Therapeutic Hypothermia Order Set after Cardiac Arrest

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Therapeutic Hypothermia Order Set
after Cardiac Arrest
Addressograph only
Page 1of 3
(Circle items and complete check boxes where appropriate.
Strike through any undesired orders.)
Appropriate Exclusion and Inclusion check boxes must be completed prior to start of therapy:
Exclusion Criteria: Do NOT proceed with treatment orders if any of the following criteria are met:
___ Patient is within 72 hours of a major operative procedure
___ Uncontrolled bleeding
___ Shock (mean arterial pressure less than 75 despite interventions)
___ Known sepsis
___ More than12 hrs have elapsed since return of spontaneous circulation
___ Time to return of spontaneous circulation > 60 minutes
___ Not a primary cardiac arrest (ie., not ventricular tachycardia, ventricular fibrillation, asystole, or pulseless electrical
activity)
___ Glasgow Coma Scale motor score greater than 5 (patient follows verbal commands)
___ Minimal pre-morbid cognitive state
___ DNAR level B or C
___ Temperature less than 32° C after arrest
Inclusion Criteria: Both criteria must be met:
___ Return of spontaneous circulation for at least 30 minutes since cardiac arrest
___ Patient is on mechanical ventilation
Baseline
procedures and
consults
(Arterial line must
be placed before
the patient is
cooled)
Vital signs
Sedation and
Neuromuscular
blockade
Cooling Phase
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Consult (circle one): interventional radiology surgery critical care anesthesia for A-line placement
Consult (circle one): interventional radiology surgery critical care anesthesia for central line placement
Place temperature-sensing Foley to monitor temperature unless some contraindication
If Foley not used for temperature sensing, place temperature-sensing esophageal probe for this purpose
Consult neurology
Obtain baseline EEG as soon as possible upon transfer to the ICU
Transduce and record temperature every 15 minutes until 32°-34° C is achieved, then every 30 minutes
Monitor other vital signs per ICU routine
Monitor CVP every 2 hours
Midazolam 0.1 mg per kg per hr or _____ rate; titrate up for unexplained tachycardia
Fentanyl 1.5 mcg per kg per hr or _____ rate
Other sedation or analgesia (specify):___________________________________________________
Meperidine every 2 hrs prn shivering to a maximum of 2 doses (circle one below):
a. 25-50 mg if normal renal function
b. 12.5-25 mg if creatinine clearance is less than 30 ml per minute
14. If shivering persists 30 minutes after meperidine dose: start cisatracurium 0.2 mg per kg IV bolus, followed by
1 mcg per kg per minute continuous infusion (NOTE: cisatracurium cannot be started until patient has received
more than 15 minutes of continuous IV sedation)
a. Titrate cisatracurium to abolish shivering (maximum dose 3 mcg per kg per minute)
b. keep train-of-four more than 0
Goal is to achieve core temperature of 32°-34° C within 4 hrs of arrest
15. If core temperature is more than 34° C at start of protocol:
a. Infuse 2 liters of refrigerated 0.9% NS over 30 minutes if no evidence of pulmonary edema, then
call MD for further fluid orders.
b. Place ice packs around neck, in axillary areas, and in groin
16. Set Gaymar machine on automatic rapid mode with set point 33° C. Remove ice packs when target temperature
is achieved
17. If unable to achieve target core temperature within 4 hrs, call MD for further orders
Therapeutic Hypothermia Order Set
after Cardiac Arrest
Addressograph only
Page 2 of 3
(Circle items and complete check boxes where appropriate.
Strike through any undesired orders.)
