DO NOT USE UNAPPROVED ABBREVIATIONS
PATIENT IDENTIFICATION LABEL
ELIZABETH, NJ
AUTHORIZATION IS HEREBY GIVEN TO DISPENSE THE GENERIC OR
APPROVED THERAPEUTIC EQUIVALENT UNLESS OTEHRWISE
SPECIFIED.
THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST: Maintenance Orders
PAGE 1
DATE:
_______________
 PHONE ORDER  ORDER READ BACK AND VERIFIED WITH
 VERBAL ORDER
ORDERING PHYSICIAN FOR T.O./V.O.
MD NAME:________________/ _____________ R.N.
TIME:
_______________
ORDERED
1. Maintenance/ICU Phase/Nursing orders:
 Surface cooling pads with cooling device set to automatic mode with goal temperature of 33°C.
 Goal temperature is 33°C for 24 hours from initiation of cooling protocol.
 Replace electrolytes as needed every 6 hours. See pharmacy PRN orders:
 Monitor for shivering and document Bedside Shivering Assessment Scale (BSAS) every hour. Medicate as
necessary.
 Monitor skin condition; reposition every 2 hours.
 If the patient awakens and follows commands at any time, DISCONTINUE the Hypothermia Protocol and allow the
patient to passively warm.
2. Pharmacy Orders:
IV fluids:
□ 1000 mL NS at ______ mL/hour. Infuse NS at 4°C until target temperature is reached. Avoid subclavian and jugular
lines.
Analgesia/Sedation:
 Fentanyl 50 mcg IV bolus followed by Fentanyl 500mcg/100mL D5W IV infusion at 50 mcg/hr. Titrate to pain scale
≤3. Increase by 10 mcg/hr every 15 minutes until pain goal met.
 Lorazepam (Ativan®) 20mg/100mL D5W IV infusion at 2mg/hr. Increase by 1 mg/hr every 30 minutes to maintain
BIS score 40-60.
 Midazolam (Versed®) 50 mg/100ml D5W IV infusion at 1mg/hr. Increase by 1 mg/hr every 30 minutes to maintain
BIS score 40-60.
 Propofol (Diprivan®) 1000mg/100mL IV infusion at 5 mcg/kg/min. Increase by 5 mcg/kg/min every 5 minutes to
maintain BIS score 40-60.
Shivering protocol during cooling and re-warming period (48 hours):
 Acetaminophen (Tylenol®) 650mg oral solution every 6 hours via OGT for 24 hours; then q6h PRN T≥38.3°C
 Acetaminophen (Tylenol®) 650 mg suppository every 6 hours rectally for 24 hours, then Q6h PRN T T≥38.3 °C
 Magnesium sulfate 2 gm/50mL Sterile Water IVPB PRN shivering once.
 Meperidine (Demerol®) 50 mg IV Push slowly over 10 minutes every 1 hour PRN shivering not responsive to
magnesium sulfate. May repeat once.
 Vecuronium 0.1mg/kg IVP over 1 to 2 minutes once PRN shivering unresponsive to magnesium sulfate or meperidine
 Start Vecuronium 100mg/100mL D5W IV infusion at 1mcg/kg/min. Increase by 1mcg/kg/min every hour to maintain 1
to 2 twitches with TOF monitor.
PRN orders during cooling period (24 hours):
 KCl 10meq/100mL IVPB every 6 hours PRN for Potassium <3.4 mmol/L
 Magnesium sulfate 2gm/50mLSterile Water IVPB every 6 hours PRN for Magnesium <1.8 mg/dL
 Calcium Chloride 1 gm IV push every 6 hours PRN for serum Calcium <6 mg/dL
Unit Secretary/RN:
_____________________________________ Date&Time:___________________
PHYSICIAN SIGNATURE________________________________
DATE/TIME: ____________________________
ORDER NOTED BY:
_____________________________________ Date&Time:___________________
RN’s Full Signature
USE BALL POINT PEN ONLY
Revised 10/25/12
DO NOT USE UNAPPROVED ABBREVIATIONS
PATIENT IDENTIFICATION LABEL
ELIZABETH, NJ
AUTHORIZATION IS HEREBY GIVEN TO DISPENSE THE GENERIC OR
APPROVED THERAPEUTIC EQUIVALENT UNLESS OTEHRWISE
SPECIFIED.
THERAPEUTIC HYPOTHERMIA AFTER CARDIAC ARREST: Maintenance Orders
PAGE 2
DATE:
_______________
 PHONE ORDER  ORDER READ BACK AND VERIFIED WITH
 VERBAL ORDER
ORDERING PHYSICIAN FOR T.O./V.O.
MD NAME:________________/ _____________ R.N.
TIME:
_______________
ORDERED
DVT prophylaxis:
 Complete the VTE risk assessment in SCM.
GI Prophylaxis:
 Famotidine (Pepcid ® ) 20 mg via OG tube every 12 hours
 Lansoprazole (Prevacid®) 30 mg via OG tube daily.
Opthalmic lubricant:
 Lanolin/Mineral Oil/Petrolatum ophthalmic (Lacrilube®) apply 1” to each eye every 6 hours
3. Lab orders
 BMP, Magnesium, Calcium, Phosphorus, lactate, CBC, PT, PTT and ABG every 6 hours until normo-thermic.
 CKMB, CPK, Myoglobin, Troponin, q8h x 2.
4.
Nutrition
□ NPO for 48 hours except for medications through OGT.
5. Rewarming Phase/Nursing orders:
 At 24 hours, begin re-warming to 36.5°C over 12 hours (0.3°C/hr) using the surface cooling device at moderate
setting.
 Keep temperature at 36.5 to 37°C with cooling device for next 24 hours.
 Continue sedation at current rate until normo-thermic; then titrate off as tolerated
 Discontinue vecuronium infusion, if still infusing.
 Monitor and record vital signs and temperature every 15-30 minutes until normo-thermic.
6. Other Orders:
Unit Secretary/RN:
_____________________________________ Date&Time:___________________
PHYSICIAN SIGNATURE________________________________
DATE/TIME: ____________________________
ORDER NOTED BY:
_____________________________________ Date&Time:___________________
RN’s Full Signature
USE BALL POINT PEN ONLY
Revised 10/25/12