Unique Plan Description: Therapeutic Hypothermia (MH WH)
Plan Selection Display: Therapeutic Hypothermia (MH WH)
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2024-01-23 10:39:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-03-19 11:05:06
Available at all facilities: Yes

Therapeutic Hypothermia (MH WH)
Vital Signs
	Vital Signs
		T;N, VS including temp, every 15 min during induction/cooling, until target temperature achieved, then q1h during maintenance phase.
	Vital Signs/Hemodynamic Monitoring
		MAP goal 70-100mmHg is preferred for optimal cerebral perfusion. Monitor primary temperature with foley/bladder probe continuously
Diet
	NPO
		T;N
Laboratory
	CBC with Diff
		T;N+240, Timed, Q6H, spec type = Blood
	Comprehensive Metabolic Panel
		T;N+240, Timed, Q6H, spec type = Blood
	Blood Gases Arterial (ABG) - MH/WH/JE
		T;N+240, Timed, Q6H, spec type = Blood
	Blood Gases VENOUS (VBG)
		Timed, Q6H, spec type = Blood
	Lactate
		T;N+240, Timed, Q6H, spec type = Blood
	Magnesium Level
		T;N+240, Timed, Q6H, spec type = Blood
			Comment: Goal Mg level > 3 mg/dl
	Phosphorus
		T;N+240, Timed, Q6H, spec type = Blood
	Ionized Calcium
		T;N+240, Timed, Q6H, spec type = Blood
	Glucose Level
		T;N, Timed, Q6H, spec type = Blood
			Comment: Goal range: < 180. Initiate Insulin Infusion Protocol for BS >180
		T;N, Stat, spec type = Blood
	CK
		T;N+240, Timed, Q6H, spec type = Blood
	hs Troponin T - MH/WH/JE
		T;N+240, Timed, Q6H, spec type = Blood
	Pregnancy Test Urine
		T;N, Stat, Stat, Urine Random, spec type = Urine
			Comment: if woman of child bearing age
Diagnostic Tests
	ECG
		Stat, Indication: Myocardial Infarction (Acute)
		T;N+480, Routine, Indication: Myocardial Infarction (Acute)
		T;N, Routine, Indication: Myocardial Infarction (Acute)
			Comment: dysrhythmia or morphology change on cardiac monitor, PRN
	Echo w Doppler resting
		Stat
			Comment: Hypothermia protocol; If ongoing hypotension with cardiac etiology, ongoing arrhythmia, indeterminate EKG, Additional ECHO may be needed in 24 hours.
	Chest 1 View
		T+1;0600, Routine, Myocardial Infarct, DAILY
			Comment: while intubated
IV Solutions
	Sodium Chloride 0.9%
		500 mL, Invasive Monitoring Line, Total Volume = 500
			Comment: Arterial Line Pressure Bag 300 mmHg
Patient Care
	Arterial Line Monitoring
		
	Integumentary Assessment-Focused
		T;N, Q4H-Sch
			Comment: Skin assessment under cooling wraps minimum of every 4 hours while wraps in place
	Intake and Output
		T;N, Q1H
			Comment: Notify MD if urine output >300ml/hr or <30ml for two consecutive hours
	Notify MD
		T;N, PRN MAP <70, despite use of vasopressor
		T;N, If magnesium level >4.0mg/dL
	Initiate MD Plan for:
		Insulin Infusion Protocol for blood sugar > 180. Blood Glucose must be drawn out of line, not via fingerstick, during cooling phase. Blood Sugar goal range: <180.
	Notify MD
		T;N, of need for central line access and arterial line insertion
Therapies
	Consult Respiratory Therapy-Assess and Treat
		T;N
			Comment: Maintain PO2 90-100 mmHg and normal pH (ABGs must be temperature controlled) Patient on Therapeutic Hypothermia Protocol
Consults/Follow-up
	Consult Social Work
		T+1;0800, Evaluation
			Comment: Post therapeutic hypothermia cardiac arrest
	Consult Cardiologist
		Reason for Referral: Acute Cardiac Arrest

