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Post Cardiac Arrest Induced Hypothermia Protocol Orders
Orders preceeded by a “” must be checked to be initiated.
Orders preceeded by a “” will be initiated unless deleted by a single line and provider initials.
SICU/MICU Standard infusions to be used for all medications unless specified by order
Date
Admit to
Diagnosis
Consults
Invasive
Monitoring
Time of Return of Spontaneous Circulation (ROSC) :
 MICU
 SICU
Dr. ___________________________ Service
S/P Cardiac Arrest
Other: _________________________________
 Critical Care
 Cardiology __________________________________
 Anesthesia __________________________________
 Neurology consult at 48 hr post code_____________________________
 Other: ______________________________________
 Continuous cardiac monitoring
 Arterial Line per protocol
 Two large bore peripheral lines for 1) NSS volume resuscitation, & 2) NSS KVO/ meds
 Temperature sensing urinary catheter to monitor temp
 NG/OGT to low continuous suction with Salem Sump tube; interrupt only for med
administration per protocol.
 Central Line per protocol. CVP goal ___________ mmHg.
 Vigileo monitor
(All fluids used during the cooling and re-warming phases should be dextrose free if possible)
Cooling Phase
Time
Cooling
Started:
___________
Maintenance
Phase
BP & Volume
Management
Goal: reach target of 33o C in 4 hours
 If core temp is less than 33 o C, allow patient to warm to 33 o C
 Initiate cooling with ice packs to patient’s axilla and groin until cooling blanket in use.
 Insert rectal probe. Initiate cooling blanket using auto setting to reach target of 33 o C. Place
blankets under and over patient. Correlate rectal and foley temp to insure accuracy.
 Iced Saline Administration: initiate within 5 minutes of ICU arrival: Select one
 No cardiac shock present
 Infuse 1500 ml iced NSS (4 o C) IV as fast as possible.
 If core temp remains greater than 34.5 o C, infuse an additional 500 ml iced NSS over
10 minutes. Repeat 500 ml infusions of iced NSS until core temp less than 34.5 o C to a
max of 30 ml/kg total.
 Cardiac shock/LV failure/low EF
 Infuse 1500 ml iced NSS (4 o C) IV over 60 minutes.
 If core temp remains greater than 34.5 o C, infuse an additional 500 ml iced NSS over
30 minutes. Repeat 500 ml infusions iced NSS until core temp less than 34.5 o C to a
max of 30 ml/kg total.
 If unable to obtain target core temperature within 5 hours, contact provider for further
cooling orders.
 If patient awakens, discontinue active cooling & contact provider STAT. Begin active rewarming to reach temperature of 37 o C within 8 hours.
Urinary output replacement will take place as designated below:
 Replace urine output every hour with NSS (room temp). Titrate to previous hour’s urine output.
□ 0.5 ml/1 ml of IVF replacement to urine output
□ 1 ml/ 1 ml of IVF replacement to urine output
Observe closely for fluid overload.
Physician Signature_____________________________________ Date/Time __________________
Nurse Signature________________________________________ Date/Time __________________
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GOAL: MAP
greater than 80
mm Hg
If MAP remains less than 80 after initial cooling infusion, evaluate urine output.
If urine output is less than 0.5 ml/kg/hr, contact provider for additional volume replacement
If urine output is greater than 0.5 ml/kg/hr, initiate pressor below to maintain
MAP greater than 80
 NOREPInephrine (Levophed) IV start at 2 mcg/min. Titrate up to 12 mcg/min.
□ DOPamine (Inotropin) IV start at 2 mcg/kg/min. titrate up to 10 mcg/kg/min.
□ EPINEPHrine (Adrenalin) IV start at 0.01 mcg/kg/min. Titrate up to 0.1 mcg/kg/min.
For MAP over 100, initiate
 NITROglycerin IV start at 5 mcg/min. Titrate to maintain MAP 70 to 100.
