7777FORESTLANE,DALLAS,TX75230 Page1of15
ECMOORDERS(Physician) Lastupd:10/12/16
Admission Status
Admission Status
Priority: R Date:TODAY Time:NOW
Expectpatienttobehereequaltoorgreaterthantwomidnights: PatientStatus:
AdmittingService: BedType:
IcertifythatthePreadmissionAssessment iscompleteandsigned: AssigntoPhysician:
MedicalReason:
Comment:
Icertifythatthepatientstatusisappropriateandisbasedonmybest clinical judgement andthepatient’s condition asdocumented inthemedicalrecord.
Selectedrationaleforinpatientstatusforexpectedstaytwomidnights:
Other
Nursing
X ECMO:Guidelines
Priority: R Date:TODAY Time:NOW Comment:InitiateECMOGuidelines
Nolineremovals, noneedlesticks,norectaltemperatures,nodeep nasal/oral suctioning,nosuctioning pasttheendoftheEndotracheal tubeortheplacement orremovalofanasalororalgastrictube,ora FoleywithoutwrittenorderfromMDorNP
VitalSigns
Priority: R Date:TODAY Time:NOW Frequency: PerUnitRoutine
Comment:
CardiorespiratoryMonitor
Priority: R Date:TODAY Time:NOW EKGCable: Comments:5leadCVICU
PulseOximeter
Priority: R Date:TODAY Time:NOW Continuous:Yes until(time):
SpotCheck: Frequency: IfPulseox: ,notifyphysician
Comment:
MonitorNIRS
Priority: R Date:TODAY Time:NOW Cerebraloximeter: Yes
Somaticoximeter: No
Comments:
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page2of15
ECMOORDERS(Physician) Lastupd:10/12/16
MonitorETCO2
Priority: R Date:TODAY Time:NOW Comment:unlessonHFOV
NGTubeInsert/Manage
Priority: R Date:TODAY Time:NOW GItube#1size(fr): SuctionSetting:Gravity
Comment:aspirateevery8hoursandPRN
Foley
Priority: R Date:TODAY Time:NOW
NOTE:CAUTIPrevention Protocolrequiresassessment QShift
InsertFoleycathforthefollowing indication:I&OCriticalCarePt. Foley/Cath Duration: DCperProtocol
Foleytype: Comment:gravitydrainage
REFLEXSET:CAUTI:Prevention Protocol
IntakeOutput
Priority: R Date:TODAY Time:NOW INTAKEANDOUTPUT:Strict
Comments:
NotifyPhysician urineoutput:
UrineOutput(mls): 30 ml in: 2 hrs or if hematuria is present
UrineOutput(mls): in: hrs
X MaintainTotalIVFluids
Priority: R Date:TODAY Time:NOW
Comment:
ArterialLine
Priority: R Date:TODAY Time:NOW Site:
Transduce: Yes
Comments: Zeropressurelinestotransducer everyshiftandPRN
MeasureCVP
Priority: R Date:TODAY Time:NOW Site: Transduce:Yes
Comments: Zeropressurelinestotransducer everyshiftandPRN
X
HOMECMO ****PatientInformationLabel****
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ECMOORDERS(Physician) Lastupd:10/12/16
X DressingChange
Priority: R Date:TODAY Time:NOW
Type: Wettodry: Damptodry: Applyto:
Coverwith: Frequency: AdditionalInstructions:
Cannulationsitedressingchangeevery7daysandPRN, use Betadine only
ChestTubeManagement
Priority: R Date:TODAY Time:NOW
ChesttubetoWallSuction: ChesttubetoWaterSeal: Comment:Mediastinal/pleuraltubes.Recorddrainagehourly
