736 Battlefield Blvd N, Chesapeake, VA 23320
THERAPEUTIC HYPOTHERMIA PROTOCOL
*****EMERGENCY DEPARTMENT/INTENSIVE CARE UNIT*****
Allergies: __________________
Ht: __________ Wt: __________Kg
1.
Admit
to
Intensive
Care
Unit:
Date
Time
a. Time of Arrest: ____________________________________
Ordered Ordered
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.
b.
c.
d.
e.
f.
g.
h.
i.
DNR/DNI or severely impaired cognitive status prior to cardiac arrest
Glascow Motor Scale GREATER than 5 or patient is following commands
Pulseless GREATER than 60 minutes
GREATER than 12 hrs since return of Spontaneous Circulation (ROSC) Initiate hypothermia
therapy as soon as possible.
Metastatic Cancer or other terminal illness
Comatose baseline due to CNS depressing drugs, ICH or SAH, or other possible causes (i.e. drug
intoxication, pre-existing coma)
Sepsis as etiology for arrest
Uncontrollable bleeding
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.
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736 Battlefield Blvd N, Chesapeake, VA 23320
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
FiO2 to maintain O2 saturation > 94%
PEEP: 5
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.
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736 Battlefield Blvd N, Chesapeake, VA 23320
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
1
Anxious, agitated or restless or both
4
2
Cooperative, oriented and tranquil
5
Deep / Asleep
Brisk response to light glabellar tap or loud auditory
stimulus
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
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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
736 Battlefield Blvd N, Chesapeake, VA 23320
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.
b.
c.
d.
e.
f.
g.
h.
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.
Obtain access (arterial line and central line)
Assess patient for baseline Ramsay Scale Score and Train of Four (TOF)
Initiate sedation and paralytic. All patients are to be paralyzed prior to hypothermia therapy
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)
If UNABLE to achieve target core temperature WITHIN 4 HOURS, notify MD for further orders.
Consider ice packs to neck, groin, and axilla.
Room Temperature – Turn room thermostat to lowest setting during cooling and
maintenance phase
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: _____________________________
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Date:_________________________
736 Battlefield Blvd N, Chesapeake, VA 23320
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
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736 Battlefield Blvd N, Chesapeake, VA 23320
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)
No Shivering
Mild: Localized shivering to neck and or chest
Moderate: Shivering involving neck and/or chest and upper extremities
Severe: Generalized (total body) shivering involving all 4 extremities
If Bedside Shivering Assessment Scale (BSAS) greater than or equal to 1:
0
1
2
3
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: _____________________________
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Date:_________________________
736 Battlefield Blvd N, Chesapeake, VA 23320
Intensive Care Electrolyte Replacement Orders for Hypothermia Therapy
1. The Ordering of replacement protocols automatically discontinues previous (prn, one-time) replacement orders for
each electrolyte ordered.
2. The physician indicates which orders to initiate. These orders will remain in effect until the patient is discharged
from the ICU or contraindications are present.
3. Contraindications to using these replacement protocols include:
-Serum creatinine greater than (>) 2 (M.D. may write an order to give at a higher level)
-Urine output less than 200cc over previous eight hours
4. Based on physiological interactions, if several electrolytes are known to be low, they should be replaced in the
following order: (This is not an order for additional labs.)
a. Calcium (if IONIZED level <4), should be replaced before Magnesium or Phosphate