Other _____________________________________________________________
Ventilator
Management
Analgesia
Settings:
Mode: SIMV PRVC P/S OTHER _______________
Vt _________ RR ______ FiO2__________ PEEP _______cm H20
 Continuous ETCO2 monitoring. Maintain ETCO2 at 35 to 45
 O2 Weaning Protocol - maintain O2 sat. greater than 92%
 No weaning parameters, vent weaning or wake-ups until core temp is 37˚C.
 Follow VAP Bundle otherwise.
Use Faces, Numeric Scale or FLACC to assess pain
Goal for analgesia: less than 3 or minimal pain behaviors
 FentaNYL (Sublimaze): Bolus with 25 mcg IV. Follow with continuous infusion at 25 mcg/hr.
Titrate up to150 mcg/hr.
Sedation
Goal for
sedation:
RASS (-3).
Prevention of
Shivering
Goal: BSAS
of 0
Use Richard Agitation-Sedation Scale (RASS) to assess sedation
Discontinue after patient is warmer than 36 o C and after NMBA discontinued.
 Propofol (Diprivan): Begin at 10 mcg/kg/min IV. Titrate up to 50 mcg/kg/min for RASS -3.
 DEXMEDetomidine (Precedex): Begin at 0.3 mcg/kg/hr IV. Titrate up to 0.7 mcg/kg/hr
Use Bedside Shivering Assessment Scale (BSAS) to assess shivering.
Basic Anti-Shivering Meds (NOT PRN):
 BusPIRone (Buspar): 30 mg per NG/OG every 8 hours x 3 doses. Start now.
 Acetaminophen (Tylenol): 650 mg per NG/OG every 6 hours x 4 doses. Start now.
If BSAS is not 0 within 30 minutes after the administration of Acetaminophen and/or
Buspirone, consider
□ Meperidine (Demerol): 50 mg IVP every 30 minutes PRN x 2 doses within 24 hrs. For patient
with CrCL less than 30, decrease dose to 25 mg IVP every 30 minutes PRN x 2 doses within 24
hrs.
Consider the use of Midazolam (Versed) if above medications not effective to control shivering.
If BSAS continues above 0 after the administration of the above meds,
begin a Neuro Muscular Blocking Agent (NMBA).
Before starting, verify that the patient is adequately medicated with analgesia and
sedative agents at goal and receiving mechanical ventilation.
Alert
pharmacy
that infusion
is to begin
 Vecuronium (Norcuron): Bolus with 0.1mg / kg IV. Begin infusion at 1 mcg /kg /min. Titrate to
maintain BSAS of 0.
If significant renal or hepatic dysfunction, consider:
 Cisatracurium (Nimbex): Bolus with 0.2 mg/kg IV. Begin infusion at 2.5 mg /kg /min. Titrate
to BSAS “0”.
 Petrolatum ophthalamic ointment (Lacrilube) to each eye every 4 hours while on NMBA
***Discontinue paralytics after patient is rewarmed to greater than 36 o C
Physician Signature_____________________________________ Date/Time __________________
Nurse Signature________________________________________ Date/Time __________________
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DVT
Prophylaxis
Other
Medications
Nursing
Electrolyte
Replacement
 Sequential compression devices (SCDs)
 Anti-embolism stocking: Knee-length
 Enoxaparin (Lovenox) 40 mg SC daily (unless on Heparin), start now.
For CrCl less than 30, decrease to 30 mg SC daily, start now.
 Famotidine (Pepcid) 20 mg IV q12h, start now.
For CrCL less than 50, decrease to 20 mg IV daily, start now.
 Call physician if Blood Sugar greater than 150 to obtain insulin protocol orders.
 Acetaminophen (Tylenol) 650 mg NG/OG/PR every 4 hours PRN for a temp
greater than 37 o C for total of no more than 4 gm per 24 hrs including doses for shivering.
 Critical care bed with rotational therapy
 Daily weight
 Diet: NPO
 Elevate head of bed 30 degrees when stable
 Apply hands free defibrillator pads
 Document intake and output monitoring every hour. Contact Provider for urine output less than
0.5 ml/kg/hr despite replacement volume
 Document vital signs and pain every hour and as needed.
 Monitor rectal temp, foley temp and water temp closely. Document per protocol: every 15
minutes during cooling until core temp has been reached, then every 30 minutes.
