POST OP CARDIAC SURGERY PHYSICIAN ORDER SHEET

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					                     POST-OP CARDIAC SURGERY
                     PHYSICIAN’S ORDER SHEET
                            USE BALLPOINT PEN ONLY.
                 CARDIAC INTENSIVE CARE UNIT
    These orders are to be used as a guideline and do not replace sound clinical judgement and professional practice standards.
                      Patient allergy and contraindications must be considered when completing these orders.
         Automatically Activate, if not in agreement, cross out and initial    Activated by Checking Box
  * ELDER ALERT (* START LOWER DOSE IF PATIENT > 65 YEARS OLD)
  ALLERGIES:     None known                 YES ____________________________________________________
  Patient’s Height: ____________                      Patient’s Weight: _____________
                ALL MEDICATION and INTRAVENOUS ORDERS                                       GENERAL ORDERS
 ORDER      DATE                   TIME                                   ORDER    DATE                TIME
    #                                                                       #

             Discontinue ALL pre-operative medications                              Admit to the Cardiac ICU
            ANTIBIOTICS                                                           LABORATORY TESTS (if applicable)
             Cefazolin 1 g IV q8h x 6 doses                                       On ICU arrival:
             Cefazolin 2 g IV q8h x 6 if body weight > 80 kg
                                                                                         12 Lead ECG
             Vancomycin 1 g IV q12h x 4 doses, if allergic to
               cephalosporins (see back of sheet)                                        CXR - repeat on POD (post-op day) #1
             Alternate: _____________________________                                   ABG, (mixed venous gas). Repeat PRN only
                                                                                         CBC, INR, PTT, Na, K, Cl, CO2, Glucose,
            HEMODYNAMIC MANAGEMENT                                                        Urea, Cr, Ca, Phosphate, Mg, TnT, Albumin
                Order vasoactive infusions, dose range and                               (repeat on POD #1 and daily while in the Cardiac
                 titration parameters including those infusing                            ICU. TnT on POD #1 only. Reassess in 5 days.
                 from the O.R.                                                       INR, PTT, CBC x 1 if total chest tube drainage
            Drug #1: _________________________________                                > 100 mL/h x 2h. Repeat CBC q4h & PRN while
            Dose Range: ______________________________                                total chest tube drainage >100mL/h
            Titrate to: _________________________________
                                                                                  MONITORING (if applicable)
            Drug #2: _________________________________                               Continuous ECG, oximetry, CVP, (PAP), MAP
            Dose Range: ______________________________                               Record HR, oximetry, all pressures on admission &
            Titrate to: _________________________________                             PRN until stable, THEN q1h
            Drug #3: _________________________________                               Record rhythm strip on admission, q8h & PRN
            Dose Range: ______________________________                               PCWP: measure as specified:________________
            Titrate to: _________________________________
                                                                                     Cardiac output on admission & q1h until stable,
                  Milrinone infusion: _______________________                        THEN q4h
                   (see back of sheet)                                               Temp q1h until > 36ºC THEN q4h. Notify physician
                                                                                      if temp > 38.5ºC
            INTRAVENOUS THERAPY
             IV D5/0.45% NaCl @ 75 mL/h                                          NURSING INTERVENTIONS
             IV D5/0.45% NaCl @ 100 mL/h                                            Notify physician if urine output < 30 mL/h x 2h
             Total IV fluid intake not to exceed above rate                         Weigh daily in A.M.
             Pentaspan 250 mL IV bolus if MAP <____mmHg                             Chest tubes to -20cm water suction
                and CVP <____mmHg; may repeat x 1                                    Notify physician if total chest tube drainage
                within the first 24h (max: 28 mL/kg/24h)                              > 100 mL/h x 2h
             Alternate: _____________________________                               Milk chest tubes gently PRN if visible clots
            ORAL CARE                                                                Endoscopic vein harvest site: Keep leg wrapped
             Chlorhexidine 0.12% mouth rinse 15mL PO BID                             with tensor for 48h (re-wrap q12h to assess leg)
               if intubated.


PHYSICIAN’S SIGNATURE
(GENERIC EQUIVALENT AUTHORIZED)                                    M.D.

FAX SENT    DATE                   TIME

REV April 29, 2008        7102-0850-3                                                                                                 Part 1 of 4
 ANTIBIOTICS
 •	   Vancomycin	should	only	be	used	if	there	is	a	history	of	an	unknown	reaction,	anaphylaxis,	hives,	or	angioedema	to	
      penicillins or cephalosporins.
 •	   Patients	with	a	history	of	a	simple	maculopapular	rash	to	penicillin	can	safely	receive	cefazolin.


