STAT
PATIENT LABEL
eHIM
Jefferson Regional Medical Center
PHYSICIAN ORDER THERAPEUTIC
HYPOTHERMIA ORDERS
POST CARDIAC ARREST
ER /CATH LAB/CVU/ICU
AUTHORIZATION IS HEREBY GIVEN TO DISPENSE THE GENERIC OR CHEMICAL EQUIVALENTS (UNDER THE FORMULARY SYSTEM)
UNLESS THE PRODUCT IS CIRCLED
ADMIT
ATTENDING MD
CONSULTS
q ICU
q CVU
Admit to Dr. ____________________________________________________________________________________________
• Consult Critical Care Physician (Pittsburgh Pulmonary)
• Consult Park Cardiovascular for vascular access assistance
q Cardiologist: ______________________________________________________________________________
q Other: ___________________________________________________________________________________
COOLING PHASE
Time Cooling
Started:_______
q Initiate Internal Cooling (preferred method)
q Initiate External Cooling
• Insert temperature sending foley
• If core temperature is greater than 34°C at initiation of protocol, bolus with refrigerated 0.9% NSS.
Bolus at 100/mL/min with a maximum of 2 liters total; this is to include EMS and ED volume.
(All fluids given during the cooling and rewarming phases should be dextrose free if possible).
• For in house arrests that meet criteria for cooling; if temperature is greater than 34°C at initiation of protocol,
bolus with refrigerated 0.9% NSS. Bolus at 100/mL/min with a maximum of 2 liters.
If utilizing Internal Cooling:
• Insert arterial line
• Insert ICY central venous catheter using the femoral site (if patient for cardiac cath utilize the
left femoral vein for insertion)
• Obtain the Thermogard machine and set target temp to 33°C and rate at MAX power
If utilizing External Cooling:
• Insert arterial line
• Insert femoral central venous catheter (if patient for cardiac cath utilize the left femoral vein for insertion)
• Obtain the Cincinnati Sub Zero hypothermia machine and Kool Kit wraps
• Set patient temp to 33°C and auto control
If target temperature not achieved within 4 hours of initiation, add ice packs to groin and axillae, give bolus of 500mL
refrigerated 0.9% NSS X1, call MD if target temperature still not achieved within 1 hour.
LABS EVERY
6HRS X 24HRS
DIAGNOSTICS
SEDATION
ANALGESIA
• Temperature corrected ABG
• BMP
• PT / INR, PTT, CBC
• Calcium, Magnesium, Phosphorous
• Lactate Level
q Stat Chest X-Ray after central line placement and intubation
q Stat EKG
q propofol (Diprivan): _____mcg/kg/min IV and titrate every 5 minutes to goal sedation scale of 0-1.
Preferred sedation unless contraindicated.
q lorazepam (Ativan) bolus ___mg IV then start infusion
• Bolus with ___mg IV prior to any infusion rate increase
q lorazepam (Ativan) ____mg/hr IV continuous infusion, titrate to sedation scale of 0-1
q fentanyl (Sublimaze) ____mcg/hr IV and titrate as needed
OR:
q morphine ____mg/hr IV via continuous PCA and titrate as needed
• Refer to non verbal pain scale for rating
DATE/TIME:
PHYSICIAN SIGNATURE:
PHYSICIAN ORDER THERAPEUTIC HYPOTHERMIA ORDERS
POST CARDIAC ARREST ER /CATH LAB/CVU/ICU
*PO0100*
PO0100
PAGE 1 OF 3
02-039B-1109
AUTHORIZATION:
STAT
PATIENT LABEL
eHIM
IV FLUIDS
BP & VOLUME
MANAGEMENT
02-039B-1109
SETTINGS
PHYSICIAN ORDER THERAPEUTIC
HYPOTHERMIA ORDERS
POST CARDIAC ARREST
ER /CATH LAB/CVU/ICU
• BP, MAP, Heart Rate, RR, O2 Sat, end tidal CO2, Temp, and cardiac rhythm hourly
• Document hourly Bedside Shivering Assessment Scale
• CVP hourly
• Record foley temp q 1hr. Do not allow patient temp to fall less than 32ºC
• Document hourly urine output
VITAL SIGNS
VENTILATOR
Jefferson Regional Medical Center
Tidal Volume: 6-8 cc/kg not to exceed 800 Mode: Assist Control
Rate: 10 FiO2: 100% PEEP: 5
• ABG 1/2hr after above settings and notify Pittsburgh Pulmonary Group if pH less than 7.34 or greater than 7.52
• RT to titrate FiO2 to maintain SaO2 greater than or equal to 94%
• Do not use warm humidification on the ventilator during the period of therapeutic hypothermia or during rewarming
q 0.9% Normal Saline at_____mL/hr IV
q 0.45% Normal Saline at____mL/hr IV
(All fluids during the cooling and rewarming phase should be dextrose free if at all possible)
• Do not replace potassium unless it is less than 3meq/L during cooling phase.
