PHYSICIAN'S ORDERS Mark  in  for desired orders. If  is blank, order is inactive.

indicates Performance Measurement.

CARDIAC SURGERY - POSTOPERATIVE Unit  CVICU Isolation  Standard

 Contact

 Strict Contact

 Droplet

 Airborne

Diagnosis  Attending Surgeon

Admitting Physician  Contact upon arrival

Consulting Cardiologist Consulting Internal Medicine

Trinity Hospitalists (903)528-1550 CVC/Trinity (903)595-5514

Consulting Other Physicians Allergies  NKDA

 Penicillin

Code Status  Full Code

 Morphine Sulfate

 DNR





Activity  turn every 2 hours while intubated; out of bed to chair 4 hours after extubation as tolerated. Diet  NPO until extubated

 Progress diet as tolerated once extubated. Start with ice chips and progress to regular, high fiber diet.

Nursing Orders  Hyperthermia blanket on patient until core temperature equals 97 degrees Fahrenheit.  If patient remains intubated past anesthesia recovery period (typically around 8 hours), contact provider if restraints are needed.  Initiate VAP preventative care including oral care every 4 hours while intubated.  On POD #1, discontinue urinary catheter. Patient must be extubated and all vasoactive drips discontinued.  On POD #1, initiate bowel protocol. Scan protocol to pharmacy. Monitoring  Blood pressure, pulse, respiratory rate documented every 15 minutes while intubated, advancing to every 1 hour post extubation and hemodynamically stable.  Hemodynamic profile with body temperature documented every 1 hour and as needed while intubated.  Peripheral pulse checks and neurological checks every 1 hour and as needed.  Twelve hours post extubation, if patient hemodynamically and respiratory stable may progress vital signs to every 4 hours.  Intake and output every 1 hour.  Do not wedge PA catheter, use PADP  Remove PA catheter 2 hours after extubation if off inotropes.  Remove arterial line 2 hours after extubation if off vasopressors/dilators. Glucose Monitoring  Accuchecks every 4 hours with low dose sliding scale until patient begins to eat. After patient starts eating, change accucheck schedule to AC and HS and continue low dose sliding scale.  If blood glucose greater than 150mg/dl, initiate IV insulin protocol. Incision Care  Keep sternal incision dressed x 48 hours. Change sterile dressing every 24 hours or as needed for drainage.  Cleanse all incisions with Chlorhexidine Gluconate before redressing.  Dry, sterile chest tube dressing changes every 24 hours and as needed.  Central line sterile dressing changes every Wednesday and as needed. Drains  Chest tube(s) to negative 20 centimeter H2O suction  ______________________________________________________ Prescriber's Signature Scanned to pharmacy / entered into TDS by: _______________________Date_____________Time______

TRINITY MOTHER FRANCES HOSPITALS AND CLINICS

*DT171*

PHYSICIAN ORDERS CARDIAC SURGERY POSTOPERATIVE E.F. 171-0651 Rev. 9/11 Pg. 1 of 3

Orders verified by: _______________________Date_____________Time______

PHYSICIAN'S ORDERS Mark  in  for desired orders. If  is blank, order is inactive.

indicates Performance Measurement.

CARDIAC SURGERY POSTOPERATIVE Respiratory Ventilator Orders:  See postoperative anesthesia orders for initial orders unless specified below.  Mode:  SIMV  Other:________ TV:______ FiO2: ____ Peep:_____ cm Rate:________ Pressure support:________  Ventilator weaning per "Ventilator Weaning Post Cardiac Surgery" order set  Other:_______________________________  Initiate assess and treat protocol (includes Bronchodilator Protocol). Diagnostic Radiology:  CXR STAT on arrival to unit  EKG:  12-lead in AM To be read by:  CVC/Trinity

 CAET

 Sigal

Laboratory  Upon arrival to unit draw:  H & H, platelets, magnesium, potassium  PT/PTT  Lab Misogram: Stay ahead 2 units packed red blood cells (PRBC's).  POD 1 and 2 at 04:00: CBC, Renal Profile, Magnesium and Ionized Calcium.  Other:_____________________________________________________________________________________  If chest tube output is greater than or equal to 100 mL/hour in one hour, draw PT and PTT. Notify surgeon. Miscellaneous: Temporary Pacemaker:  On  Off a. Rate ___________________________ b. Milliamps______ c. Demand:  Yes  No  Isolate wires in fingertip of glove.  Change pacemaker battery at 0800 daily.  Keep spare battery at bedside at all times.