 Document RASS and BSAS every 30 minutes until goal is reached and then every hour.
 Perform neuro check using Glasgow Coma scale and document.
 Assess skin for breakdown every hour
 Do not bathe patient during cooling, maintenance, or warming phase
Hold Electrolytes for Serum Creatinine greater than 2 mg/dl and contact physician
Send STAT K+ and Mg++ level for any arrhythmia
Anticipated Re-warming Time _____________
POTASSIUM:
Cooling and Maintenance Phase. DISCONTINUE 8 HRS PRIOR TO REWARMING.
 Potassium: Repeat K+ level 1 hour after infusion
 K+ less than 3: give 10 mEq KCl/100 ml IVPB over 1 hour x 4 doses
 K+ 3-3.5: give 10 mEq KCl/100 ml IVPB over 1 hour x 2 doses
 K+ greater than 3.5: repeat K+ in two hours
8 HOURS PRIOR TO REWARMING, DISCONTINUE ABOVE K+ ORDERS AND BEGIN
ORDERS BELOW:
Potassium: DO NOT treat 3 or greater within 8 hours PRIOR to warming.
 K+ less than 3: give 10 mEq KCl/100 ml IVPB over 1 hour x 2 doses
Repeat K+ level 1 hr after infusion
MAGNESIUM: Cooling and Maintenance Phase.
DO NOT REPLACE after re-warming has begun.
 Magnesium: Repeat Mg++ level 1 hour after infusion
 Mg++ 1.6 to 2: give 1 gram Magnesium Sulfate/50 ml IVPB over 30 min x 1 dose
 Mg++ less than 1.6: give 1 gram Magnesium Sulfate /50 ml IVPB over 30 min. x 2 doses
CALCIUM: Cooling and Maintenance Phase.
DO NOT REPLACE after re-warming has begun.
 Calcium: Repeat Ca++ level 1 hour after infusion
 Ca++ less than 7.5 (or ionized Ca less than 1): give 1 gram Calcium Gluconate
IV push over 10 minutes x 1 dose
Physician Signature_____________________________________ Date/Time __________________
Nurse Signature________________________________________ Date/Time __________________
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Rewarming
Phase
Target Temperature: 36.5 to 37˚C.
 Begin re-warming 24 hours from time cooling was started. Rewarm passively to 36.5 o C by
changing cooling machine controls to Manual mode. Increase target temperature 1 o C every 3
hours.
 Empty urinary collection device at start of rewarming. Follow strict I&O.
 Remove cool packs if present
 Monitor temp/VS/ rhythm every 15 minutes until target temp is reached. Then monitor every 30
minutes.
 Continue sedation and NMBA until temperature is greater than 36 o C. If on NMBA,
discontinue NMBA first. Wait one hour and then discontinue sedation.
 After target temperature is reached, assess for shivering every 30 minutes x 2 then every hour.
Contact provider for orders if shivering persists after re-warming target temperature has been
reached.
 Do Not permit Hyperthermia for 72 hours after the start of Hypothermia. Treat with
Acetaminophen (Tylenol) NG/OG/PR every 4 hours PRN Temp greater than 37o C.
 Remove cooling blanket from under patient after goal temp of 37o C achieved. Continue to use
blanket over patient to maintain temperature at 37o C
Lab Tests
ICD9
Test
STAT
CXR
EKG


Every
8 hrs
At 12
hrs
At 24 hrs At 37
degrees



Bedside glucose unless on IV Insulin Protocol
Potassium, Magnesium
ABG/ionized calcium
BMP
CBC with Diff
Hepatic Function Panel: TP, Alb, Bili, Alk phos, ALT,
Every
4 hrs



















AST
Coagulation Profile
Lactate
Troponin I
Blood Cultures x 2
Amylase, Lipase
Repeat serum Ca, K, or Mg 1 hr after replacement
Infusion.
Stat K and Mg for any arrhythmia






Draft 1-5-2011-ddb
Physician Signature_____________________________________ Date/Time __________________
Nurse Signature________________________________________ Date/Time __________________
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