Neuromuscular Blockade Protocol
Laboratory
	CBC with Diff
		T+3;0400, Routine, Q48H, spec type = Blood
IV Solutions
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	cisatracurium 100mg/NS 50 mL
		100 mg, EVERY BAG, 1 mcg/kg/min, T;N
		50 mL, IV, Routine, TOF Goal: 2, Incremental Increase: 1 mcg/kg/min, Incremental Decrease: 1 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 10 mcg/kg/min
			Comment: Conc: 2 mg/mL.  Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving.  Begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus)MAX: 10 mcg/kg/minNotify provider if maximum dose ordered is not sufficient to reach goal TOF.                                    Retest TOF 30 minutes after a bolus dose or when continuous infusion of NMB is given/initiated/changed. Retest every 2 hours after a clinically stable and satisfactory level of blockade is achieved
	cisatracurium 200mg/NS 100 mL
		200 mg, EVERY BAG, 1 mcg/kg/min
		100 mL, IV, Routine, TOF Goal: 2, Incremental Increase: 1 mcg/kg/min, Incremental Decrease: 1 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 10 mcg/kg/min
			Comment: Conc: 2 mg/mL.  Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving.  Begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus)MAX: 10 mcg/kg/min)Notify provider if maximum dose ordered is not sufficient to reach goal TOF.                                        Retest TOF 30 minutes after a bolus dose or when continuous infusion of NMB is given/initiated/changed. Retest every 2 hour after a clinically stable and satisfactory level of blockade is achieved
	rocuronium 250 mg/25 mL
		250 mg, EVERY BAG, 4 mcg/kg/min
		25 mL, IV, Routine, TOF Goal: 2, Incremental Increase: 1 mcg/kg/min, Incremental Decrease: 1 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 12 mcg/kg/min
			Comment: Conc: 2.5 mg/mL.  Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving.  MAX: 12 mcg/kg/minNotify provider if maximum dose ordered is not sufficient to reach goal TOF.                Retest TOF 30 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 hours after a clinically stable and satisfactory level of blockade is achieved
	rocuronium 250mg/NS 100mL
		250 mg, EVERY BAG, 4 mcg/kg/min
		100 mL, IV, Routine, TOF Goal: 2, Incremental Increase: 1 mcg/kg/min, Incremental Decrease: 1 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 12 mcg/kg/min
			Comment: Conc: 2.5 mg/mL.  Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving.  MAX: 12 mcg/kg/minNotify provider if maximum dose ordered is not sufficient to reach goal TOF.                Retest TOF 30 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 hours after a clinically stable and satisfactory level of blockade is achieved
	vecuronium 50mg/NS 50 mL
		50 mg, EVERY BAG, 0.8 mcg/kg/min
		50 mL, IV, TOF Goal: 2, Incremental Increase: 0.2 mcg/kg/min, Incremental Decrease: 0.2 mcg/kg/min, Incremental Freq: 30 min(s), Max Dose: 1.6 mcg/kg/min
			Comment: Conc: 1 mg/mL.  Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving.  Do not give if patient has hepatic dysfunction or creatinine clearance <50 mL/min.  Begin continuous infusion after bolus dose. MAX: 1.6 mcg/kg/minNotify provider if maximum dose ordered is not sufficient to reach goal TOF. Retest TOF 30 minutes after a bolus dose or when continuous infusion of NMBD is given/initiated/changed. Retest every 2 hours after a clinically stable and satisfactory level of blockade is achieved
Medications
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	cisatracurium
		0.2 mg/kg, Injection, IV Push, Once, STAT
			Comment: Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving cisatracurium, begin continuous infusion after bolus dose.  Use cisatracrium if patient has hepatic dysfunction or creatinine clearance <50 mL/min (do not give bolus).
	rocuronium
		1 mg/kg, Injection, IV Push, Once, STAT
			Comment: Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving rocuronium.
	vecuronium
		0.1 mg/kg, Injection, IV PUSH, Once, STAT
			Comment: Use ideal body weight for dosing.  Determine supramaximal TOF setting before giving vecuronium. Dilute with 10mL sterile water for injection. Concentration = 1 mg/mL
	LacriLube ophthalmic ointment
		1 appl, Ointment, EYE, BOTH, Q8H
			Comment: Discontinue when NMB Protocol discontinued.
		1 appl, Ointment, EYE, BOTH, Q1H, PRN, dry eyes
			Comment: Discontinue when NMB Protocol discontinued.
Patient Care
	Resuscitation Status
		T;N, Full Code
		T;N, No Code
	VTE Advisor
		Medical