b. Magnesium should be replaced before Potassium
5. Discontinue replacement orders upon transfer out of Intensive Care.
6. The physician has ordered the following:
 Potassium Replacement:
IF NO PICC, CVP OR MEDIPORT USE 10 MEQ KCL/100ML STERILE H2O
ENTERAL ROUTE is preferred for patients without rhythm disturbances. Tube feeding must be at
goal or patient tolerating a full liquid diet
Serum
Level
(mEq/L)
If patient receiving
potassium in IV infusion
3.9 - 4
None
10 mEq KCL po / NG or
If patient NOT receiving other
potassium infusion
10 mEq KCL po /NG or
10 mEq KCL / 100 ml Sterile Water
over 1 hour
20 mEq KCL po / NG or
3.7 – 3.8
Infusion Rate
10 mEq/Hour
10 mEq/hour
10 mEq KCL/100 ml Sterile
Water IV over 1 hour
20 mEq KCL in 100 ml Sterile
Water IV over 2 hours
Recheck serum
level
In am
2 hours post IV
repletion or
4 hours post enteral
repletion
*DO NOT REPLACE POTASSIUM DURING REWARMING PHASE UNLESS LESS THAN 3.5mEq/L*
3.5 – 3.6
10 mEq/100 ml Sterile Water IV
over 1 hours and
20 mEq/100 ml Sterile Water IV
over 2 hours
20 mEq KCL IV in 100 ml Sterile
Water
over 2 hours X 2 doses
10 mEq/hour
2 hours post IV
repletion
3.3 – 3.4
20 mEq KCL IV in 100 ml
Sterile Water over 2 hours
X 2 doses
20 mEq/100 ml Sterile Water IV
over 2 hours X 2 doses and
10 mEq/100 ml Sterile Water IV over
1hour
10 mEq/hour
2 hours post IV
repletion
3.2 or
less
20 mEq/100 ml Sterile Water IV
over 2 hours X 2 doses and
10 mEq/100 ml Sterile Water IV
over 1 hour
20 mEq KCL/100 ml Sterile Water
IV over 2 hours X 3 doses
10 mEq/hour
2 hours post IV
repletion
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736 Battlefield Blvd N, Chesapeake, VA 23320
 Magnesium Replacement:
Serum Level (mg/dl)
Dose
Infusion Rate 1 gm/hr
Recheck serum level
Magnesium 3 grams IV in
100 ml 0.45% NaCl over 2
hours
Over 2 hours
50 ml/hr = 1.5 gm/hour
In AM
1.3 – 1.4
Magnesium 4 grams IV in 100
ml sterile water over 3 hours
Over 3 hours
33 ml/hr = 1.3 gm/hour
In 4 hours post repletion
Less than or equal to 1.2
Magnesium 5 grams IV in 100
ml 0.45% NaCl over 4 hours
Over 4 hours
25 ml/hr = 1.25 gm/hour
In 4 hours post repletion
1.5 – 1.8
 Phosphate Replacement:
ENTERAL route is preferred for patients without rhythm disturbances. Tube feeding must be at goal or
patient
tolerating a full liquid diet
Serum Level
Dose of Sodium Phosphate
Infusion Rate
Recheck serum level
(mg/dl)
(1 ml = 3 mmol)
With AM labs
If 2.5 – 1.6 and patient able Neutra-Phos 1 tablet by mouth Every 8 hours times 3 doses
to tolerate ENTERAL dose or NG
9 mmol NaPO4 in 100 ml
Over 4 hours
With AM labs
2.3 – 2.5
a.
1.7 – 2.2
1.1 – 1.6
Less than or equal to 1
0.45% NS over 4 hours
12 mmol NaPO4 in 100 ml
0.45% NS over 4 hours
18 mmol NaPO4 in 100 ml
0.45% NS over 6 hours
24 mmol Na PO4 in 100 ml
0.45% NS over 6 hours
(25 ml/hr)
Over 4 hours
(25 ml/hr)
Over 6 hours
(17 ml/hr)
Over 6 hours
(17 ml/hr)
With AM labs
4 hours post repletion
4 hours post repletion
 Calcium Replacement:
a.
b.
c.
Do not administer calcium and magnesium or calcium and phosphate through the same IV at the same time.
Calcium gluconate is the preferred agent and may be administered through either a central or peripheral access. Call
MD if the serum bicarbonate (HCO3) or serum CO2 greater than or equal to 25.
Calcium chloride should be used for severe symptomatic hypocalcemia (e.g. hypotension, refractory shock,
neuromuscular irritability, psychiatric abnormalities or laryngeal spasm). Call MD for dosing.
Calcium chloride, if used, must be given through a central access.
Serum IONIZED Calcium
Level (mmol/L)
4.3 – 4.4
4.0 – 4.2
3.8 – 3.9
3.6 – 3.7
3.4 – 3.5
3.3 – or below
Initiate replacement and
call M.D.
