ST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI

Transcription

1 Date & Time TAVR Pre-Op Admission Clinical Pathway Page 1 of 3 1. Admit as INPATIENT to Dr.. For Surgery Today or Tomorrow 3. Diagnosis: 4. Allergies: Pharmacy Mnemonic: PRETAVR 5. Vital signs on arrival. Height (in inches and cm) and weight (in lbs and kg) with CVU scales & record on front of chart. 6. Verify TAVR Pre-Op Admission checklist for required chart documents is on patient chart **Contact Valve Clinic/TAVR Coordinator at [ ] if not present** Notify Surgery Posting Desk of Cardiac Surgery - (Notify Supervisor if posting desk is closed) Consult Anesthesiology to see patient during pre-admission assessment 7. CM: Prep patient for Transcatheter Aortic Valve Replacement with surgical clippers Pre-operative patient instructions: o NPO after midnight the night prior to surgery. (Except medications as instructed. Take with a sip of water) o Provide with and instruct patient in use of: 1. Hibiclens (chlorhexidine gluconate 4% topical) bath or shower the night before surgery and in A.M. of surgery. 2. Bactroban (mupirocin) nasal ointment 2% to each nare two times daily. 3. Peridex (chlorhexidine gluconate 0.12%) mouthwash 0.12% four times daily 8. CM: SCIP - Surgical Care Improvement Project (Nursing Order Do Not Delete) 9. Consent for: Blood Administration Cardiac Surgery: 10. Copy of H&P and recent consults on chart including pulmonology, nephrology, and cardiology. 11. Notify Heart Team (CT surgeon, Cardiologist, & Anesthesia) of admission and location of patient Cardiologist: CT Surgeon: 12. Respiratory Therapy: Pre-Op ABG/PFT s and Incentive Spirometry instruction. (if Cath Lab ABG's are within normal limits do not repeat) Bedside Spirometry for patients with hx of COPD or smoking. Complete PFT 13. Place IV: Normal KVO Insert Saline Lock 14. CM: If patient routinely on AM Beta Blocker, instruct patent to take 1/2 dose the morning before surgery. Record date/time of last dose; if not taken within the last 24 hours prior to surgery - notify anesthesia. 15. DISCONTINUE ALL METFORMIN CONTAINING DRUGS (Actoplus Met, Fortamet, Glucophage, Glucovance, Metaglip, Metformin, Janumet, Glumetza, or Riomet) AT LEAST 48 HOURS PRIOR TO SURGERY. Notify MD: if patient has taken ANY METFORMIN CONTAINING DRUGS within 48 hrs. prior to time of scheduled surgery. For Diabetics: Check Glucose (Accucheck) on day of surgery if patient is a diabetic. If blood glucose is > 180 administer 5 units of Regular Insulin IV push STAT. Then recheck Accucheck glucose in 30 minutes and initiate Intensive Insulin Orders (attached) CVR ONLY

2 Date & Time TAVR Pre-Op Admission Clinical Pathway Page 2 of 3 Pharmacy Mnemonic: PREOPCVS 16. Medications: Patient Height inches Weight kg Pre-Op Antibiotics (Check one box below) 1. Low Risk Patient A.M. admit and is not Diabetic: (Select one box below) Administer Kefurox (cefuroxime) 1.5 grams IV (start within one hour of skin Administer Ancef (cefazolin) 2 grams IV if patient < 120 kg (start within one hour of skin Administer Ancef (cefazolin) 3 grams IV if patient > 120 kg (start within one hour of skin 2. High Risk Patient ( Pt. is Diabetic, inpatient or BMI 30) (Select one box below) Administer Kefurox (cefuroxime) 1.5 grams IV (start within one hour of skin OR Administer Ancef (cefazolin) 2 grams IV if patient < 120 kg (start within one hour of skin OR Administer Ancef (cefazolin) 3 grams IV if patient > 120 kg (start within one hour of skin AND Administer Vancomycin 15 mg/kg IV(start within two hours of skin 3. Penicillin and/or Cephalosporin Allergy: (Select one box below) Administer Vancomycin 15 mg/kg IV (start within two hours of skin AND A. Gentamicin 2 mg/kg (ideal body weight) IV if patient is on Dialysis OR Gentamicin 5 mg/kg (ideal body weight) IV if patient is NOT on Dialysis OR B. Levaquin 750 mg IV CM: Select reason for use of Vancomycin below: Significant penicillin allergy or allergy to cephalosporins Known prior colonization with MRSA High-risk due to inpatient hospitalization within the last year Patient has chronic wound care or on dialysis Increased MRSA rate either facility-wide or procedure-specific Hospital inpatient for >24 hrs prior to procedure High-risk due to residence in long-term care setting within the last year *Redose Kefurox or Ancef in surgery if chest is open greater than 4 hours

