PLACE LABEL HERE

TRANSCATHETER AORTIC VALVE REPLACMENT (TAVR)

POST-PROCEDURE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

ALLERGIES:______

  1. Is this a CMS inpatient only procedure?  Yes, admit as inpatient, proceed to # 3  No, proceed to # 2
  2. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?

Yes, admit as inpatient, proceed to # 3No, place in observation

  1. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference:_____

  1. Telemetry: If patient Medical/Surgical, must complete form # 36084
  2. Isolation:  Contact  Droplet  Airborne For: ______
  3. Consults:

DIAGNOSTICS:

  1. Stat ECG on admission to CVICU, unless pacer dependent; obtain ECG once pacer is off
  2. Stat portable CXR on admission to CVICU
  3.  Portable CXR in AM: reason Congestive Heart Failure
  4. Transthoracic Echocardiogram AM of POD #1: to read. Reason: Heart Failure
  5. PRN Diagnostics:

For Arrythmias or ST changes: STAT ECG

For acute respiratory distress: STAT Portable CXR

LABORATORY:

  1. STAT labs on admission to CVICU; RN to draw:

CBC

PT/INR

PTT

Chem 7

Mg+

Ionized Calcium

  1. Q4hr labs: Start 4 hrs after admission to CVICU: H&H and K+
  2. POD #1, AM Labs:

CBC

Chem 7

Magnesium level

B-Natriuretic Peptide

  1. PRN Labs:

Temp 101oF: STAT urine, blood and sputum culture

  1. ABGs

STAT Cardiovascular ABG on admission to CVICU if intubated

ABG in AM if on positive pressure ventilation (includes CPAP and BiPAP)

PRN Cardiovascular ABG if respiratory distress or hemodynamically unstable

Copy to pharmacy Order writer’s initials______

*3-37009* FORM 3-37009 INITIATED 11/2015 Page 1of 5

PLACE LABEL HERE

TRANSCATHETER AORTIC VALVE REPLACMENT (TAVR)

POST-PROCEDURE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

VITAL SIGNS:

  1. Continuous ECG with ST segment, hemodynamic and ABP monitoring. Notify physicianwith any change in the baseline cardiac rhythm. No Routine PAOP/PAWP; follow PAD.
  2. VS q 15 mins for the first 2 hrs or if actively titrating vasoactive drugs until stable, then q 30 mins x 2 hrs, then hourly.
  3. CO/CI on admission and q 1 hr x 4, then q 4 hrs and prn
  4. Maintain temperature 96.8°F. Temperatures below 96.8°F: apply warm blankets and/or forced air warming device.
  5. Notify physician for:SBP less than 90 mm Hg

MAP less than 60 mm Hg

Cardiac index less than 2

HR less than 60 bpm or greater than 120 bpm

New onset atrial fib or atrial flutter

Change in neurological status

Changes in peripheral vascular status

Hgb less than 8

ST or ischemic changes on the ECG

Temperature greater than 101F

  1. Neurological checks hourly until awake, then q 2 hrs x 24 hrs and prn
  2. Peripheral vascular checks q 2 hr x 24 hrs then q 4 hrs and prn

ADDITIONAL ORDERS:

  1. Foley to gravity drainage for strict I&O. Notify Physician if urine output is <30 ml/hr x 2 consecutive hrs.

D/C POD #1 unless otherwise specified by Physician. Initiate Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)

  1. Hourly intake and output (including CT drainage)
  2. Daily weights by 0600 and record in kg
  3. NGT/OGT to low intermittent suction. Discontinue NGT/OGT upon extubation.
  4. Chest tubes:

Chest tubes to (-) 20 cm suction

Do not ambulate off suction without an order

Notify Physician if chest tube output is 200 ml/hr or greater, and obtain stat portable CXR, Hgb/Hct, PT/PTT, platelets and fibrinogen

Maintain occlusive CT dressing

  1. Temporary Pacemaker

Adjust MA/sensitivity prn and document

 Assess underlying rhythm every shift and prn

Insulate and secure pacing wires per routine

Initiate transvenous pacing if HR < 50 and prn

MODE:  Atrial  Ventricular or  AV Sequential to temporary pacer at ______bpm

Atrial MA ______Ventricular MA ______ Demand  Asynchronous

Place VVI demand mode at 50 BPM if no bradycardia or heart block

  1. OSA Screen: If patient screens positive for suspected sleep apnea or has reported sleep apnea, initiate Sleep Apnea Orders (form # 21266)
  2. Initiate Venousthromboembolism (VTE) orders (form # 30058)

