ADULT CARDIOTHORACIC POST-OPERATIVE ORDERS 1 of 5

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1 Actual Estimated DOWNTIME Entered into electronic record after POST-OPERATIVE 1 of 5 Actual Weight kg Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Patient Condition: Procedure: Admit to: Service/Attending: Notify Cardiologist of Admission: Advance Directive Status (supporting documentation in chart): ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 1. OXYGEN SUPPORT/VENTILATION: Utilize Extubation/Weaning from Mechanical Ventilation (#TX PUL.4 PTC) Ventilator Settings per Anesthesia Positive End Expiratory Pressure: Tidal Volume: ml/kg Rate: Fraction of Inspired Oxygen (FiO2): + Pressure Support Cough, deep breathe and incentive spirometry every 2 hours post extubation Elevate head of bed at least 30 degrees when hemodynamically stable Monitor mixed venous oxygen saturation with vital signs 2. VITAL SIGNS/HEMODYNAMICS: Every 15 minutes x 1 hour, every hour x 8 hours, then every 2 hours x hours as needed Hemodynamic profi le within 30 minutes of admission then every 6 hours and as needed All pressure line fl ush packs and transducers per Hemodynamic Monitor protocol Discontinue pulmonary artery catheter if patient is extubated and cardiac index is greater than 2 without inotropic support. Mediastinal and/or pleural chest tubes to closed seal drainage at 20 cm water suction. Measure and record output every hour x 12 hours, then every 2 hours. Notify provider if chest tube s output is greater than 200 ml/hour or 100 ml/hour x 2 Milk chest tubes to maintain patency Cardiac Surgery Algorithm/Decision Tree: Hemodynamic Management Low Cardiac Index (DTKH ) Cardiac Surgery Protocol/Decision Tree: Hemodynamic Management Fluid Resuscitation (DTKH ) with: Voluven Albumin 5% Cardiac Surgery Algorithm/Decision Tree: New Onset Atrial Fibrillation (DTKH ) Utilize Electrolyte Replacement Protocol (#TX IV s and Meds 33 PTC) 3. ACTIVITY: Turn and position every 2 hours Advance activity as tolerated 4. DIET: Nothing by mouth except ice chips. May have sips of clear fl uids after extubation and with the presence of bowel sounds. Advance Diet to: House Heart Health: Diabetic: American Diabetic Association Other: Nasogastric (NG) Tube to low intermittent wall suction. Clamp 30 minutes post medication. Discontinue NG tube when bowel sounds are present post extubation 5. INTAKE AND OUTPUT: Measure every hour x 12 hours, then every 2 hours Daily Weight Indwelling urinary catheter Initials Place STAT barcode sticker within this box only on form copy being scanned

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3 DOWNTIME Entered into electronic record after POST-OPERATIVE 2 of 5 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. 6. INCISION CARE: Change initial sternal dressing post-operative day 2 then daily until discharge Chlorhexidine 2% wipes daily starting post-operative day 2 If able to shower, patient to use chlorhexidine 4% wash to cleanse incisions Provena negative pressure wound therapy Other: 7. PACEMAKER: Pacemaker setting: Emergency epicardial pacing may be instituted for symptomatic bradycardia (heart rate less than 50 beats per minute). Connect ventricular wires to negative pole; ground wire to positive pole. Notify Physician. Temporary pacemaker settings as follow: Milliampere (MA) = 20 Rate = 90 Sensitivity = Demand 8. LABS & DIAGNOSTICS: Within 30 Minutes of Admission: Arterial Blood Gas (ABG), Prothrombin Time (PT), Activated Partial Thromboplastin Time (aptt), Fibrinogen Ionized Calcium Upright Chest X-ray for endotracheal tube placement (ETT)/post-operative Electrocardiogram (EKG); omit if ventricular pacemaker dependent Within 30 Minutes of Admission AND Every 8 Hours x 3: Complete Blood Count (CBC), Basic Metabolic Panel (BMP), Magnesium Post-Operative Day 1: Comprehensive Metabolic Panel (CMP) in morning Upright Chest X-ray for line position EKG Additional Labs: 9. MEDICATIONS: A. DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS (Risk Assessment on Back) REQUIRED to ( ) check all that apply: Heparin 5000 units subcutaneous every 8 hours Enoxaparin 40 mg subcutaneous daily Enoxaparin 30 mg (if Glomerular Filtration Rate is less than 30) subcutaneous daily Pneumatic Compression Device (PCD): Knee High Pump Foot Pump Other Orders: DVT Prophylaxis not indicated (Reason): DVT Prophylaxis contraindicated (Reason): B. EXISTING MEDICATIONS: Refer to Powerchart Medication History C. NEW MEDICATIONS Calcium Supplements (if Ionized Calcium is less than 4.5 or Serum Calcium is less than 8) Calcium Gluconate 1 gram (4.65 meq) in 50 ml Normal Saline intravenous over 1 hour as needed Calcium Chloride 1 gram (13.6 meq) in 50 ml Normal Saline intravenous over 1 hour as needed Surgical Infection Prophylaxis Anesthesia End Time: Cefazolin intravenous every 8 hours x 3 doses (not to exceed 48 hours after anesthesia end per surgical care improvement project measures) dispense as written dose: 1 gram (weight 60 kg or less) 2 grams (weight more than 60 kg) Gastrointestinal Prophylaxis Famotidine 20 mg nasogastric tube every 12 hours Pantoprazole 40 mg daily: by mouth nasogastric tube intravenous Initials Place STAT barcode sticker within this box only on form copy being scanned

