringe and it should be indicated when ordering the lab.
Follow Serial Laboratory checks per Hypothermia Electrolyte Replacement Protocol if used
a. ABG q 6 hrs and PRN
b. ScvO2 q6h until rewarming process complete. Call MD for Scvo2 <65
c. Lactic Acid q 6 hours until warming process complete
d. Repeat CPK – MB, CK, Troponin q 6 hours times 2
e. Ionized Calcium, CBC / PT / INR/PTT/ Fibrinogen/ BMP/ Mg / Phosphorous every 6 hrs
13. NUTRITION:
a. NPO
b. Nutrition Consult Day #3 (Do not start Tube feedings until rewarming process completed)
14. IV FLUIDS:
Infuse 2 liters (ROOM TEMPERATURE) of 0.9 % NaCL over 30 minutes if MAP < 80 and CVP < 8.
Give in addition to the 2 liters given at induction of therapy X 1 only.
CALL MD IF GOAL IS NOT MET
Maintenance IVF: D5NS at 75ml/hr unless specified by MD : ______
15. GI PROPHYLAXIS:
Pantoprazole 40 mg IV daily
16. VENOUS THROMBOSIS:
Sequential Compression Device
MD must check √ box below to order
□ Heparin 5000 units subcutaneously every 8 hours if less than 70 years old
□ Heparin 5000 units subcutaneously every 12 hours if greater than or equal to 70 years old
17. ANTIEPILEPTIC PROPHYLAXIS:
Keppra 1gm q12 IVPB
18. PRE-MEDICATION FOR PRBC & PLATELETS (unless hypothermic):
MD must check √ box below to order
□ Acetaminophen Liquid 160 mg/5ml – Give 650 mg per oral gastric tube X 1 dose
Diphenhydramine Liquid 25 mg/10ml – Give 25mg per oral gastric tube X 1 dose
OR
□ Acetaminophen Supp 650 mg X 1 per rectum
Diphenhydramine 25 mg IV X 1 dose only
19. BLOOD GLUCOSE CONTROL:
ALL BLOOD MUST BE DRAWN FROM ALINE/VASCULAR ACCESS DEVICE. DO NOT DO
FINGERSTICKS
- Give 1 unit Regular insulin SQ for 10mg/dl for BG >140.
- Initiate Intensive Insulin Therapy Infusion Protocol for BG >170 X 2 consecutively. (Scan protocol to pharmacy)
20. VASOACTIVE AGENTS: Hypotension MAP < 80
Levophed (Norepinephrine) Infusion: (4mg / 250ml ) Begin at 2 – 4mcg/min, titrate to
maintain MAP ≈ 70-80 mmHg. Maximum Dose: 30 mcg/min
Notify MD if unable to maintain GOAL. May consider Neosynephrine (Phenylephrine)
Drip
21. ANTIHYPERTENSIVES: Hypertension for MAP > 100 consistently
Nitroglycerin Infusion: ( 100 mg/ 250 ml) Begin at 10 mcg/min for MAP > 100 mmHg
(titrate to MAP 80-100) Maximum Dose: 200 mcg/min
Consider Esmolol for hypertension with tachycardia or with acute ischemia/MI w/o LV dysfunction. Call MD for further orders.
□ Esmolol (Brevibloc) 2.5gm/250ml NS. Start at 50mcg/kg/min and titrate by 50mcg/kg/min every
5-10 min. Call MD if more than 200mcg/kg/ min required. Maximum rate of 300 mcg/kg/min.
22. HEPARIN INFUSION THERAPY:
If patient is currently on or requires Heparin therapy post AMI/PCI:
a. Initiate Integrilin/Heparin protocol if ordered
b. Integrilin dosing does not change. Continue dosing based on original protocol.
c. Administer full dose Heparin bolus then reduce heparin protocol titration rate by 50% while patient is in the Cooling Phase.
d. Once patient begins warming phase, draw PTT stat and adjust heparin infusion based on ORIGINAL protocol rate.
23. RE-WARMING PHASE:
DO NOT PERMIT HYPERTHERMIA > 98.6° F (37°C) in the first 24 hours after cooling phase
a. Initiate 24 hours after target temperature reached.
b. Rewarm to 98.6 ˚ F (37 ˚C) over 12 hours.
c. Initiate “Warming Algorithm”
d. Hold all potassium containing fluids if serum K is > 3.5 immediately before and during
re-warming phase. DO NOT INITIATE rewarming until last drawn K level is known.
DO NOT INITIATE rewarming and notify MD if K >5.0.
e. Stop NEUROMUSCULAR BLOCKADE infusion after temperature reaches 96.8 ˚ F (36 ˚ C)
f . MANAGEMENT OF SHIVERING:
BEDSIDE SHIVERING ASSESSMENT SCALE (BSAS)
0 / No Shivering
1 / Mild: Localized shivering to neck and or chest
2 / Moderate: Shivering involving neck and/or chest and upper extremities
3 / Severe: Generalized (total body) shivering involving all 4 extremities
If Bedside Shivering Assessment Scale (BSAS) greater than or equal to 1:
Meperidine 12.5-25 mg IV q4-6 hours PRN shivering (not to exceed 100 mg) – AVOID in renal failure , history of seizures, MAO inhibitors, Buspar, SSRI Antidepressants, or late term pregnancy
Or (alternative use only if Meperidine cannot be used)
□ Dexmetatomidine 1mcg/kg IV over 10 minutes q4 hours PRN shivering (Not to exceed 24 hours)
g. Acetaminophen 650 mg via NGT or rectally every 4 hours if temperature spikes
greater than 98.6˚F (37˚C). Do not exceed 3 gm/day.
h. Maintain normothermia for 48 hours using acetaminophen. Use standard cooling blanket
to target temperature of 98.6˚F (37˚C) as needed to help maintain normothermia
24. ELECTROLYTE REPLACEMENT
If serum creatinine 2 or less initiate the Intensive Care Electrolyte Replacement for Hypothermia Therapy.
(See attached order set)
If serum creatinine greater than 2 initiate the Renal Electrolyte Replacement for Hypothermia Therapy.
(See attached order set)
Physician Signature: ______Date:______