DIET:

  1. NPO while intubated. Once extubated, start ice chips, then advance as tolerated

Copy to pharmacy Order writer’s initials______

FORM 3-37009 INITIATED 11/2015 Page 1of 5

PLACE LABEL HERE

TRANSCATHETER AORTIC VALVE REPLACMENT (TAVR)

POST-PROCEDURE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

ACTIVITY:

  1.  Bedrest with HOB 15 deg until hours after hemostasis
  2.  Bedrest with HOB 30 deg until extubated
  3.  Dangle at bedside 2 hours after extubation or hemostasis
  4.  Up Ad Lib
  5. Turn Side to Side q2hrs while in bed

DRESSINGS:

  1. Keep original dressing intact (reinforce if needed) for the first 48 hrs
  2. If bleeding from incision(s), apply manual pressure to site until bleeding stops. If unsuccessful, notify Physician.
  3. Change Chest tube dressings daily. Start 48 hours post-op
  4. Change incision dressings daily if applicable. Start 48 hours post-op

RESPIRATORY:

  1. Oxygenation: Initial ventilator settings per anesthesia, or:  Mode: ______Rate: ______VT: 8-10 ml/kg

FiO2: ______PEEP: ______PS: ______

  1. Cardiac surgery respiratory weaning protocol when patient awake and stable (policy # 7504-10-04-05)

Do not extubate. State reason ______

  1. Cough and deep breath and incentive spirometry q 1 hrs post extubation while awake
  2. If progressed to BIPAP, stat ABG and CXR; notify Physician of results
  3. Oxygen per Protocol (Form #34431)

IV FLUIDS:

  1. D5 ½ NS with 20mEq of Potassium at 25 ml/hr OR

 Other:

  1. Arterial and PA pressure lines to pressure transducer system. Use 0.9% NS - NO HEPARIN in flush bags.
  2. NS 500 ml for CO injectate
  3. Flush unused Swan Ganz ports with NS 10 ml q 8 hrs
  4. Flush unused peripheral INTs with NS 10 ml q 8 hrs

ELECTROLYTE REPLACEMENT (recheck level 2 hours after infusion completed, repeat if needed):

  1. If ionized Ca++ is < 1.1, give Calcium Chloride (CaCl) 1 gm in 50 ml NS IV piggyback in central line over 10 minutes
  2. Initiate Cardiovascular surgery electrolyte replacement protocol (form # 40046)

INITIAL FLUID RESUSITATION:

  1. Lactated Ringers 500 ml bolus IV OVER 15 minutes for PAD < 8 or CI < 2.2, maximum 2 L
  2.  Sodium Chloride 0.9% (NS) 150mL/hr, for 1L

 Other: ______

INFUSIONS: MUST NOTIFY PHYSICIAN PRIOR TO INITIATING

  1. Cardene (nicardipene) 40 mg/200 ml premix: 5 mg/hr starting dose or ____ mg/hr to max 15 mg/hr

Titrate 2.5mg/hr q15min to maintain systolic140 mmHg or ______

  1. EPInephrine 4 mg/250 ml NS: 1 mcg/min or ____ mcg/min starting dose to max 10 mcg/min

Titrate 1mcg/min q1min to maintain CI of 2.2 or ______

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

  1. Levophed (norepinephrine) 4 mg/250 ml NS: 2 mcg/min or ____ mcg/min starting dose to max 30 mcg/min

Titrate 2-10mcg/min q2min to maintain systolic > 100 mmHg or ______

  1. Pitressin (vasopressin) 50 units/500 ml NS: 0.02 units/min or ____ units/min starting dose to max 0.04 units/min

Titrate 0.01units/min q15min to maintain systolic > 100 mmHg or ______

  1. Milrinone 20 mg/100 ml NS: 0.25 mcg/kg/min or ____ mcg/kg/min starting dose.

Do not titrate without physician order.

  1. Amiodarone protocol (form # 17044), initiate if HR >130 bpm and SBP> 80mmHg
  2. Other: ______

BLOOD GLUCOSE MANAGEMENT:

  1. Initiate Critical Care Insulin SQ Standing Orders (form# 21386)
  2.  D/C SQ insulin orders and initiate EndoTool Insulin Infusion Standing Orders (form #38635)
  3. If Insulin infusion initiated, transition to SQ insulin using EndoTool recomendations
  4. If patient is receiving insulin, initiate Hypoglycemia Treatment Protocol (form#2513)
  5. Consult Hospitalist: ______

SCHEDULED MEDICATIONS:

  1. Antibiotics:

Preop dose Ancef(cefazolin) 2 gm (or 3 gm if > 120 kg) IV;Pre-op dose given at ___, then 2 gm IVPB q 8 hr x 3 doses

ORIf allergic to penicillin and cephalosporin, give Vancomycin IV; Pre-op dose given at ___, then

Patient weight < 90 kg, give 1 gm IV q 12 hrs x 2 doses

Patient weight ≥ 90 kg, give 1.5 gm IV q 12 hrs x 2 doses

  1. Bactroban (mupirocin) 2% ointment to bilateral nares twice daily x 5 days (D/C if nasal culture negative)
  2. Stress Ulcer Prophylaxis: Pepcid (famotidine) 20 mg IV q 12 hrs; change to po when tolerating orals

OR

Protonix (pantoprazole) 40 mg IV daily; change to po when tolerating orals

  1. Aspirin (enteric coated) 81 mg po or NG daily; Hold if platelets < 100,000.
  2. Plavix (clopidogrel) 300mg PO or NG x 1 dose at 1700 day of surgery

and then 75mg PO or NG daily, start POD #1

  1. Lopressor (metoprolol) 12.5 mg or ______mg po or NG tube q8hr.

Hold if SBP100, HR <60, or receiving inotropic drugs

OR

D/C Lopressor (metoprolol).Lopressor (metoprolol) contraindicated because:

  1. Peridex (chlorhexidene) oral rinse BID while intubated
  2. Colace (docusate sodium) 100mg PO BID. Hold for loose stools.

Copy to pharmacy Order writer’s initials______

FORM 3-37009 INITIATED 11/2015 Page 1of 5

PLACE LABEL HERE

TRANSCATHETER AORTIC VALVE REPLACMENT (TAVR)

POST-PROCEDURE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

PRN MEDICATIONSSee policy 520-06 for range orders and pain intensity guidelines.

  1. Mild Pain, Temp>100.5F, HA: Tylenol (acetaminophen) 650 mg po or PR q 4 hrs prn
  2. Moderate Pain:

Norco (HYDROcodone/acetaminophen) 5/325 mg or 10/325mg 1 tab po q 4 hrs prn. DC if Percocet ordered.

or If patient cannot take tablet, Hycet elixir (HYDROcodone/acetaminophen 7.5/325 mg/15 ml) 15 ml po q 4 hrs prn intead of Norco. DC if Percocet ordered.

or Percocet (oxyCODONE/acetaminophen) 5/325 mg or 10/325 mg 1 tab po q 4 hrs prn. DC if Norco ordered.

and/or  Toradol (ketorolac) 30 mg IV (or IM if no IV access) q 6 hrs prn (15 mg if CrCl 31-50, > 65 y/o old or <50 kg) or 10 mg po q 6 hrs prn (max combined duration of IV and po ketorolac is 5 days). DC if CrCl < 30.

  1. Severe Pain (Begin when Epidural or PCA has been discontinued)

Morphine 1-2 mg IV q 3 hrs prn, DC if CrCl < 30. Hold for excessive sedation. DC if Dilaudid ordered.

or  Dilaudid (HYDROmorphone) 0.25-0.5 mg IV q 3 hrs prn. If CrCl < 30, dose at 0.25 mg. Hold for excessive sedation. DC if Morphine ordered.

  1. Nausea/Vomiting: Zofran (ondansetron) 4 mg IV or po q 6 hrs prn

If N/V persists, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 y/o)

  1. Sleep:  Ambien (zolpidem) 5 mg (female or males ≥ 65 y/o) or 5-10 mg (male < 65 y/o) po at HS prn
  2. Indigestion: Maalox XS (aluminum/magnesium/simethicone) 30 ml po four times daily prn
  3. Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement
  4. Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

If no BM after 48 hrs:  Dulcolax (biscodyl) 10 mg per rectum daily prn

and/or Senokot-S (docusate/senna) 2 tablets po at bedtime nightly

84.Cough: Robitussin (guaifenesin) 15 ml po q 4 hrs prn

85.Sore Throat:Chloraseptic (phenol/sodium phenolate) throat spray q 2 hrs prn

ADDITIONAL ORDERS:

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-37009 INITIATED 11/2015 Page 1of 5