3 TAVR Pre-Op Admission Clinical Pathway Page 3 of Lab: A). CBC w/diff, CMP and HgB A1c, BNP, and Clean-Catch Urinalysis (DO NOT repeat labs if done within 72 hrs. of surgery and within normal limits). B) PT, PTT, (if not done within 7 days of surgery). C) HIV 1-2, HBsAg, HCV (On all patients that have had blood transfusions; Do not repeat if already done) D) Type & cross match 4 units of packed cells for surgery 18. Studies: Place results on chart. A) EKG (do not repeat if done within 72 hours and no chest pain Indication: Pre-Op Transcatheter Aortic Valve Replacement B) Chest X-ray: PA and Lateral view Indication: Pre-Op Transcatheter Aortic Valve Replacement C) Carotid Ultrasound (do not repeat if done within last 3 months). D) Obtain Euroscore, STS Score (Place results in chart) E) Obtain CTA-Chest, Abdomen, & Pelvis (TAVR Protocol) report and place on chart F) Obtain Heart Catheterization report and place on chart G) Obtain Transthoracic and/or Transesophogeal Echo report(s) and place on chart 19. Consult cardiac rehab for pre-op teaching, case management, and pastoral care. / Date Time Physician Signature

4 Date & Time Intensive Insulin Orders Page 1 of 2 Pharmacy Mnemonic: IINSPROT 1. Endocrinologist consult: Consult Diabetes Management Team 2. Consult pharmacy for glucose management. 3. Initiate IV insulin flowsheet and keep on the bedside record. 4. Start IV: 0.9% Sodium Chloride 1000 ml at ml per hr. Dextrose 5% 1000 ml with 20 meq KCl at ml per hr. Dextrose 5% and 0.45% Sodium Chloride 1000 ml with 20 meq KCl at ml per hr. Other: 5. Mix insulin infusion: 100 units Humulin R into 100 ml 0.9% Sodium Chloride to equal a concentration of 1 unit per ml. 6. Piggyback insulin infusion into large volume IV using IMED or equiv pump. 7. Start insulin infusion on pump at rate determined by the following: Find blood glucose range on Blood Glucose Table with a multiplier of 0.03 (This equals the number of units of insulin per hour.) 8. Check blood glucose every hour by finger stick. Do not use alternate sites without endocrinology approval. Adjust current multiplier according to the directions under Insulin Actions on the Blood Glucose Table. 9. Target range for blood glucose: Treat for hypoglycemia as indicated on Blood Glucose Table. 11. Notify ordering physician if: A.) Patient is scheduled for surgery or transfer to floor. B.) C.) D.) Other physicians order insulin subcutaneous, IV or in TPN. Feedings, TPN or steroids are started, stopped, or changed. Other physicians turn off insulin infusion for any reason. E.) Blood Glucose is greater than Obtain lab glucose if finger stick blood glucose is less than 50 or greater than 500.

5 Date & Time Intensive Insulin Orders Page 2 of 2 Blood Glucose Table Multiplier Pharmacy Mnemonic: IINSDEXT Blood Glucose D50W IV Push Insulin Actions 372 to If blood glucose increases, go to the next higher multiplier 324 to to If blood glucose decreases less than 1 row/hr, go to the next higher multiplier 245 to to If blood glucose decreases greater than 1 row/hr, maintain current multiplier 185 to to Maintain current multiplier 141 to to to Go to next lower multiplier 111 to to to to ml 60 to ml 50 to ml 40 to ml Recheck blood glucose in 30 min. Administer D50W IV push Less than ml Nurse 1: I asked another nurse to independently double check the insulin prior to administration to this patient. / Date Time Nurse 1 Signature Nurse 2: I verified that: order matches medication and dose, pump settings are correct, armband matches medication, amount drawn up in syringe matches order. / Date Time Nurse 2 Signature / Date Time Physician Signature