POST-OP CARDIAC SURGERY PHYSICIAN S ORDER SHEET USE BALLPOINT PEN ONLY. CARDIAC INTENSIVE CARE UNIT

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1 PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALLERGIES: None known YES Patient s Height: Patient s Weight: ALL MEDICATION and INTRAVENOUS S GENERAL S Discontinue ALL pre-operative medications ANTIBIOTICS Cefazolin 1 g IV q8h x 6 doses Cefazolin 2 g IV q8h x 6 if body weight > 80 kg Vancomycin 1 g IV q12h x 4 doses, if allergic to cephalosporins (see back of sheet) Alternate: HEMODYNAMIC MANAGEMENT Order vasoactive infusions, dose range and titration parameters including those infusing from the O.R. Drug 1: Drug 2: Drug 3: Milrinone infusion: (see back of sheet) INTRAVENOUS THERAPY IV D5/0.45% 75 ml/h IV D5/0.45% 100 ml/h Total IV fluid intake not to exceed above rate Pentaspan 250 ml IV bolus if MAP < mmhg and CVP < mmhg; may repeat x 1 within the first 24h (max: 28 ml/kg/24h) Alternate: ORAL CARE Chlorhexidine 0.12% mouth rinse 15mL PO BID if intubated. Admit to the Cardiac ICU LabORATORY Tests (if applicable) On ICU arrival: 12 Lead ECG CXR - repeat on POD (post-op day) 1 ABG, (mixed venous gas). Repeat PRN only CBC, INR, PTT, Na, K, Cl, CO 2, Glucose, Urea, Cr, Ca, Phosphate, Mg, TnT, Albumin (repeat on POD 1 and daily while in the Cardiac ICU. TnT on POD 1 only. Reassess in 5 days. INR, PTT, CBC x 1 if total chest tube drainage > 100 ml/h x 2h. Repeat CBC q4h & PRN while total chest tube drainage >100mL/h Monitoring (if applicable) Continuous ECG, oximetry, CVP, (PAP), MAP Record HR, oximetry, all pressures on admission & PRN until stable, THEN q1h Record rhythm strip on admission, q8h & PRN PCWP: measure as specified: Cardiac output on admission & q1h until stable, THEN q4h Temp q1h until > 36ºC THEN q4h. Notify physician if temp > 38.5ºC Nursing Interventions Notify physician if urine output < 30 ml/h x 2h Weigh daily in A.M. Chest tubes to -20cm water suction Notify physician if total chest tube drainage > 100 ml/h x 2h Milk chest tubes gently PRN if visible clots Endoscopic vein harvest site: Keep leg wrapped with tensor for 48h (re-wrap q12h to assess leg) FAX SENT REV April 29, Part 1 of 4

2 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/1.73m 2 umol/l mcg/kg/min NRF < > anuric 0.20 REV April 29, Pg 2 Part 1 of 4

3 PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALL MEDICATION and INTRAVENOUS S GENERAL S Glucose Management Human Regular Insulin infusion - titrate to serum glucose 5-8 mmol/l Check blood glucose by glucometer q1h with Insulin changes until glucose is 5-8 mmol/l and no dose change x 2h, then monitor q4h. For serum glucose < 2.2 mmol/l STOP INSULIN INFUSION Administer D50W 50 ml IV push For glucose mmol/l STOP INSULIN INFUSION OR Administer Insulin at half the previous rate Administer D50W 25 ml IV push For tight glucose control - complete Intensive Care Insulin Order Sheet BETA BLOCKER THERAPY Consider post-op Beta Blocker for all patients, especially if on a Beta Blocker pre-op. Metoprolol 25 mg PO/NG BID Alternate: Hold if: - systolic BP < 110 mmhg - HR < 55 bpm & not paced - Has inotrope or vasopressor infusion ELECTROLYTE MANAGEMENT During first 24 hours postop: If serum Mg < 1mmol/L & Cr < 130 umol/l: Give Magnesium Sulfate 4g IV over 2h x 1 (contraindicated if anuric) If serum K < 3 or > 5.5 mmol/l, notify physician If serum K < 4 mmol/l : Give Potassium Chloride 20 mmol in 100 ml Sterile Water IV to infuse at 25 ml/h x 4 h Draw serum K, one hour post infusion of Potassium Chloride ORAL CARE Mouth care q2h while awake Tooth brushing BID ACTIVITY Physiotherapy consult Deep breathing and supported coughing Dangle within 6h post-op as tolerated Up in chair within 12-24h post-op as tolerated NUTRITION NPO until extubated, THEN clear fluids Increase to Modified Fat, 100 mmol Sodium diet Controlled Carbohydrate diet OR Controlled Carbohydrate diet with HS snack Other: Respiratory Management Wean and extubate per protocol when criteria met. Wean according to protocol. Physician order required to extubate. T - Piece FiO L/min Other Post extubation - titrate oxygen to SpO 2 > 95% Ventilator Settings (Complete if not an early extubation candidate) FiO 2 Mode VT/Pressure PEEP 5 cm H 2 O (minimum) or cm H 2 O FAX SENT REV April 29, Part 2 of 4

4 PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALL MEDICATION and INTRAVENOUS S GENERAL S PAIN MANAGEMENT * Morphine 2 mg IV q5min PRN (max 8 mg/h) Start first dose 4 hours post-op: Acetaminophen 650 mg PO/NG/PR q4h X 48h OR substitute/alternate with * Acetaminophen 325 mg with Codeine 30 mg 1-2 tabs PO/NG q4h X 48h THEN either agent 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: Pacemaker Settings Mode: Rate: bpm Atrial Output: 10 ma or Ventricular Output: 10 ma or Notify physician if failure to sense, capture or pace and with the presence of competition or rhythm change. Shivering/Hypothermia Management * Meperidine 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 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 FAX SENT REV April 29, Part 3 of 4

5 PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALL MEDICATION and INTRAVENOUS S GENERAL S 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 FAX SENT REV April 29, Part 4 of 4