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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
