COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders
DATE &
TIME
Page 1 of 4
Admitting Physician: ________________________________________________________
ALLERGIES: _____________________________________________________________
1. Goal Temperature: 33°C or 91.4°F as quickly as possible
2. Maintain patient temperature at 33° C for 24 hrs from the time < 34°C is achieved.
3. Initial labs:
 CBC
 TPN Panel
 Liver Panel
 PTT/PT
 CPK
 Troponin
 BNP
 ABG
 BHCG (If female of child bearing age)
 Art Lactate
 Fibrinogen
 Cortisol level
 Ca ++ Ionized
 Lipase
 Amylase
4. Non-Contrast Head CT to R/O Bleed (Pt not a candidate for hypothermia if bleed present)
5. Apply continuous temperature monitoring: (Required for operation of the cooling machine)
 Insert esophageal temperature probe
 Insert Urinary/Bladder temperature probe
6. Set up for cuff or arterial blood pressure monitoring per physician' s orders
7. VS every 15 minutes, with particular attention to arrhythmia detection until goal temperature
obtained, then every 1 hr
8. Notify Physician if temperature < 32° C (89.6° F) or > 34° C (93.2° F)
9. Urine output every hour
10. Assess skin for burns caused by ice/cooling blankets every two hours
11. Keep Head of Bed (HOB) greater than 30 degrees at all times
12. Turn off ventilator heating unit
13. Pain, Shivering, & Sedation (See: Shiver score below; RASS score on pg 2 of orders)
 Fentanyl loading dose 50 mcg slow IV push over 2 min
 Fentanyl IV Drip (Concentration: 4mcg/ml) titrate from 0.5 to 1.0 mcg/kg/hr to maintain a
shivering score ≤ 1
 Midazolam IV Drip (Concentration: 1mg/1ml) titrate from 0.02 to 0.1 mg/kg/hr to maintain a
RASS score of -4 (Deep sedation)
Or
 Propofol IV Drip Titrate up to 75 mcg/kg/min to maintain a RASS score of -4 (Deep sedation)
14. Assess for shivering and document hourly
0= no shivering
1= one or more of the following: piloerection, peripheral cyanosis without other cause;
without visible muscular activity
2= visible muscular activity confined to one muscle group
3= visible muscular activity in more than one muscle group
4= gross muscular activity involving the entire body
15. Call physician for a score of 2 or more for greater than 5 minutes despite deep sedation
Continued on page 2
Date/Time: _____________________________
MD Signature: __________________________
MD#: _________________________________
COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders
Page 2 of 4
DATE &
TIME
16. Richmond Agitation Sedation Scale (RASS) every 1 hr & PRN during sedation &/ or paralysis
Richmond Agitation Sedation Scale (RASS)
Target
Description
+4
Combative, violent, danger to staff
+3
Pulls or removes tube(s) or catheters; aggressive
+2
Frequent nonpurposeful movement, fights ventilator
+1
Anxious, apprehensive , but not aggressive
0
Alert and calm
-1
Awakens to voice (eye opening/contact) >10 sec
-2
Light sedation, briefly awakens to voice (eye opening/contact) <10 sec
-3
Moderate sedation, movement or eye opening. No eye contact
-4
Deep sedation, no response to voice, but movement or eye opening to
physical stimulation
-5
Unarousable, no response to voice or physical stimulation
17. Paralysis
 Initiate Neuromuscular Blocker (NMB) if shivering occurs with adequate sedation:
 Train-of-four (TOF) every hour and maintain Neuromuscular Blocker (NMB) drip between 1-2 out
of 4 twitches
 Cisatracurium (Nimbex) IV Drip 0.15 mg/kg loading dose followed by a continuous infusion of
1- 3 mcg/kg/min titrate to 1-2 out of 4 twitches on TOF
Or
 Vecuronium IV Drip 0.8-1.2 mcg/kg/min titrate to 1-2 out of 4 twitches on TOF
18. Palliative care consult
19. External cooling
 Initiate cooling with Blanketrol III and Cooling Kit (Head wrap, Patient Vest, Lower Bed
Blanket)
Adjust target temperature to 33°C (91.4° F)
 Infuse chilled intravenous normal saline via peripheral line or femoral venous catheter at
____ ml/hr for ___ liters at 4° C
Do not exceed 2 liters
Stop infusion and notify physician if Sa02 < 90%
Do Not infuse chilled NaCl through a jugular or subclavian line
 Apply ice packs to axilla, neck and groin regions using sheets, towels, or pillowcases to
protect patient’s skin
Remove ice packs once goal temperature is reached and continue maintenance of
hypothermia with cooling blankets alone
Continued on page 3
Date/Time: _____________________________
MD Signature: __________________________
MD#: _________________________________
COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders
Page 3 of 4
DATE &
TIME
 Strict NPO
20. Notify physician of:
 Hypotension (MAP < 80 mm Hg)
 Oliguria
 Cardiac arrhythmias (Bradycardia < 35 bpm & hypotensive)
 Decerebrate/decorticate posturing
 Developing anisocoria (difference in pupil size)
 Seizure activity
21. Accucheck every 4 hr and PRN change in pt condition (Call physician if glucose > 180)
 Initiate Insulin Infusion Protocol for two consecutive blood glucoses > 180 mg/dL
 Glucose goal on infusion protocol is 140 mg/dL - 180 mg/dL
22. Potassium & Magnesium recheck every 4 hr and PRN
 Potassium Chloride 40 mEq IV at 20 mEq/hour every 6 hours PRN Hypokalemia < 3.4
Prior to rewarming, measure serum K+
Hold all K+ containing fluids if K+ > 3.5 immediately before and during rewarming
 Magnesium 2 gm IV PRN Hypomagnesemia levels less than 1.8
Rewarming Phase
23. Repeat lab every 6 hours & PRN until temperature ≥ 36.5°C (Begin when target temperature reached):
 CBC
 TPN Panel
 CPK
 Troponin
 ABG
24. Notify physician when 24 hrs of therapeutic hypothermia is reached (Temp maintained < 34°C)
25. Rewarming Schedule (No more than 0.5°C/hr until target temperature of 36.5°C):
Minimal Hours
Time
(Round to nearest hr)
Target Temp.
Begin to 2 hrs
33.5°C
2 hrs to 4 hrs
34°C
4 hrs to 6 hrs
34.5°C
6 hrs to 8 hrs
35°C
8 hrs to 10 hrs
35.5°C
10 hrs to 12 hrs
36°C
12 hrs to 14 hrs
36.5°C
Begin = 24 hrs at temp maintained < 34°C
Physician will determine the rewarming times
Recommended rewarming is 0.25 °C/hr
Continued on page 4
Date/Time: _____________________________
MD Signature: __________________________
MD#: _________________________________
COMMUNITY MEMORIAL HOSPITAL OF VENTURA
DOCTOR’S ORDERS
Therapeutic Hypothermia Physician Orders
Page 4 of 4
DATE &
TIME
26. When 24 hours of therapeutic hypothermia have been reached initiate rewarming with the aid of
the Blanketrol III
27. When patient rewarmed to ≥ 36.5°C (97.7° F) thermal blankets can be removed
28. Turn on ventilator heating unit after the patient reaches ≥ 36.5°C (97.7° F)
29. Monitor temperature and vital signs every 15 min during rewarming procedure
30. Stop NMB infusion after core temperature reaches 36° C (96.8° F)
31. Notify M.D. of temperature > 38°C (100.5° F)
32. Additional Orders:
Date/Time: __________________________
MD Signature: _______________________
MD#: ______________________________