4 DOWNTIME Entered into electronic record after POST-OPERATIVE 3 of 5 RISK FACTORS DEEP VEIN THROMBOSIS (DVT) PROPHYLAXIS RISK ASSESSMENT AGE points IMMOBILITY points SURGERY points greater than 60 years 2 Coma 2 Hip/Pelvic/Long Bone Fracture years 1 Patient confi ned to bed greater than 72 hours Recent uninterrupted travel greater than 4 hours 2 1 Multiple Trauma 5 Laparoscopic/Pelvic Surgery 2 Major Surgery greater than 45 minute duration 2 PRE-EXISTING/CURRENT MEDICAL CONDITIONS points points Ischemic Stroke/Paralysis 5 Current Heart Failure/ Myocardial Infarction 1 Previous DVT or Pulmonary Embolism (PE) 3 Obesity (greater than 20% Ideal Body Weight [IBW]) 1 Hypercoagulation State* 3 Pregnancy/Postpartum less than 1 month 1 Cancer 2 Severe Dehydration 1 Central Venous Catheter greater than 1 week (excludes Renal Nephrotic syndrome 1 2 Access) Varicose Veins/Vein Surgery/Phlebitis 1 Infection (severe/sepsis) 1 Infl ammatory Bowel Disease 1 Chronic Obstructive Pulmonary Disease (COPD)/Respiratory Distress/Steroid or Oxygen Dependent 1 Chemotherapy 1 Estrogen Use (oral contraceptives, hormone replacement therapy [HRT]) 1 Family Medical History unexplained DVT 1 *Examples of Hypercoagulation State: Protein C or S defi ciency Antithrombin III defi ciency Lupus Anticoagulant Homocystinemia LOW RISK (Score of 1 or less) No prophylaxis Ambulate MODERATE TO HIGH RISK* (Score of 2-4) Heparin 5000 units subcutaneous every 8 hours -OR- Pneumatic Compression Device (PCD) HIGHEST RISK/MULTI MODAL* (Score of 5 or higher) Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) *Recommendations apply to general medical and surgical patients. Please see below for additional recommendations for specific patient populations. ALTERNATIVE RECOMMENDATIONS FOR SPECIFIC PATIENT POPULATIONS Neurosurgery Heparin 5000 units subcutaneous every 8 hours -AND- Pneumatic Compression Device (PCD) Orthopaedic Surgery See form KH00202 Total Knee/Hip Arthroplasty Post-Operative Orders Trauma/ Spinal Cord Injury Enoxaparin 30 mg subcutaneous every 12 hours -AND- Pneumatic Compression Device (PCD) Consider platelet monitoring for prolonged anticoagulation Coronary Artery Bypass Surgery Enoxaparin 40 mg subcutaneous daily (Enoxaparin 30 mg subcutaneous daily if Creatinine Clearance [CrCl] less than 30 ml/minute) Bariatric Surgery Enoxaparin 40 mg subcutaneous every 12 hours High Risk Bleeding (any population History of with moderate Heparin-induced to high venous Thrombocytopenia thromboembolism [VTE] risk) Pneumatic Compression Device (PCD) Fondaparinux 2.5 mg subcutaneous daily (Contraindicated if Creatinine Clearance [CrCl] less than 30 ml/minute) References: Modifi ed From: Motyke, GD, Zebal, LP and Caprini, et al. A Guide to Venous Thromboembolism Risk Factor Assessment. Journal of Thrombosis and Thrombolysis, Geerts W, Bergqvist D, Pineo G et al. Prevention of Venous Thromboembolism. Chest 2008; 133: 381S-453S