If potassium less than 3meq/L give:
• 10meq KCL in 50cc sterile water over 1hour X2. Repeat potassium level at end of infusion and repeat 10meq KCL
in 50cc sterile water X2 if still less than 3meq/L. If potassium still less than 3meq/L after 4 replacements notify MD
q norepinephrine (Levophed) IV start at 0.5 mcg/min and titrate as needed to keep MAP greater than 75
q Other pressor agent:_________________________________
q nitroglycerin IV start if MAP greater than 120. Start at 5mcg/min, increase by 5mcg/min q5minutes
until MAP less than 120
MEDICATIONS TO
PREVENT
SHIVERING
If shivering occurs despite sedation:
q meperidine (Demerol) 25mg IV q3-4hrs as needed for 2 doses. If patient has renal insufficiency or greater than
65yrs give meperidine (Demerol) 12.5mg IV q3-4hrs as needed for 2 doses
NEUROMUSCULAR
BLOCKING AGENT
(FOR MANAGEMENT
OF SHIVERING IF
OTHER METHODS
INEFFECTIVE)
Before starting neuromuscular blocking agent, verify that the patient is adequately medicated with analgesic and sedative agents
and on mechanical ventilation.
OTHER
MEDICATIONS
q Lacrilube to both eyes q4H and prn if on neuromuscular blocking agent.
OTHER ORDERS
• N/G / OG to low intermittent suction
• Implement ventilator orders
• Obtain RBG every 6hrs (may require more frequent monitoring when cooled)
• DO NOT use fingersticks for RBG must use blood from arterial line or central venous catheter
• Saline gauze patches to eyes
Keep defibrillator on and ready at bedside during entire process.
Obtain baseline train of four then monitor q1hr.
Titrate to achieve train of four 1-2 of 4.
q cisatracurium (Nimbex):_______mg (0.2mg/kg) IV bolus then start infusion _____ mcg/min (2.5-3mcg/kg/min)
continuous infusion
DATE/TIME:
PHYSICIAN SIGNATURE:
PHYSICIAN ORDER THERAPEUTIC HYPOTHERMIA ORDERS
POST CARDIAC ARREST ER /CATH LAB/CVU/ICU
*PO0100*
PO0100
PAGE 2 OF 3
STAT
PATIENT LABEL
eHIM
Jefferson Regional Medical Center
PHYSICIAN ORDER THERAPEUTIC
HYPOTHERMIA ORDERS
POST CARDIAC ARREST
ER /CATH LAB/CVU/ICU
02-039B-1109
STOP
THERAPEUTIC
HYPOTHERMIA
FOR ANY OF THE
FOLLOWING AND
NOTIFY MD
• Ventricular tachycardia or fibrillation
• Asystole
• Sustained SVT
• Refractory hypotension (defined by the need for more than 2 pressors)
• Suspected sepsis
REWARMING
• Begin rewarming 24hrs from time cooling initiated
• Target temperature (36.5ºC). Target temperature to be obtained over 10 – 12 hours; stop rewarming once
patient temperature is 37ºC to prevent overshoot
• Goal is to warm slowly by maximum of 0.25ºC/hr to avoid rebound hyperthermia
• Empty foley at start of rewarming. Monitor urine output very closely during rewarming
• Remove any ice packs. May increase room temperature
• Utilize the hypothermia machine to gradually increase temp by 0.25ºC per hr if using external cooling.
• If using central cooling change rate to controlled rate, dial to 0.25ºC/hr and charge target temp to 36.5ºC.
• Monitor vital signs, rhythm, CVP and urine output q1hr.
• Continue sedation and neuromuscular blocking agent until temperature is equal to or greater than 36ºC.
• Discontinue neuromuscular blocking agent first, then wean sedation
• Do not permit hyperthermia in first 24 hours after cooling phase.
• If temp greater than 37.5ºC give Acetaminophen 650mg PR X1. May apply ice packs groin and axillae.
• Temperature corrected ABG q2hr during rewarming
• Notify MD if pH is less than 7.34 or greater than 7.52
• If SaO2 is less than 94% respiratory therapy to titrate FiO2 to maintain Sat greater than 94%
• RBG q2hr during rewarming. Potassium every 4 hrs.
• Discontinue potassium containing fluids during rewarming, however, correct to normal range if needed
• If CVP less than 8 give 250cc NSS IV every 15 minutes up to 4 doses. If ineffective call MD for further
fluid replacement orders
TIME COOLING
STARTED:_____
TIME REWARMING
TO START:______
TIME REWARMING
FINISHED:______
SHIVERING
DURING
REWARMING
PHASE
• Observe for shivering and document shivering assessment q1hr.
• If off neuromuscular blockade, and shivering occurs during rewarming apply warm blankets
q meperidine (Demerol) 12.5mg IV, X1
• If above methods ineffective, call MD for further orders
DATE/TIME:
PHYSICIAN SIGNATURE:
PHYSICIAN ORDER THERAPEUTIC HYPOTHERMIA ORDERS
POST CARDIAC ARREST ER /CATH LAB/CVU/ICU
*PO0100*
PO0100
PAGE 3 OF 3