IABP: ___________________________________________________________________________ Consults  Cardiac rehab: evaluate and treat. IV Fluids

 D5 normal saline at 50 mL/hour

 _____________________________________________________________

IV Drips  Notify surgeon when exceeding upper dose ranges of any IV drip or if single agent not effective for desired effect (i.e. one inotrope AND one vasopressor/vasodilator). Cardiac Index Less than 2.1  Normotensive (MAP greater than or equal to 60 mmHg): DOBUTamine (DOBUTREX): Start at 3 mcg/kg/minute. Titrate up to a maximum of 12 mcg/kg/minute.  Hypotensive (MAP less than 60 mmHg): EPINEPHrine: Start at 1 mcg/minute. Titrate up to a maximum 12 mcg/minute. Hypotension: MAP less than 60 mmHg  norepinephrine (LEVOPHED): Start at 1 mcg/minute. Titrate up to a maximum 12 mcg/minute. Hypertension: MAP greater than 90 mmHg  Need for rapid correction (i.e. high chest tube outputs, low CI, MAP greater than 105 mmHg): nitroprusside (NIPRIDE): Start at 0.5 mcg/kg/minute and titrate up to a maximum of 10 mcg/kg/minute  Criteria not met for rapid correction: niCARdipine (CARDENE): Start at 5 mg/hr. Titrate up by 2.5 mg increments no more than every 15 minutes up to a maximum dose of 15 mg/hr. Volume: CI less than 2.1 or SVR greater than 1300 OR MAP less than 60 mmHG ACCOMPANIED BY CVP less than 10 mmHg OR PADP less than 12 mgHg  hydroxyethyl starch (VOLUVEN) 500 mL IV bolus. May repeat once (total of 1000 mL) if needed.  After VOLUVEN, albumin 5% 250 mL IV bolus. May repeat up three times (total of 1000 mL) if needed.

Prescriber's Signature Scanned to pharmacy / entered into TDS by: _______________________Date_____________Time______

TRINITY MOTHER FRANCES HOSPITALS AND CLINICS

*DT171*

PHYSICIAN ORDERS CARDIAC SURGERY POSTOPERATIVE E.F. 171-0651 Rev. 9/11 Pg. 2 of 3

Orders verified by: _______________________Date_____________Time______

PHYSICIAN'S ORDERS Mark  in  for desired orders. If  is blank, order is inactive.

CARDIAC SURGERY - POSTOPERATIVE IV Drips - Sedation (select only one)  propofol (DIPRIVAN) - Start at 10 mcg/kg/min and titrate up to a maximum of 50 mcg/kg/min as needed to obtain Ramsay score 3-5. Wean prior to CPAP trials.  dexmedetomidine (PRECEDEX) - Start at 0.2 mcg/kg/hr (no bolus) and titrate up to a maximum of 1 mcg/kg/hr as needed to keep calm. May continue up to 4 hours post extubation if necessary at half rate required while intubated. Medications - Scheduled:  Discontinue all previous medications unless otherwise ordered.  calcium chloride 1 gram IVPB on arrival to ICU.  Continue IV Insulin Protocol: Adult Insulin Protocol (1206) through POD #1. Scan IV Insulin Protocol to pharmacy.  pantoprazole (PROTONIX) 40 mg IV daily. Change to PO after extubation.  metoprolol (LOPRESSOR) 25 mg PO every 6 hours  aspirin 81 mg PO daily Start in AM on POD #1  clopidogrel (PLAVIX) 75 mg PO daily  ramipril (ALTACE) 2.5 mg PO daily Antibiotics:  Final dose should be given no later than 48 hours after last intraoperative dose.  ceFAZolin dose and schedule per pharmacy based on weight and CrCl Every 8 hours x 5 doses, if CrCl > 30 mL/min Wt < 60 kg = 1 g IV Wt > 60 kg = 2 g IV