5 DOWNTIME Entered into electronic record after POST-OPERATIVE 4 of 5 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. Nausea Medication Prochlorperazine 10 mg intravenous every 6 hours as needed Ondansetron 4 mg intravenous every 8 hours as needed Vasospasm Medication Diltiazem 30 mg by mouth every 8 hours with fi rst dose at 0400 Antiplatelet Medication Aspirin 81 mg by mouth starting the next morning and then daily Constipation Medication Docusate 100 mg by mouth twice a day Temperature Greater than F (38.5 C) Medication Acetaminophen 650 mg every 8 hours as needed: by mouth per rectum Bronchodilator Medication dose route interval D. INTRAVENOUS INFUSIONS Anti-arrhythmic Infusion Amiodarone 150 mg bolus Amiodarone 1 mg per minute x 6 hours then 0.5 mg per minute x 18 hours Vasospasm Infusion Diltiazem infusion at mg/hour Stop Diltiazem infusion 4 hours after fi rst oral dose given Afterload Reducer Infusion Nitroprusside infusion at mcg/kg/minute Pressor Infusion DOBUTamine infusion at mcg/kg/minute DOPamine infusion at mcg/kg/minute Epinephrine infusion at mcg/minute Norepinephrine infusion at mcg/minute Keep Vein Open for all Central Lines without Infusion Normal Saline Hemodynamic Management Protocol Preference Bolus Fluid Resuscitation 5% Albumin Voluven 500 ml intravenous x 2 (not to exceed total 50 ml/kg/day) Maintenance Intravenous Fluid Hydration Lactated 100 ml/hour Normal ml/hour Additional Intravenous Orders (include indication) E. ANALGESIC/SEDATION Analgesic Medication Ketorolac: 30 mg intravenous every 6 hours as needed x 3 days for age 64 years or less and/or 50 kg or more 15 mg intravenous every 6 hours as needed x 3 days for age 65 years or more and/or 49 kg or less Hold if Creatinine is 1.2 or more Initials Place STAT barcode sticker within this box only on form copy being scanned

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7 DOWNTIME Entered into electronic record after POST-OPERATIVE 5 of 5 ( ) Check, circle and/or fill in all orders to be implemented as appropriate. Sedation Medication Propofol 10 mg/ml infuse at mcg/kg/minute. Titrate per protocol Dexmedetomidine Hydrochloride infusion at mcg/kg/hour. Titrate per protocol Narcotic Analgesic Medication Morphine mg (route): intravenous intramuscular (interval): Dilaudid mg (route): intravenous intramuscular (interval): dose route interval F. INSULIN/ANTIDIABETIC AGENT Continuos Insulin Infusion Complete Order Set KH OR- MDN-CGS Insulin Software Program Sliding Scale Regular Insulin (Antidiabetic Agent) Complete Adult Subcutaneous Insulin Orders (KH01169) G. IMMUNIZATIONS Per New York State Department of Health Mandatory Immunization Program and Kaleida Policy CL.6: All patients 6 to 64 years old with chronic health conditions and all patients age 65 or older admitted to Kaleida will be screened to determine eligibility for the pneumococcal immunization and all eligible patients will be offered the vaccine. All patients admitted to Kaleida age 6 months and older will be screened to determine eligibility for influenza immunization and all eligible patients will be offered the vaccine. The immunization(s) will be held if the patient has a contraindication. Please select the appropriate contraindication(s) and sign the Adult Pneumococcal/Influenza Vaccination Screening & Orders (KH01183) to have the immunization(s) held. H. ADDITIONAL MEDICATIONS Medication dose route interval indication a. b. c. d. 10. ADDITIONAL : NURSING TORB From: Date: Time: Signature: NOTED BY RN Date: Time: Signature: PROVIDER Date: Time: Print Name/Stamp: Signature: TORB = Telephone Orders Read Back Place STAT barcode sticker within this box only on form copy being scanned

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