 HEMODYNAMIC MANAGEMENT
 •			 Milrinone	infusions	are	not	to	be	titrated	by	nursing


                             Milrinone dosing for renal dysfunction to be ordered by the physician
                                   (all patients to receive a 50 mcg / kg IV load over 10 minutes)

            Creatinine Clearance                      s-Creatinine                       Regimen
            mL/min/1.73m2                             umol/L                             mcg/kg/min
                    NRF                               <120                               0.50
                    50                                120                                0.43
                    40                                145                                0.38
                    30                                200                                0.33
                    20                                300                                0.28
                    10                                > 500                              0.23
                    5                                 anuric                             0.20




REV April 29, 2008   7102-0851-0                                                                               Pg 2   Part 1 of 4
                     POST-OP CARDIAC SURGERY
                     PHYSICIAN’S ORDER SHEET
                            USE BALLPOINT PEN ONLY.
                 CARDIAC INTENSIVE CARE UNIT
    These orders are to be used as a guideline and do not replace sound clinical judgement and professional practice standards.
                      Patient allergy and contraindications must be considered when completing these orders.
                  Automatically Activate, if not in agreement, cross out and initial                Activated by Checking Box

             * ELDER ALERT (* START LOWER DOSE IF PATIENT > 65 YEARS OLD)

                ALL MEDICATION and INTRAVENOUS ORDERS                                      GENERAL ORDERS
 ORDER      DATE                    TIME                                   ORDER    DATE              TIME
    #                                                                        #

           GLUCOSE MANAGEMENT                                                       ORAL CARE
            Human Regular Insulin infusion - titrate to                             Mouth care q2h while awake
              serum glucose 5 - 8 mmol/L                                             Tooth brushing BID
               Check blood glucose by glucometer q1h with
                  Insulin changes until glucose is 5-8 mmol/L                       ACTIVITY
                  and no dose change x 2h, THEN monitor q4h.                         Physiotherapy consult
               For serum glucose < 2.2 mmol/L                                       Deep breathing and supported coughing
                   STOP INSULIN INFUSION                                            Dangle within 6h post-op as tolerated
                   Administer D50W 50 ml IV push                                    Up in chair within 12-24h post-op as tolerated
               For glucose 2.3 - 3.5 mmol/L
                   STOP INSULIN INFUSION OR                                        NUTRITION
                      Administer Insulin at half the previous rate                   NPO until extubated, THEN clear fluids
                   Administer D50W 25 ml IV push                                    Increase to Modified Fat, 100 mmol Sodium diet
            For tight glucose control - complete Intensive                          Controlled Carbohydrate diet
              Care Insulin Order Sheet
                                                                                          OR
           BETA BLOCKER THERAPY                                                      Controlled Carbohydrate diet with HS snack
            Consider post-op Beta Blocker for all patients,                         Other: _________________________________
              especially if on a Beta Blocker pre-op.
            Metoprolol 25 mg PO/NG BID
                                                                                    RESPIRATORY MANAGEMENT
            Alternate: _____________________________
                                                                                     Wean and extubate per protocol when criteria met.
              Hold if: - systolic BP < 110 mmHg
                                                                                     Wean according to protocol. Physician order
                       - HR < 55 bpm & not paced
                                                                                       required to extubate.
                       - Has inotrope or vasopressor infusion
                                                                                     T - Piece FiO2 _____ @ _____L/min
           ELECTROLYTE MANAGEMENT
                                                                                     Other ________________________________
            During first 24 hours postop:
                                                                                     Post extubation - titrate oxygen to SpO2 > 95%
               If serum Mg < 1mmol/L & Cr < 130 umol/L:
                 Give Magnesium Sulfate 4g IV over 2h x 1
                 (contraindicated if anuric)                                        VENTILATOR SETTINGS
               If serum K < 3 or > 5.5 mmol/L, notify physician                    (Complete if not an early extubation candidate)
               If serum K < 4 mmol/L :                                                FiO2 ______________
                 Give Potassium Chloride 20 mmol in 100 mL                             Mode ______________
                 Sterile Water IV to infuse at 25 mL/h x 4 h                           VT/Pressure _________
               Draw serum K, one hour post infusion of                                PEEP         5 cm H2O (minimum) or
                 Potassium Chloride                                                                 ___ cm H2O

PHYSICIAN’S SIGNATURE
(GENERIC EQUIVALENT AUTHORIZED)                                     M.D.