Every 12 hours x 3 doses, if CrCl 10-30 mL/min Every 24 hours x 1 dose, if CrCl < 10 mL/min

 Vancomycin dose and schedule per pharmacy based on weight and CrCl Wt < 100 kg = 1g IV Wt > 100 kg 1.5 g IV

Every 12 hours x 3 doses, if CrCl > 60mL/min Every 24 hours x 1 doses, if CrCl 20-59 mL/min Dose per pharmacy, if CrCl < 20 mL/min

  Medications - Contingency (PRN)  ondansetron (ZOFRAN) 4 mg IV push every 4 hours as needed for nausea; maximum dose 24 mg per 24 hours.  acetaminophen (TYLENOL) 1300 mg suppository every 4 hours as needed for temperature greater than 101 degrees; max 4 g/24 hr.  potassium chloride (KCl) 20 mEq in 100 mL IV piggyback over 1 hour as needed if potassium is less than 4 mmol/L.  magnesium sulfate 2 grams IV piggyback over 1 hour as needed if magnesium is less than 2 mg/dL.  magnesium sulfate 4 grams IV piggyback over 1 hour as needed if magnesium is less than 1.6 mg/dL.    NO TORADOL UNLESS APPROVED BY SURGEON Analgesics (while intubated)  morphine 2-4 mg every 5 minutes IV push as needed for pain while intubated unless allergic. Do not exceed ____ mg in ___ hours. Analgesics (after extubation)  HYDROcodone/acetaminophen 5/325 mg (NORCO) 1-2 tablets by mouth every 4 hours as needed for mild pain (pain scale 1-3).  oxyCODONE/acetaminophen (5/325) (PERCOCET) 1-2 tablets by mouth every 4 hrs as needed for moderate pain (pain scale 4-7).  morphine 8 mg IM every 4 hours as needed for severe pain (pain scale 8-10). Discontinue when taking PO. Date:____________ (Required)

Time:_______________ (Required)

Cell/Pager:__________________________ Scanned to pharmacy / entered into TDS by: _______________________Date_____________Time______

TRINITY MOTHER FRANCES HOSPITALS AND CLINICS

*DT171*

PHYSICIAN ORDERS CARDIAC SURGERY POSTOPERATIVE E.F. 171-0651 Rev. 9/11 Pg. 3 of 3

_______________________________________ Prescriber's Signature

_______________________________________ Printed Name Orders verified by: _______________________Date_____________Time______

PHYSICIAN'S ORDERS Mark
in  for desired orders. If  is blank, order is inactive.

VENTILATOR WEANING POST CARDIAC SURGERY Arterial Blood Gases
Post surgery ABG will serve as the baseline for CICU recovery care.
If not available, obtain ABG with critical care panel upon arrival to CICU.
Obtain ABG prior to extubation and as clinically needed unless otherwise ordered by physician. Goal parameters of arterial blood gas: Maintain ABG parameters within: • PaO2 greater than 80 mmHg • PaCO2 between 35-45 mmHg • pH between 7.35-7.45 • SaO2 greater than 92%

Oxygen
At all times, adjust oxygen as needed to maintain SpO2 greater than or equal to 92% or greater than preoperative evaluation unless other wise ordered.
Do not decrease oxygen to less than 40%.