Mechanical Ventilation
Activity
	ICU Progressive Mobility Protocol
		
Diet
	NPO
		T;N
Laboratory
	Blood Gases Arterial (ABG) - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
			Comment: To be done 30 min after intubation
	Blood Gases Arterial (ABG) - FH
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
	Blood Gases VENOUS (VBG)
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
			Comment: To be done 30 min after intubation
	Comprehensive Metabolic Panel
		T+1;0400, Routine, Q24H, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, Q24H, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T;N, Stat, Tube Placement F/U
		T+1;0001, Routine, Infiltrate, Portable
		T+1; 0001, Routine, Infiltrate, DAILY, Portable
IV Solutions
Sedation
	Diprivan 1000 mg/100 mL vial Premix IV
		1,000 mg, EVERY BAG, 5 mcg/kg/min
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved. Change bottle and tubing q12hr.
	Triglycerides
		T+3;0400, Routine, Q3D-Lab, spec type = Blood
			Comment: Order if Diprivan ordered
	midazolam 50 mg/NS 50 mL Premix
		50 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.5 mg/hr, Incremental Decrease: 0.5 mg/hr, Incremental Freq: 30 min(s), Max Dose: 4 mg/hr
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved.  Give 1mg Midazolam IV push with an increase in rate of continuous Midazolam infusion.
		50 mg, EVERY BAG, 2 mg/hr
	midazolam 50 mg/NS 50 mL IV
		50 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.5 mg/hr, Incremental Decrease: 0.5 mg/hr, Incremental Freq: 30 min(s)
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved.  Give 1mg Midazolam IV push with an increase in rate of continuous Midazolam infusion.
		50 mg, EVERY BAG, 2 mg/hr
	dexmedetomidine 400 mcg/NS 100 mL
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate to desired goal OR BIS goal, Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
	dexmedetomidine 400 mcg/NS 100 mL Premix IV
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 mcg/kg/hr, Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate desired goal OR BIS goal. Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
	fentaNYL 2500mcg/NS 250mL (MH)
		250 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		2,500 mcg, EVERY BAG, 25 mcg/hr
	fentaNYL 1000 mcg/100 mL Premix IV (JE/WH)
		100 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		1,000 mcg, EVERY BAG, 25 mcg/hr
	fentaNYL 1250mcg/NS 125mL
		125 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		1,250 mcg, EVERY BAG, 25 mcg/hr
Medications
	midazolam
		1 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-mild (Rass +1 to +2) or with increase in rate of continuous midazolam drip
		2 mg, Injection, IV Push, Q2H, PRN for agitation
			Comment: agitation-moderate (Rass +3 to +4)
Analgesia
	Tylenol 325 mg/10.15 mL elixir
		650 mg, Elixir, NASOGASTRIC, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild, or CPOT 1-2
	acetaminophen 160 mg/5 mL oral liquid
		650 mg, Elixir, NASOGASTRIC, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild, or CPOT 1-2
	acetaminophen
		650 mg, Suppository, RECTALLY, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild or CPOT 1-2
	oxyCODONE 5 mg/5 mL oral solution
		5 mg 5 mL, Solution, NASOGASTRIC, Q4H, PRN, pain-moderate
			Comment: or CPOT 3-5
		10 mg 10 mL, Solution, NASOGASTRIC, Q4H, PRN, pain-severe
			Comment: or CPOT 6-8
	acetaminophen-hydrocodone 108 mg-2.5 mg/5 mL oral liquid
		10 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-moderate
			Comment: or CPOT 3-5
		20 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-severe
			Comment: or CPOT 6-8
	acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL oral solution
		10 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-moderate
			Comment: or CPOT 3-5
		20 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-severe
			Comment: or CPOT 6-8
	fentaNYL
		25 mcg, Injection, IV Push, Q15MIN, PRN pain-moderate
			Comment: (CPOT 3-5) or with an increase in rate of continuous fentanyl drip. First line treatment: IV Push Fentanyl, after 3 doses within 1 hour and unable to reach target pain goal, notify ordering LIP.  Max IV push dose 200mcg in 1 hour
		50 mcg, Injection, IV Push, Q15MIN, PRN pain-severe
			Comment: (CPOT 6-8) First line treatment: IV Push Fentanyl, after 3 doses within 1 hour and unable to reach target pain goal, notify ordering LIP Max IV push dose 200mcg in 1 hour
Miscellaneous
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Reconstitute with 10mL normal saline and infuse over 2 minutes.  Does NOT require filtration.
	famotidine
		20 mg, Injection, IV Push, BID
	Dulcolax
		10 mg, Suppository, RECTALLY, Q3D, PRN constipation, T+4
			Comment: If no BM despite Miralax and Senna
	MiraLax oral powder for reconstitution
		8.5 gm, Packet, By Mouth, DAILY
	Senna
		8.8 mg, Syrup, By Mouth, BID, T+2
			Comment: Give if no BM within the past 48 hours
	chlorhexidine 0.12% oral rinse
		15 mL, Solution, Mouthwash, BID
Patient Care