FAX SENT    DATE                    TIME


REV April 29, 2008         7102-0851-0                                                                                         Part 2 of 4
                     POST-OP CARDIAC SURGERY
                     PHYSICIAN’S ORDER SHEET
                            USE BALLPOINT PEN ONLY.
                 CARDIAC INTENSIVE CARE UNIT
    These orders are to be used as a guideline and do not replace sound clinical judgement and professional practice standards.
                      Patient allergy and contraindications must be considered when completing these orders.
                  Automatically Activate, if not in agreement, cross out and initial                    Activated by Checking Box

              * ELDER ALERT (* START LOWER DOSE IF PATIENT > 65 YEARS OLD)

                ALL MEDICATION and INTRAVENOUS ORDERS                                          GENERAL ORDERS
 ORDER      DATE                    TIME                                   ORDER    DATE                  TIME
    #                                                                        #
            PAIN MANAGEMENT                                                        PACEMAKER SETTINGS
             * Morphine 2 mg IV q5min PRN (max 8 mg/h)                            Mode: ________       Rate: ________ bpm
             Start first dose 4 hours post-op:                                    Atrial Output: 10 mA or _________________
                Acetaminophen 650 mg PO/NG/PR q4h X 48h                            Ventricular Output: 10 mA or _____________
                OR substitute/alternate with
                * Acetaminophen 325 mg with Codeine 30 mg                                 Notify physician if failure to sense, capture or
                1-2 tabs PO/NG q4h X 48h THEN either agent                                 pace and with the presence of competition or
                                                                                           rhythm change.
                q4h PRN
             Co-analgesic: Naproxen 500mg PO/NG/PR x 1
                PRN IF pre-op Cr < 110 umol/L & no history of
                GI bleed/intolerance (Hold if active bleeding or
                serum K> 5.5 umol/L)
             Refer to Cardiac Anaesthesia Spinal Opioid/
                Epidural Order Sheet
             Alternate: ______________________________
            SHIVERING/HYPOTHERMIA MANAGEMENT
             * Meperidine 12.5 - 25 mg IV q5min PRN x 24h
               (max: 37.5 mg/24h)
             Forced Air Warmer for temp < 35.5ºC
               - remove when temp reaches 36ºC
            GI MANAGEMENT
             * Dimenhydrinate 25 - 50 mg IV q1h PRN X 2
                doses within the first 24h post-op
             *Metoclopramide 5-10 mg IV/PO q6h PRN
             If Dimenhydrinate/Metoclopramide ineffective:
                give Granisetron 1 mg IV q12h PRN
                x 2 doses within first 48h
             Alternate: ______________________________
             If history of treated peptic ulcer disease or
                expected ventilation > 24h:
                 Ranitidine 50 mg IV q8h
                 Ranitidine 150 mg PO BID
                 Alternate: ___________________________
             Docusate 200 mg PO BID until first BM. THEN
                Docusate 100 mg PO BID
             Bisacodyl 10 mg supp PR daily PRN
             Bisacodyl 10 mg supp PR at 0600 on POD #3 if
                no BM

PHYSICIAN’S SIGNATURE
(GENERIC EQUIVALENT AUTHORIZED)                                     M.D.

FAX SENT    DATE                    TIME


REV April 29, 2008         7102-0852-7                                                                                                Part 3 of 4
                     POST-OP CARDIAC SURGERY
                     PHYSICIAN’S ORDER SHEET
                            USE BALLPOINT PEN ONLY.
                 CARDIAC INTENSIVE CARE UNIT
    These orders are to be used as a guideline and do not replace sound clinical judgement and professional practice standards.
                      Patient allergy and contraindications must be considered when completing these orders.
                  Automatically Activate, if not in agreement, cross out and initial            Activated by Checking Box

                * ELDER ALERT (* START LOWER DOSE IF PATIENT > 65 YEARS OLD)

                ALL MEDICATION and INTRAVENOUS ORDERS                                      GENERAL ORDERS
 ORDER      DATE                   TIME                                    ORDER    DATE          TIME
    #                                                                        #

            ANTIPLATELET MANAGEMENT
             Start on POD #1:
                ECASA 325 mg PO/NG daily
                Alternate: _________________________
            COAGULATION MANAGEMENT
             Protamine 25 mg/h IV x 6h
             Antifibrinolytic Infusion (specify agent & dose):
               ______________________________________
             Alternate ______________________________
             Heparin 5000 units subcut BID X 8 doses
               (Hold if plt < 85 or if actively bleeding)
             Mechanical valves require anticoagulation on
               POD #1 (contraindicated if epidural in place).
               Specify agent & dose:
               _____________________________________


            OTHER MEDICATIONS
            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________

            _________________________________________



PHYSICIAN’S SIGNATURE
(GENERIC EQUIVALENT AUTHORIZED)                                     M.D.

FAX SENT    DATE                   TIME


REV April 29, 2008        7102-0853-4                                                                                         Part 4 of 4

				
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