Weaning Process
Begin weaning when (all 3 must be met): • SpO2 is greater than 92% or equal to or greater than preoperative SpO2 on 40-50% oxygen • Patient is awake. • Patient is capable of spontaneous ventilation
Add pressure support of 10 cm H20 to ventilator settings and begin weaning IMV.
Decrease IMV by two breaths per minute every 20-30 minutes (or at discretion of RN and respiratory therapist) to an IMV of four while maintaining hemodynamic stability.
If respiratory rate exceeds 26 breaths per minute, correlate patient's clinical status with current tachypneic situation by: • Treatment and elimination of causative agent (such as pain or anxiety). • Returning to previous IMV rate. • Obtain ABG and compare results to ABG goals as above.
When patient has been weaned to an IMV of four, obtain weaning parameters to include tidal volume, vital capacity, negative inspiratory pressure, and ratio of respiratory frequency to tidal volume (f/Vt).
If patient is unable to successfully do mechanics of weaning parameters, confirm the following: • Sustained head lift time of five seconds • SpO2 greater than 92% or equal to preoperative baseline • Intact cough and gag reflex • Bilateral equal hand grasp and release • Absence of restlessness or confusion • Regular respiratory pattern • Respiratory rate appropriate for age • Clear bilateral breath sounds • Adequate respiratory effort that can be evidenced by obtaining an inspiratory tidal volume in CPAP mode that is equivalent to incentive spirometry. The patient must achieve 40% of predicted inspiratory volume based on incentive spirometry nomogram or preoperative incentive spirometry level obtained.
Successful Weaning Mechanics Parameters • Tidal volume 5-7 mL/kg • ratio of respiratory frequency to tidal volume (f/Vt) < 105 • Vital capacity 10-12 mL/kg • Negative Inspiratory Force (NIF) greater than negative 20 mmHG (>-20 mmHg).
Once values and/or patient's clinical status are within acceptable limits, place patient on continuous positive airway pressure (CPAP) of 5 with pressure support (PS) of 10. Obtain ABG in 30 minutes.
Call pressure support ABG and weaning parameters to surgeon or anesthesiologist for extubation and/or further orders.

Post Extubation
Initiate oxygen at 4 liters via nasal cannula. Titrate to maintain SpO2 equal to or greater than preoperative SpO2 unless otherwise specified by physician.
If patient's clinical condition necessitates obtaining additional ABG's, obtain and notify physician of results. Examples include: Progressive down trending of SpO2 despite upward titration of supplemental oxygen, confirmation of patient's pH level and change in hemodynamic stability of unknown cause. Date:____________ (Required)

Time:_______________ (Required)

Cell/Pager:__________________________ Scanned to pharmacy / entered into TDS by: _______________________Date_____________Time______

TRINITY MOTHER FRANCES HOSPITALS AND CLINICS

*DT171*

PHYSICIAN ORDERS Ventilator Weaning Post Cardiac Surgery E.F. 171-1287, Rev. 08/09 Pg. 1 of 1

_______________________________________ Prescriber's Signature

_______________________________________ Printed Name Orders verified by: _______________________Date_____________Time______

PHYSICIAN'S ORDERS Mark  in  for desired orders. If  is blank, order is inactive.

BOWEL PROTOCOL Purpose: To establish bowel function in the patient based on patient's normal bowel pattern. Goal: Patient to have a soft formed stool every 1-3 days. 1.

Review patient history to establish patient's normal bowel pattern at home if possible (i.e. bowel movements in the morning, afternoon, or nights). Initiate this protocol based on history (i.e. if they normally have a bowel movement in the evenings, initiate protocol at that time).

2.

Diet If taking PO:  Order "high fiber diet: - whole grains, vegetables, and fresh fruit if not immunocompromised and if no diet restriction.  If not on fluid restriction, increase fluids to 2000 - 2500 mL per day.  If on TF, switch to fiber-containing formula  Jevity 1.2 (Rate to be recommended by Dietitian)  Order Nutritional Consult

3.

Medication Regimen for Bowel Regulation  docusate sodium (COLACE) 200 mg PO twice a day  magnesium hydroxide (MILK OF MAGNESIA) 30 mL PO daily as needed if no bowel movement in 24 hours (contraindicated in renal patients)  For renal patients (creatinine greater than 1.5), bisacodyl suppository (DULCOLAX) 1 PR daily as needed if no bowel movement in 24 hours

IF NO Bowel Movement ON 2nd DAY OF ADMISSION, INITIATE:  polyethylene glycol 3350 (MIRALAX) 17 g PO daily: (1 heaping tablespoon) should be dissolved in 8 ounces of water, juice, soda, coffee or tea. This product may be used up to 2 weeks. 4.