	Restraint non violent, initiate
		T;N
	Enteral Tube
		T;N Per Orogastric Tube (OG) Insert as needed, clamp
		T;N Per Orogastric Tube (OG) Insert as needed
		T;N Per Orogastric Tube (OG) Connect to low continuous suction
		T;N Per Nasogastric Tube (NG) Insert X Ray as needed, clamp
		T;N Per Nasogastric Tube (NG) Insert X Ray as needed
		T;N Per Nasogastric Tube (NG) Connect to low intermittent suction
	Foley Catheter
		T;N, Insert, Critically ill requiring accurate output
Therapies
	Mechanical Ventilator Settings
		
	Mechanical Ventilator Wean Protocol
		
	Perform Spontaneous Awakening Trial
		T;N, DAILY
			Comment: •	If all SAT Safety screening questions are answered NO (no exclusions present), the RN will conclude it is SAFE to perform a SAT and Proceed to awakening trial•	If on Precedex maintain current settings•	If on Fentanyl, turn infusion off.•	If on Fentanyl, if the patient should complain of or demonstrate sign/symptoms of pain while the continuous sedative infusion is off, the RN may administer bolus doses of analgesics as ordered or maintain the continuous analgesic if needed for active pain •	If on Propofol or Versed, turn infusion off. The RN will also hold all sedative prn pushes.•	If the patient fails the SAT, the RN will attempt PRN doses if able to reach target. If the need to resume the continuous infusion exists, it will be restarted at ½ the previous dose.  RN will repeat SAT and next ordered interval•	If the patient is able to open his/her eyes to verbal stimulation without failure criteria or does not display any of the failure criteria after shutting off sedation, the RN will conclude the patient has passed the SAT and will contact the RT to complete the SBT safety screen
	Spontaneous Awakening Trial Tolerance
		T;N
			Comment: Fail: conditional:1.	Not able to wean continuous sedation off2.	Maintains SAT RASS > + 2 despite interventions3.	SPO2 < 90%4.	RR > 35 BPM > 5 mins5.	New arrhythmias6.	Symptomatic change in HR either increase or decrease7.	Use of accessory muscles8.	Abdominal paradox9.	Diaphoresis10.	Dyspnea11.	Other
	ARDS Protocol
		
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Patient on ventilator.
	Consult Occupational Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Patient on ventilator.
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: JE/FH ETCO2 monitoring to be done Q6H. MH continuous monitoring
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up

	Consult Dietitian
		T;N, Regarding: Nutrition Assessment, Dietitian Assess and Treat
			Comment: initiate nutrition assessment as appropriate