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Dose of Calcium
Gluconate
1 gram Calcium gluconate in
50 ml NS over 30 min
2 grams Calcium gluconate in
50 ml NS over 45 min
3 grams Calcium gluconate in
100 ml NS over 1 hour
4 grams Calcium gluconate in
100 ml NS over 90 min
5 grams Calcium gluconate in
150 ml NS over 90 min
6 grams Calcium gluconate in
150 ml NS over 90 min
Infusion Rate
Over 30 minutes
(100 ml/hr)
Over 45 minutes
(38 ml/hr)
Over 1 hour
(100 ml/hr)
Over 90 minutes
(66 ml/hr)
Over 90 minutes
(100 ml/hr)
Over 90 minutes
(100 ml/hr)
Recheck serum level
4 hours post infusion
4 hours post infusion
4 hours post infusion
4 hours post infusion
4 hours post infusion
4 hours post infusion
736 Battlefield Blvd N, Chesapeake, VA 23320
RENAL POTASSIUM REPLACEMENT ORDERS
HYPOTHERMIA THERAPY
CRITICAL CARE ONLY
Date
Ordered
Time
Ordered
1. Discontinue all previous Potassium replacement orders
2. May give IV or enteral route of administration but not both
3. Enteral route is preferred route for patients without severe hypokalemia or
rhythm disturbances.
a. Tube feeding must be at goal or patient tolerating full liquid diet
b. If dose is greater than 40meq give in divided doses 4 hours apart
4. IV repletion is recommended for potassium levels less than 3.2 mmol/dl
5. Standard Dilution and rate of administration for IV repletion:
• Peripheral access: 10 meq/100ml diluents/hour
• Central access: 20 meq/100ml diluents/hour or 10 meq/50ml diluents/hour
•Central access (fluid restricted 20 meq/50ml diluent
6. Repeat serum potassium level post infusion:
2 hours post IV repletion OR
4 hours post enteral repletion
7. Discontinue Potassium replacement orders upon transfer out of critical care
Criteria:
•Serum Creatinine greater than 2 mg/dl
•OR Serum Creatinine has increased 0.5 mg/dl or more in last 24 hours
•OR urine output less than 0.5ml/kg/hr IBW for two consecutive hours
RENAL POTASSIUM REPLACEMENT
Potassium Level
Potassium
Replacement
Route
Peripheral
Normal Saline or D5 W
Diluent/Volume
Central
Central
Fluid
Restricted
Length of Infusion
3.7 – 3.8 mmol/L
10meq KCl
Enteral/IV
100 ml
50 ml
50 ml
1 hour
*DO NOT REPLACE POTASSIUM DURING REWARMING PHASE UNLESS IT IS LESS THAN 3.5 mEq/L*
3.5 – 3.6 mmol/L
3.3 – 3.4 mmol/L
3.2 mmol/L or less
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20meq KCl
30meq KCl
40meq KCl
Enteral/IV
Enteral/IV
IV
200 ml
300 ml
400 ml
100 ml
150 ml
200 ml
50 ml
100 ml
100 ml
2 hours
3 hours
4 hours
736 Battlefield Blvd N, Chesapeake, VA 23320
RENAL MAGNESIUM REPLACEMENT PROTOCOL
HYPOTHERMIA THERAPY
CRITICAL CARE ONLY
Date
Ordered
Time
Ordered
1. Discontinue all previous magnesium PRN replacement orders
2. Repeat Magnesium level post IV infusion
a. 4 hours, if initial level less than or equal to 1.4mg/dl
b. In AM, if initial level greater than 1.4mg/dl
3 .Give IV route ONLY
4. Enteral route is preferred route for patients without rhythm
disturbances
Tube feeding must be at goal or patient tolerating a full liquid diet
5.Discontinue all replacement protocols upon transfer out of critical care
Criteria:
• Serum Creatinine greater than 2mg/dl
• OR Serum Creatinine has increased 0.5mg/dl or more in last 24 hours
• OR Urine output less than 0.5ml/kg/hr IBW for last two hours
RENAL MAGNESIUM IV REPLACEMENT
Level
1.7 or greater
1.5 – 1.6 mg/dl
1.3 – 1.4 mg/dl
1.1 – 1.2 mg/dl
1mg/dl or less
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Dose (IV)
None
1 gram Magnesium Sulfate
2 grams Magnesium Sulfate
3 grams Magnesium Sulfate
4 grams Magnesium Sulfate
Diluent/Volume
None
NS 100 ml
Sterile H2O 50 ml
NS 100 ml
Sterile H2O 100 ml
(use 2 doses of 2 grams dosing)
Length of Infusion
None
30 minutes
60 minutes
90 minutes
2 hours
736 Battlefield Blvd N, Chesapeake, VA 23320
RENAL PHOSPHATE REPLACEMENT ORDERS
HYPOTHERMIA THERAPY
CRITICAL CARE ONLY
Date
Ordered
Time
Ordered
1. If Ionized Calcium less than or equal to 4mg/dl, replace calcium prior
to replacing phosphorus
2. Repeat Phosphate Level post infusion:
a. 4hours post IV infusion /last enteral dose, if phosphate
level less than or equal to 2.2 mg/dl
b. In Am post IV infusion/last enteral dose, If phosphate level
greater than 2.2 mg/dl
3. Discontinue replacement protocol upon transfer from critical care
Criteria: -Serum creatinine greater than 2mg/dl
- OR Serum creatinine has increased 0.5mg/dl or more in last 24 hours
- OR Urine output less than 0.5ml/kg/hr IBW for last 2 hours
RENAL PHOSPHOROUS IV REPLACEMENT
Level
2.3 – 2.4 mg/dl
2.1 – 2.2 mg/dl
1.9 – 2.0 mg/dl
1.7 – 1.8 mg/dl
1.5 – 1.6 mg/dl
1.4 mg/dl or less
Information Only
Sodium Phosphate
1 ml provides
3 mmol phosphate
3 mmol
6 mmol
9 mmol
12 mmol
15 mmol
18 mmol
Volume of
infusion
Length of Infusion
Central or Peripheral
50 ml D5W
2 hours
100 ml D5W
4 Hours
PHOSPHOROUS ENTERAL REPLACEMENT PROTOCOL- NEUTRA-PHOS
Level
PO or NG Dose
2.5 – 2.6 mg/dl
1 packet
2.3 – 2.4 mg/dl
2 packets
2.1 – 2.2 mg/dl
2 packets
1.9 – 2.0 mg/dl
2 packets
1.8 mg/dl or less use IV protocol
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Frequency
Times one dose
Times one dose
Every 2 hours for 2 doses
Every 2 hours for 3 doses
736 Battlefield Blvd N, Chesapeake, VA 23320
RENAL CALCIUM REPLACEMENT ORDER
HYPOTHERMIA THERAPY
Date
Ordered
Time
Ordered
1.Discontinue all previous calcium PRN replacement orders
2.Calcium replacement should be administered if the patient has:
a. Ionized calcium 4 or less
b. Ionized Calcium greater than 4 but less than 4.5 and exhibiting:
1. Refractory Shock in the setting of sepsis, post-op, massive blood transfusions, status post
parathyroid surgery, renal disease, pancreatitis,
rhabdomyolysis, unexplained poor cardiac performance
2. Neuromuscular Irritability (tetany, muscle spasms, Chvostek’s or
Trousseau’s sign, weakness, hyperactive reflexes, seizures)
3. Psychiatric abnormalities in a previously asymptomatic patient
4. Laryngeal spasm
3. Repeat Ionized Calcium level
a. 4 hours post infusion if less than 4 mg/dl and symptomatic
b. In AM if greater than or equal to 4 mg/dL
4. Use Calcium Chloride for severe symptomatic hypocalcemia (HYPOTENSION)
5. DO NOT administer calcium and magnesium through the same IV at the same time.
6. Discontinue Calcium replacement orders upon transfer out of critical care.
CALCIUM IV REPLACEMENT
Serum Bicarbonate (HCO3) OR Serum CO2 less than or equal to 30mmol/L OR Chloride greater than 112mmol/L
Level
Volume
Length of Infusion
CALCIUM GLUCONATE (Preferred)
4.3 – 4.4mg/dl
3 grams in 100 ml
60 minutes
4.1 – 4.2mg/dl
4 grams in 100 ml
90 minutes
3.9 – 4.0mg/dl
5 grams in 150 ml
90 minutes
3.8 or less
6 grams in 150 ml
90 minutes
Serum Bicarbonate (HCO3) OR Serum CO2 greater than 30 mmol/L. USE CENTRAL LINE ONLY
Level
Volume
Length of Infusion
CALCIUM CHLORIDE USE CENTRAL LINE ONLY
4.3 – 4.4 mg/dl
1 gram in 50 ml
30 minutes
3.9 – 4.2 mg/dl
1.5 grams in 50 ml
60 minutes
3.8 mg/dl or less
2 grams in 50 ml
60 minutes
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