Initiate digital stimulation and check for impaction on day 3.

5.

If patient is ambulatory and able, allow patient to get up to bedside commode or toilet as this helps to establish a normal bowel pattern.

6.

If stools begin to become liquid, discontinue docusate sodium (COLACE) and polyethlene glycol 3350 (MIRALAX). Continue with high fiber diet, fluid support and as needed medication.

Date:____________ (Required)

Time:_______________ (Required)

Cell/Pager:__________________________

_______________________________________ Prescriber's Signature

_______________________________________ Printed Name

Scanned to pharmacy / entered into TDS by: _______________________Date_____________Time______

TRINITY MOTHER FRANCES HOSPITALS AND CLINICS

*DT171*

PHYSICIAN ORDERS BOWEL PROTOCOL E.F. 171-1241 Rev. 9/11 Pg. 1 of 1

Orders verified by: _______________________Date_____________Time______

PHYSICIAN'S ORDERS Mark  in  for desired orders. If  is blank, order is inactive.

DVT ADULT PROPHYLAXIS Start medications*:
_____ hours after surgery


____________________________________

*Unless otherwise indicated above, all medication orders will be initiated upon receipt of order.


Pharmacologic thromboprophylaxis is NOT INDICATED due to patient condition.
Contraindication: Use:
TED hose
SCD's A. Risk Factors - 1 point each
Age 41-60 years
Family history of DVT/PE
Leg swelling, ulcers, stasis, varicose veins
Inflammatory bowel disease
Central Line
Bed confinement / immobilization greater than 24 hours
Pregnancy, or postpartum less than one month
Obesity (greater than 20% over IBW)
Minor Surgery
Estrogen Therapy

Low Risk: 1 Point




Patient is on therapeutic anticoagulation. Additional pharmacologic thromboprophylaxis is not required.

B. Risk Factors - 2 points each
Age 61-70 years
Major Surgery
Malignancy
Multiple Trauma
Spinal cord injury with paralysis

Total Risk Score: _______ Moderate Risk: 2 Points High Risk: 3-4 Points

C. Risk Factors - 3 points each
Age greater than 70 years
Prior history of DVT/PE
Acute MI / CHF
Severe sepsis (sepsis with more than one organ failure)
Stroke with paralysis
Hyperviscosity syndromes
Hip or Knee Replacement*
Inherited thrombophilia
Acquired thrombophilia

Very High Risk: > 4 Points

Low Risk: 1 point OR may order IN ADDITION to pharmacologic orders below- Choose ALL that apply:
TED hose


Ambulate:_______________________________


SCD's

Moderate Risk: 2 points - Choose ONE of the following:
heparin 5000 units subcutaneous every 8 hours
fondaparinux (ARIXTRA) 2.5 mg SQ daily



enoxaparin (LOVENOX) 40 mg subcutaneous every 24 hours
enoxaparin (LOVENOX) 30 mg subcutaneous every 24 hours (dosing for CrCl less than 30 mL/min.)

High Risk / Very High Risk: 3 points or greater - Choose ONE of the following:
heparin 5000 units subcutaneous every 8 hours
For abdominal surgery only: fondaparinux (ARIXTRA) 2.5 mg SQ daily



enoxaparin (LOVENOX) 40 mg subcutaneous every 24 hours
enoxaparin (LOVENOX) 30 mg subcutaneous every 24 hours (dosing for CrCl less than 30 mL/min.)

Hip and Knee Replacement


TED hose and Sequential compression device (SCD)
enoxaparin (LOVENOX) 30 mg subcutaneous twice daily
fondaparinux (ARIXTRA) 2.5 mg subcutaneous every 24 hours
enoxaparin (LOVENOX) 40 mg subcutaneous every 24 hours
aspirin 325 mg PO daily Trauma
enoxaparin (LOVENOX) 30 mg subcutaneous every 12 hours

Laboratory
CBC (baseline initial, then every three days)
Other:


PT/INR and PTT (baseline only)


NOTE: fondaparinux (ARIXTRA) contraindicated in patients with severe renal impairment (creatinine clearance