Rewarming for TTM (MHWH)
Vital Signs
	Therapeutic Hypothermia Device
		T;N
			Comment: Set machine to increase temperature 0.25C/hour to target temperature of 37 C (98.6F). Maintain the machine at 37 C (98.6F) for 48 hours once target temperature has been achieved. Do not allow hyperthermia (37.5C/99.5F) in the first 48 hours after cooling phase. After 48 hours discontinue machine and protocol.
Diagnostic Tests
	Echo w Doppler resting
		T;N, Routine, Indication: Cardiac arrest
Medications
	calcium gluconate IVPB
		1 gm, INT, IVPB, Q6H, PRN see comment, 100 ml/hr, duration: 24 hr
			Comment: for ionized calcium <1
	potassium chloride IVPB - Central line
		40 mEq, Injection-Premix, IVPB, Q6H, PRN see comment, infuse over 4 hr, duration: 24 hr
			Comment: Once normothermia achieved if K+ <3.5 and if no evidence of CKD/AKI
Patient Care
	Notify MD
		T;N, Once normothermia reached and maintained for 48 hours for updated RASS goal parameters and weaning of sedation agents. Ensure sedation agents through Mechanical Ventilation power plan are addressed as needed.
	Discontinue Medication
		T;N, Once rewarming temperature reached and maintained for 48 hours, Discontinue Shivering protocol and any orders/medications associated with shivering.
		T;N
			Comment: if patient has received a neuromuscular blockade (NMB), solely to prevent shivering, discontinue the NMB before the sedative/analgesic agents. Do not decrease sedative/analgesic until 8 hours after last dose of NMB or train of four response 4/4. If No NMB has been used, sedation and analgesia may be weaned and sedation awakening trials attempted
		T;N, , insulin drip protocol 24 hrs after patient has been rewarmed and begin Insulin Sliding Scale Novolog Level 1
Consults/Follow-up
	Consult Neurologist
		Reason for Referral: 72 hours post-arrest
	Pharmacy Consult
		Transitioning off shivering protocol and sedation titration to BSAS. Ensure sedation agents ordered thru Mechanical Vent Powerplan