Usual
Hemodynamic
Goals: mean
arterial pressure
more than 75 and
less than 120, and
CVP more than 8
18. If CVP is less than 8 or _____, administer 500 mL 0.9% NS bolus, may repeat one time, then call MD
19. If mean arterial pressure is less than 75 or _____, select one:
a. ____ dopamine continuous IV infusion: start at 3 mcg per kg per minute and titrate to
maximum of 20 mcg per kg per minute
b. ____ norepinephrine continuous IV infusion: start at 2 mcg per minute and titrate to
maximum of 30 mcg per minute
c. Other:___________________________________________________
20. If mean arterial pressure is more than 120 or _____, select one:
a. IV nitroprusside 0.3 mcg per kg per minute, increase at 5 minute intervals to maximum of 10
mcg per kg per minute (avoid in renal failure)
b. IV nicardipine 5 mg per hr, increase at 5 minute intervals to maximum of 15 mg per hr
(preferred in renal failure)
Laboratory Studies
21. At admission to ICU (if not sent at code):
a. CBC, coagulation profile, BMP, ABG, lactate, troponin, phosphorous, magnesium
b. Repeat ABG 10 minutes after paralysis achieved (if applicable)
c. EKG
d. CXR
22. Follow-up studies (until patient completes the re-warming process):
a. Every 4 hours: ABG, BMP, lactate, magnesium, phosphorous (or as dictated by
electrolyte replacement schedule – see below)
b. Every 8 hours: CBC, coagulation profile, EKG (two times only), troponin (two times only)
c. Obtain 2 sets of blood cultures (each from a distinct site if possible) 12 hrs after initiation of
hypothermia
Check all that apply (recommend custom electrolyte orders in renal failure patients):
23. ____Administer magnesium sulfate on arrival to ICU as follows:
a. ____ less than 60 kg: 2 gm per 50 mL over 15-30 minutes, repeat once in 1 hr
b. ____ more than or equal to 60 kg: 2 gm per 50 mL over 15-30 minutes, repeat twice at 1 hr intervals
24. ____Two hrs after completing initial magnesium replacement, obtain magnesium level. If magnesium is
less than 2 mg per dl:
a. Give magnesium sulfate 2 gm IV in 100 ml NS over 1 hr
b. Repeat magnesium level 2 hrs after replacement is completed
c. Repeat IV magnesium sulfate replacement and serum magnesium levels every 2 hrs until magnesium
is more than or equal to 2 mg per dl
25. ____If K is less than 3.2 mEq per L:
a. give KCl 20 mEq IV in 100 ml sterile water (premix) over 1 hour
b. repeat K level 2 hrs after replacement is completed
c. repeat IV KCl replacement and K levels every 2 hrs until K is greater than or equal to 3.2 mEq per L
26. ____If phosphorous is less than 2.5 mg per dl:
a. Give sodium phosphate 20 mEq IV in 250 ml NS over 4 hrs
b. Repeat phosphorous level 2 hrs after replacement is completed
c. Repeat IV sodium phosphate replacement and phosphorous levels every 2 hrs until phosphorous is
more than or equal to 2.5 mg per dl
27. Discontinue all potassium-containing solutions 6 hrs prior to warming
28. ____Customized electrolyte replacement orders (recommended for renal failure):
a. __________________________________________________
b. __________________________________________________
c. __________________________________________________
Electrolyte
replacement
schedule
Therapeutic Hypothermia Order Set
after Cardiac Arrest
Addressograph only
Page 3 of 3
(Circle items and complete check boxes where appropriate.
Strike through any undesired orders.)
Nursing Care
Glucose Control
Re-Warming Phase to begin 24 hrs after
goal hypothermia
temperature is
reached
After target
temperature of 36.1° C
is reached
(do not allow
temperature to exceed
37° C for the next 48
hrs)
Co-ordination with
Standardized ICU
Order Set
29. Do not bathe patient during hypothermic or rewarming period
30. No subcutaneous medications other than prophylactic anticoagulants during protocol, until rewarmed
31. Maximum enteral tube feed rate is 10 ml per hr
32. ICU glycemic protocol (use intravenous insulin only, not subcutaneous sliding scale)
Goal is to achieve core temperature of 36.1°-37° C within 6-10 hrs of re-warming start time
33. Empty Foley at start of re-warming
34. Set Gaymar machine on automatic moderate mode with set point 36.1° C
35. If external cooling devices still in place, remove cool packs, wet linens, cooling blanket
36. Stop re-warming once temperature is 36.1° C
37. Discontinue cisatracurium once temperature reaches 35° C
38. If shivering occurs after neuromuscular blockade has been discontinued, administer meperidine
(see #13 above)
39. Obtain repeat EEG as soon as possible after rewarming commenced
40. Monitor temperature every hour for 12 hours, then per ICU routine
a. Acetaminophen 650 mg pr every 4 hrs prn temperature greater than 37° C
b. Use cooling blankets prn temperature greater than 37° C
41. Titrate midazolam to Ramsay score of 3 or _____
42. For any orders that conflict between this protocol and the standardized ICU order set, these orders take
precedence
43. If therapeutic anticoagulation is necessary, the anticoagulant dose should be decreased by 50% with further
adjustments based on PT/PTT monitoring
44. During therapeutic hypothermia, do not use the standardized electrolyte replacement schedule found in the
ICU order set
45. This protocol is concluded once normothermia is maintained for 48 hrs after target temperature achieved
For any protocol questions: contact ICU attending for clarification
Physician signature: ______________________________________
Physician name (print): ____________________________________
Checked by (nurse): ______________________________________
Transcribed by: __________________________________________
Approved: (date to be entered)
Date and time: _____________________
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