Notifyphysician foroutputmorethan ml/kg/hr
X NotifyPhysician: VitalSigns
Priority: R Date:TODAY Time:NOW
NotifyProvider: Temperature:: SystolicBP:: : HeartRate:: : Diastolic BP:: : Resp.Rate:: : O2Saturation(%)::
Comment:
X MonitorHemodynamics
Priority: R Date:TODAY Time:NOW NotifyMD:
MeanArterialPressure<: mmHgand: mmHg CVP/RAPressure: mmHgand: mmHg CerebalNIRS:
Comments:
X NotifyPhysician
Priority: R Date:TODAY Time:NOW RE:excessive bleeding
Comment:NotifyMDforexcessive bleeding
Other
ECMOOrders
ManageVAECMO
Priority: R Date:TODAY Time:NOW Maintainflows(mL/kg/min): Adjustflowtomaintain:
SVO2between: %and: %
MAPbetween: mmHgand: mmHg
SystolicBloodPressurebetween: mmhgand: mmHg
SpO2BETWEEN: %and: % AdjustECMOsweepgastomaintain:
PatientPaCO2of: mmHgto: mmHg
PatientpHof: to:
HOMECMO ****PatientInformationLabel****
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ECMOORDERS(Physician) Lastupd:10/12/16
ManageVVECMO
Priority: R Date:TODAY Time:NOW
Adjust flow (not to exceed 7 L/min): Adjustflowtomaintain:
SPO2between:78 %and:85 %
PaO2between:45 mmHgand:60 mmHg
ECMOFiO2: 100%
ECMOpumpSVO2between: %and: %AdjustECMOsweepgastomaintain:
PatientPaCO2of: mmHgto: mmHg
PatientpHof: to:
Other
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page5of15
ECMOORDERS(Physician) Lastupd:10/12/16
X HeparinFlush (10unit/mL)(FLUSHIVACCESS)IVPRN units PRN FLUSH DoseInstruction:FLUSHIVACCESS
Other
Emergency Medications:
Thefollowing medicationssecuredinbedsidecabinetforadministrationbasedon
MDorder.
X EPINEPHrineInj(KEEPINSECUREDCABINETATBEDSIDE;DOSETOBE)IVPRN MG PRN ATBEDSIDE DoseInstruction:KEEPINSECUREDCABINETATBEDSIDE;DOSETOBE
DETERMINED ANDADMINISTEREDPERPHYSICIAN ORDER
X SodiumBicarbonateInj8.4%(KEEPINSECUREDCABINETATBEDSIDE.DOSEDETERMINED AND)IVPRN MEQ PRN ATBEDSIDE
DoseInstruction:KEEPINSECUREDCABINETATBEDSIDE.DOSEDETERMINED ANDADMINISTEREDPERPHYSICIAN ORDER.
X
X
X AtropineSulfateInj(KEEPINSECUREDCABINETATBEDSIDE;DOSETOBEDETERMINED)IVPRN MG PRN ATBEDSIDE
DoseInstruction:KEEPINSECUREDCABINETATBEDSIDE;DOSETOBEDETERMINED ANDADMINISTEREDPERPHYSICIAN ORDER.
X Dextrose25%Inj(KEEPINSECUREDCABINETATBEDSIDE;DOSETOBEDETERMINED)IVPRN ML PRN ATBEDSIDE
DoseInstruction:KEEPINSECUREDCABINETATBEDSIDE;DOSETOBEDETERMINED ANDADMINISTEREDPERPHYSICIAN ORDER.
X CalciumChlorideInj(KEEPINSECUREDCABINETATBEDSIDE;DOSETOBEDETERMINED)IVPRN MG PRN ATBEDSIDE
DoseInstruction:KEEPINSECUREDCABINETATBEDSIDE;DOSETOBEDETERMINED ANDADMINISTEREDPERPHYSICIAN ORDER.
X
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page6of15
ECMOORDERS(Physician) Lastupd:10/12/16
X AlbuminHumanSoln5%
PRN ML PRN ATBEDSIDE
Other
Other
Medications:Antibiotics
Other
Antibioticswillstopin14daysunlessotherwise noted.
HOMECMO
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ECMOORDERS(Physician) Lastupd:10/12/16
Other
Medications:GIProtection
PantoprazoleInj(1MG/KG)IVQ24H
Other
Medications:Diuretic
Furosemide Inj(1MG/KG)IVPedQ12H
Other
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page8of15
ECMOORDERS(Physician) Lastupd:10/12/16
Other
ECMORiskBasedAnti-CoagulationandTransfusionParameters
X ECMO:Parameters
Priority: R Date:TODAY Time:NOW
Comment:ECMORiskBasedAnti-CoagulationandTransfusionParameters
1.Notransfusionofbloodorbloodproductsunlessindicated orapprovedbyMD/NP
2.Keep5%albuminatbedsideatalltimes
3. Have 2 units PRBC’s at bedside for cannulation
X
X ECMO:NursingTransfuse Packed
Priority: R Date:TODAY Time:NOW
Priority: Scheduled OR/DialysisDate: Time: TransfuseUnit? #ofUnits:______
Notify physician for Hgb less than______mg/dl
SpecialtrxninstructionstoRN:
RBCIndication:
OtherIndication:
**Ihaveprovidedthepatient/parent/guardianwithinformationon risks,benefits, andalternativestothistreatment**
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page9of15
ECMOORDERS(Physician) Lastupd:10/12/16
ECMO:NursingTransfuse Platel
Priority: R Date:TODAY Time:NOW
Priority:ROUTINE ScheduledOR/DialysisDate: Time:
Transfuse Unit? #ofUnits:
SpecialtrxninstructionstoRN:
PLTIndication:Other(specify):
OtherIndication:Transfuse forplateletcountlessthan80,000/mm3
**Ihaveprovidedthepatient/parent/guardianwithinformationon risks,benefits, andalternativestothistreatment**
ECMO:NursingTransfuse FFP
Priority: R Date:TODAY Time:NOW
Priority:ROUTINE ScheduledOR/DialysisDate: Time:
Transfuse Unit? #ofUnits:
SpecialtrxninstructionstoRN:
FFPIndication:Other(specify):
OtherIndication:Transfuse forPT16sec
**Ihaveprovidedthepatient/parent/guardianwithinformationon risks,benefits, andalternativestothistreatment**
ECMO:Parameters
Priority: R Date:TODAY Time:NOW
Comment:ECMORiskBasedAnti-CoagulationandTransfusionParameters
Standard(Non-SurgicalPatients) BleedingRisk
1.MaintainActivated ClottingTime:160sec-180sec
2.MaintainHeparinConcentration:0.4-0.8U/Ml
HOMECMO ****PatientInformationLabel****
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ECMOORDERS(Physician) Lastupd:10/12/16
HOMECMO ****PatientInformationLabel****
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ECMOORDERS(Physician) Lastupd:10/12/16
Anti-ThrombinLevel
Consultclinicalpharmacist fordosingonECMO
MaintainAnti-ThrombinLevels
Priority: R Date:TODAY Time:NOW
MaintainAnti-Thrombinlevel50-100%ofnormalwith
Targetrange: %
Comments:
Other
Medications:Anti-Coagulation
X Heparin (1000unit/mL)(100units/KG)ONCE
#OFDOSES:1
SpecInstruction:BolusmustbegivenforcannulationthroughCVLif available.
TitrateheparininfusiontomaintainACTorderedparameters :
X HeparinInj25000unitsin_1/2NS 250ml
ADMINISTRATIONCRITERIA
Bolus for cannulation: 100units/Kg (Maximumbolusdose: units) Initialrate: 20units/kg/hr
*Titrateaccording toECMOparameters innursingECMOorders.
**ClickNexttoviewdosageadjustment instructions** AdjustHeparintherapybasedonaPTTresultsasfollows:
DosageAdjustment RepeataPTT
aPTT less than 35aPTT- aPTT- aPTT- aPTT-
aPTTgreaterthan
RATE:ASDIRECTED
SpecInstruction:TostartIMMEDIATELYafterinitiation ofECMO.
Startpost-opcardiacpatientsat(10-20units/kg/hr). Startallotherpatientsat20units/kg/hr.
Other
Add to above:
Once the ACT has stabilized after 12-24 hours, the PTT may become excessively prolonged. Therefore guide anticoagulation after 24 hours according to the chart below.
Adjust heparin therapy based on PTT results as follows:
PTT<35, increase infusion by 200 units/hr
PTT between 35 and 45, increase infusion by 100 units/hr
PTT between 45.1 to 50, increase infusion by 50 units/hr
PTT between 50.1 to 75, no change
PTT between 75.1 to 85, decrease infusion by 100 units/hr
PTT between 85.1 to 100, half current infusion rate
if PTT >100, stop infusion and call ****PatientInformationLabel
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page12of15
ECMOORDERS(Physician) Lastupd:10/12/16
Other
Other
Laboratory -STAT
Aftercannulationobtainthefollowing
X RT:ABGW/CHEMISTRY
Priority: S Date:TODAY Time:NOW
RTComment:
X RT:ABG
Priority: S Date:TODAY Time:NOW
RTComment:
X RT:VBGW/CHEMISTRY
Priority: S Date:TODAY Time:NOW
RTComment:
X RT:VBG
Priority: S Date:TODAY Time:NOW
:T
RTComment:PUMP
X BASICMETABOLIC PANEL
Priority: S Date:TODAY Time:NOW
Comment:
X CBCW/AUTODIFFERENTIAL
Priority: S Date:TODAY Time:NOW Comment:manualdiff
HOMECMO ****PatientInformationLabel****
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ECMOORDERS(Physician) Lastupd:10/12/16
X MAGNESIUM
Priority: S Date:TODAY Time:NOW
Comment:
X PHOSPHORUS
Priority: S Date:TODAY Time:NOW
Comment:
X TRIGLYCERIDES
Priority: S Date:TODAY Time:NOW
Comment:
X ANTITHROMBINIII(ACTIVITY)
Priority: S Date:TODAY Time:NOW
Comment:
X HEMOGLOBIN PLASMAFREE
Priority: S Date:TODAY Time:NOW
Comment:
X BLOODCULTURE1
Priority: R Date:TODAY Time:NOW SpecimenDescription:CL
Comments:
X CULTUREBLOODSITE2
Priority: R Date:TODAY Time:NOW SpecimenDescription:OTH Comments:ECMOPump(arterial)
X CULTUREBLOODSITE3
Priority: R Date:TODAY Time:NOW SpecimenDescription:AL
Comments:
Other
Radiology -Stat
HOMECMO ****PatientInformationLabel****
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ECMOORDERS(Physician) Lastupd:10/12/16
X RADCHEST1VIEWPORTABLE
Priority: S Date:TODAY Time:NOW Order
detailsbelow ......
Reasonforexam: Comments: Comments: Comments:
Howispatienttransported?
StatEchoforplacement ofcannulasforVVECMOortoevaluatecannulaposition forflowproblemswithVAECMO.IftherearenoflowproblemswithVAECMO, obtainECHOat0800inthemorningaftercannulation
ECHOCARDIOGRAM
Priority: R Date:TOMORROW Time:AM URN:
Cardiologist: Reasonforexam:ECMOflowissues
Other
Laboratory -Scheduled
X ECMO:Lab/XraySchedule
Priority: R Date:TODAY Time:NOW
PressEsctoExitTextBox
Comments: IMPORTANT: XRAY/LABSCHEDULEBELOW.TRANSLATE TOKARDEX PLEASE
ECMO:
-Arterial ABGevery4hoursfor24hours,then every12hoursandPRN
-Q1hrandPRN:ACT
-Q4hrsandPRN:HeparinAssay
PATIENT:
-Q6hrsx24hrs,thenPRN:ABG, Glucose,BMP,CBC, Rapid
TEG,PT/INR,PTT,Fibrinogen,Anti-ThrombinIII
-QAM:CBCwithmanualdifferential,CMP,ABG,Mag, Lactate, Phos, Trig,Anti-ThrombinIII,PlasmaFreeHgb,ChestXRay
-QeveryotherAM:BloodCS-patientcentralline,patient arterialline,andECMOpump(arterial)
-CBConehourafterPRBCorplatelettransfusions
Other
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page15of15
ECMOORDERS(Physician) Lastupd:10/12/16
RespiratoryTherapy
RT:Ventilator
Priority: R Date:TODAY Time:NOW
VentMode: ~~~~~FillinforchangesONLY~~~~~ pHIGH:
FiO2: % P.S.: MAP: PRESSURECONTROL: pLOW: RATE: I:E: HZ: SpO2NOLESSTHAN: tHIGH: Vt: ORITIME: AMPS: MAINTAINSpO2: tLOW: PEEP+: PIP: INO: ppm BLOODGAS: VDR-ConvectiveRate: VDR:PIP: NAVAType:
VDR-DemandPEEP: NAVA-Level:
VDR-OscillatoryPEEP: NAVA-EDIPeak:
VDR-Percussive Rate: InitiateWeaningProtocol? VentComment:
RT:AIRWAYSUCTIONING
Priority: R Date:TODAY Time:NOW
:T
RTComment:SuctionEndotrachealtubeevery12hoursandPRN
RT:CPT
Priority: R Date:TODAY Time:NOW
:T
CPTType: Freq:
RTComment:
RT:LUNGCONDITIONING
Priority: R Date:TODAY Time:NOW
:T
RTComment:
Other
Consults (Palliative Care, Social Work, others???)
PT:EvalandTreat
Priority: R Date:TODAY Time:NOW
Comment:RangeofMotion/EdemamassagewhileonECMO
OT:EvalandTreat
Priority: R Date:TODAY Time:NOW
Comment:RangeofMotion/EdemamassagewhileonECMO
Other
AdministrativeData***Please donotremoveoruncheck***
X ORDERSETTRACKING
Priority: R Date:TODAY Time:NOW
*** DoNotModify,forTrackingOnly *** OrderSetUsed:ECMOORDERS
Version:1 PAGApprovalDate:20140325
Comments:
Other
HOMECMO ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page1 of4
PREECMOORDERS(Physician) Lastupd:05/03/16
Admission Status
X Admission Status
Priority: R Date:TODAY Time:NOW
Expectpatienttobehereequaltoorgreaterthantwomidnights: PatientStatus:
Admittingservice: BedType:
IcertifythatthePreadmissionAssessment iscompleteandsigned: AssigntoPhysician:
MedicalReason:
Comment:
Icertifythatthepatientstatusisappropriateandisbasedonmybest clinical judgement andthepatient’s condition asdocumented inthemedicalrecord.
Selectedrationaleforinpatientstatusforexpectedstaytwomidnights:
Other
Nursing
X ECMO:Guidelines
Priority: R Date:TODAY Time:NOW Comment:InitiateECMOguidelines
X VitalSigns
Priority: R Date:TODAY Time:NOW Frequency: PerUnitRoutine
Comment:
X CardioRespiratoryMonitor
Priority: R Date:TODAY Time:NOW EKGCable: Comments:CVICU5-lead
X PulseOximeter
Priority: R Date:TODAY Time:NOW Continuous:Yes until(time):
SpotCheck: Frequency:
IfPulseox: ,notifyphysician
Comment:
X MonitorNIRS
Priority: R Date:TODAY Time:NOW Cerebraloximeter: Yes
Somaticoximeter: No
Comments:
X MonitorETCO2
Priority: R Date:TODAY Time:NOW Comment:UnlessonHFOV
HOMECMOPRE ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page2 of4
PREECMOORDERS(Physician) Lastupd:05/03/16
X Foley
Priority: R Date:TODAY Time:NOW
NOTE:CAUTIPrevention Protocolrequiresassessment QShift
InsertFoleycathforthefollowing indication:I&OCriticalCarePt. Foley/Cath Duration: DCperProtocol
Foleytype:
Comment: REFLEXSET:CAUTI:Prevention Protocol
X ArterialLine
Priority: R Date:TODAY Time:NOW Site:
Transduce:
Comments: Prepareforplacement ofanArteriallineifnotpresent
X IVInitiate/Maintain
Priority: R Date:TODAY Time:NOW StartIV:
Comments: Place2peripheral IVsifnotpresent
X OGTube
Priority: R Date:TODAY Time:NOW GItube#1size(fr):
SuctionSetting:
Comment:
X CentralLine
Priority: R Date:TODAY Time:NOW
Comment:Prepareforcentralvenouslineifnotpresent
X PatientPositioning
Priority: R Date:TODAY Time:NOW
Comment:PositionpatientforECMOcannulation
X SurgicalPrep
Priority: R Date:TODAY Time:NOW
Comment:Movealloxygensourcesawayfromsurgicalfield
Other
ECMO
ECMOPrep
Priority: R Date:TODAY Time:NOW Priming:
3/8circuitorderandmakeavailable 2unitsofPRBC: Comments:
Other
HOMECMOPRE ****PatientInformationLabel****
MedicalCityDallasHospital7777FORESTLANE,DALLAS,TX75230 Page3 of4
PREECMOORDERS(Physician) Lastupd:05/03/16
Laboratory
X TYPEANDSCREEN
Priority: S Date:TODAY Time:NOW Comment:
REQUIREDFORPREADMITPATIENTSONLY: DateofSurgeryorProcedure: Transfusioninpast3months? Where? Pregnancyinpast3months?
X COMPREHENSIVEMETABOLIC PANEL Priority: S Date:TODAY Time:NOW
Comment:
X PROTHROMBINTIMEW/INR
Priority: S Date:TODAY Time:NOW
Comment:
X PARTIALTHROMBOPLASTINTIME
Priority: S Date:TODAY Time:NOW
Comment:
X CBCW/AUTODIFFERENTIAL
Priority: S Date:TODAY Time:NOW
Comment:
X AMYLASE
Priority: S Date:TODAY Time:NOW
Comment:
X LIPASE
Priority: S Date:TODAY Time:NOW
Comment:
X THROMBOELASTOGRAPH PROFILE
Priority: S Date:TODAY Time:NOW SpecimenType:
PediPreop(H.PEDPREIN):TEGresultsfax#: Comments:
Other
Radiology
X
Other
HOMECMOPRE ****PatientInformationLabel****
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PREECMOORDERS(Physician) Lastupd:05/03/16
AdministrativeData***Please donotremoveoruncheck***
X ORDERSETTRACKING
Priority: R Date:TODAY Time:NOW
*** DoNotModify,forTrackingOnly *** OrderSetUsed:PREECMOORDERS
Version:1 PAGApprovalDate:20140325
Comments:
Other
Associated Sets
ECMOORDERS
Add to pre-ecmo orders:
Assess neurological status
STAT echocardiogram by cardiac anesthesiologist for placement of cannulas
Add to ecmo orders:
Assess insertion sites and document hourly-Notify MD of bleeding/hematoma at site
Assess distal pulses using Doppler-hourly
Monitor for extremity swelling and compartment syndrome-hourly
Neurological checks—every 4 hours
Monitor distal reperfusion cannula for thrombosis-every 4 hours
2% chlorohexidine gluconate bathing protocol
Weigh patient daily
Maintain patient in supine position, HOB at 30 degree elevation
Place leg immobilizer on awake patient with femoral cannulation
Oral care per policy
HOMECMOPRE ****PatientInformationLabel****