Targeted Temperature Management Shivering Protocol
Laboratory
	Triglycerides
		T+3;0400, Q7D-Lab, spec type = Blood
			Comment: while on propofol.  Discontinue order when propofol discontinued.
Medications
	busPIRone
		30 mg, Tab, ORAL GASTRIC, Once, STAT
		30 mg, Tab, ORAL GASTRIC, Q8H, T;N+480, duration: 5 Dose(s)/Time(s)
			Comment: Clamp OG for 60 min after medication administration
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, IV, Once, STAT
	acetaminophen 325 mg/10.15 mL elixir
		650 mg, Elixir, ORAL GASTRIC, Q6H, T;N+480, duration: 12 Dose(s)/Time(s)
	magnesium sulfate 4gm in 100mL water
		4 gm, IVPB, Once, 5 hr, 20 ml/hr
			Comment: Unless dialysis dependent patient; If serum Mg level <3.0, Serum Magnesium goal 3.0-4.0 during cooling/shivering phase
	fentaNYL
		50 mcg, Injection, IV Push, Once, STAT
			Comment: followed by initiation of infusion
	fentaNYL 2500mcg/NS 250mL
		250 mL, IV
			Comment: Start at 50mcg/hr for shivering prophylaxis. Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate for BSAS >/= 1;Max dose of 200mcg/hr. Notify ordering LIP  If 2 dose titrations do not achieve BSAS target and move to Step 2 of shivering management. Reorder from pharmacy 1 hr before needed
		2,500 mcg, EVERY BAG, 50 mcg/hr
	propofol 1000 mg/100 mL vial Premix IV
		100 mL, IV, Routine
			Comment: Start: at 25mcg, for BSAS >/= 1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min.	Comment: Notify ordering LIP if 3 dose titrations (40mcg) do not achieve desired shivering goal and consider adding second agent from Step 2 or moving to Step 3 of shivering management protocol. Change bottle and tubing q12hr.
		1,000 mg, EVERY BAG, 25 mcg/kg/min
	dexmedetomidine 400 mcg/NS 100 mL Premix IV
		100 mL, IV, Routine, Start: T;N, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate for BSAS >/= 1. If 2 dose titrations do not achieve BSAS target, then update provider and consider adding second agent from step 2 or moving to Step 3 of shivering management. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
	dexmedetomidine 400 mcg/NS 100 mL
		100 mL, IV, Routine, Start: T;N, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate for BSAS >/= 1. If 2 dose titrations do not achieve BSAS target, then update provider and consider adding second agent from step 2 or moving to Step 3 of shivering management. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
Patient Care
	Therapeutic Hypothermia Skin Counter Warming
		T;N, Begin at initiation of TTM and includes warm blankets and/or hand warming and/or Forced air warming device
	BIS Monitoring (Bispectral Index)
		Target: 45-60
	Shivering Management Protocol
		T;N
			Comment: Step 1: Baseline interventions on initiation of cooling: Surface/skin counter warming, Tylenol, busapr, magnesium, and Fentanyl.Step 2: If bedside Shivering Assessment Scale (BSAS) >/= 1, refractory to baseline interventions, Fentanyl, and Magnesium (Step 1), then add one of the following:•	Precedex Infusion: Initiate infusion at 0.2mcg/kg/hr for BSAS.  Increase dose by 0.1mcg/kg/hr every 30 minutes. If 2 dose titrations do not achieve improvement in BSAS score, then update provider and consider adding second agent from step 2 or moving to Step 3•	Propofol Infusion: Initiate infusion at 25mcg/kg/min for BSAS. Increase dose by 5 mcg/kg/min every 5-10 minutes. If 3 dose titrations (40 mcg) do not achieve improvement in BSAS score, then update provider and consider adding second agent from step 2 or moving to Step 3Step 3: Shivering Assessment Scale (BSAS) >/=1, refractory to Steps 1-2 and all other interventions, then update Provider for Neuromuscular Blockade.
	Bedside Shivering Assessment Scale
		T;N
			Comment:  0-No shivering visually nor noted on palpation of masseter, pectoralis, deltoids, or quadriceps muscles1-Mild: Shivering localized to neck and/or thorax only; may manifest on EKG rhythm2-Moderate: Shivering involving gross movement of upper extremities (in addition to neck and thorax)3-Severe: Shivering involves gross movements of trunk and upper and lower extremities
	Notify MD
		T;N, If shivering and/or seizures not responsive to sedation titration and other interventions for initiation of NM Blockade; Paralysis should only be necessary under extraordinary circumstances AND determined patient is not seizing.

Induction/Cooling for TTM (MHWH)
Medications
	calcium gluconate IVPB
		1 gm, INT, IVPB, Q6H, PRN see comment, 100 ml/hr, duration: 24 hr
			Comment: for ionized calcium <1
	potassium chloride IVPB - Central line
		40 mEq, Injection-Premix, IVPB, Q6H, PRN see comment, infuse over 4 hr, duration: 24 hr
			Comment: Once normothermia achieved if K+ <3.0 and if no evidence of CKD/AKI
Patient Care
	Therapeutic Hypothermia Device
		T;N, Set machine to 33 C (91.4).for 24 hours. Once reaches target temp, maintain at 33 degrees C for 24 hours.
	Warming Blanket
		T;N, Add Forced air warming device at lowest setting at initiation of cooling
	Bedside Shivering Assessment Scale
		Every 30 min during induction/cooling and rewarming. Once reach target temperature, then q1h during maintenance phase.
	Notify MD
		T;N, PRN, if temperature >35c (95F) during cooling maintenance phase despite implementation of ordered interventions; if phosphate <2. If serum magnesium <1.8, for shivering unresponsive to treatment.
		When patient has been at target temperature of 33 C (91.4F) for 24 hours for orders to initiate Therapeutic Hypothermia Rewarming Phase orders.
	Do Not
		T;N, Initiate Sedation Awakening or Spontaneous Breathing Trials during cooling, maintenance, or active re-warming phase

Insulin Drip (IV Infusion) Protocol
Laboratory
	Glucose POC - RN
		T;N, Q1H
		T;N, As needed for signs and symptoms of hypoglycemia
IV Solutions
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	insulin regular 100 units/NS 100 mL Premix
		100 units, EVERY BAG, 2 units/hr
		100 mL, IV, Routine, T;N, Total Volume = 100
			Comment: Concentration: 1 unit/mL, Initial rate based on initial glucose:  181-300: 2 units/hr;  301-400:  3 units/hr; 401 or greater: 4 units/hr;   Titrate infusion to target glucose of 140-180: If glucose is:1) Less than 100 discontinue infusion, ,continue blood glucose monitoring and follow Insulin IV infusion hypoglycemia treatment parameters if necessary; restart drip at 1/2 previous rate when glucose >120.2) 100-120, decrease infusion by 1 unit/hr3) 121-139,decrease rate by 0.5unit/hr4) 140-180 , no change5) 181-249, and is greater than or equal to the previous glucose, increase infusion by 0.5 unit/hr6) 181-249, and is less than the previous glucose, maintain same rate7) 250-350, increase infusion by 1 unit/hr8) > 351, increase infusion by 2 unit/hr. Contact MD if rate >10 unit/hr.  If the glucose decreases >75mg/dl from the last glucose check, decrease insulin rate by 50% and check blood glucose in 30 minutes. If enteral and/or parenteral nutrition support is stopped or held, decrease infusion to 0.5 unit/hour and notify physician
	Dextrose 5% with 0.45% NaCl
		1,000 mL, IV, Routine, 50 ml/hr, Total Volume = 1,000
			Comment: Begin if patient not currently on dextrose containing IV or TPN when glucose is 200 or less.  If patient has a current IV order that doesn't contain dextrose, add dextrose to that IV and do not start this D5/45 Order.
Medications
	insulin regular
		5 units, Solution-Injection, IV Push, Once, PRN see comment
			Comment: Prior to starting insulin drip if initial blood glucose 301 or greater
	Dextrose 50% injection
		25 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
		50 mL, Injection, IV Push, Q15MIN, PRN low blood sugar, Routine
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	Dextrose 10% in Water (FH)
		250 mL, Injection, IVPB, Q30MIN, PRN low blood sugar, infuse over 30 min(s)
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN low blood sugar, Routine, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
Patient Care
	Notify MD
		T;N, for instructions if dietary change: abrupt change in oral intake, change to NPO status, tube feedings are held or discontinued, TPN held or discontinued.  (caloric intake necessary to prevent hypoglycemia)
		T;N, If insulin requirements > 10units/hr for further instruction
	Notify MD of Lab results
		T;N, if blood glucose is not less than 180 after 6 hours on the Insulin IV Infusion protocol.
	IV Insulin Parameters
		T;N, Decrease infusion to 0.5 units/hour if enteral and/or parenteral nutrition support is stopped or held and notify physician.
		T;N, If the glucose decreases >75mg/dl from the last glucose check, decrease insulin rate by 50% and check blood glucose in 30 minutes.
		T;N, If initial glucose < 180, do not start infusion.  Enter order for blood glucose Q4H and start infusion if necessary based on parameters.
		T;N, When glucose </= 200, and patient not on a dextrose containing IV/TPN: add D5W to current IV.  Continue same IV base, electrolytes and rate.  If patient not currently on IV or TPN, initiate D5W/0.45% sodium chloride.
		T;N, Stop insulin infusion 2 hours after administration of antidiabetic medication ordered for transition from IV infusion (long-acting insulin, etc.)
	Order Lab
		When glucose is in target range (140-180) for 6 hours, cancel glucose Q1H order and enter new glucose order Q2H.  If glucose falls out of target range, change glucose checks back to Q1H until in range again for 6 hours.
	Hypoglycemia Treatment Parameters
		T;N, When blood glucose is greater than 120 mg/dL, restart infusion at 1/2 previous rate and change glucose checks to every hour until glucose is in the target range (140-180) for 6 hours, then may change to Q2H glucose checks.
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl.  Patient should have an IV while on insulin protocol.
		T;N, glucose <60 mg/dL, discontinue infusion and treat with Dextrose 50% 25 mL OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy
		T;N, glucose 60-70 mg/dL, discontinue infusion, and administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel.  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25 mL OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, If the patient has a diet ordered and Once glucose is within normal limits, give 1 complex carb and 1 protein source.
			Comment: (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase