NEUROSURGERY ICU PLAN

NEUROSURGERY ICU PLAN Weight Allergies Patient Care Vital Signs Per Unit Standards Per Unit Standards, including cerebral perfusion pressure (CPP) and end tidal CO2. Perform Neurological Checks q1h q2h q4h Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges Out of Bed Up in Chair Bedrest, Bed Position: HOB greater than or equal to 30 degrees Bedrest STRICT, Bed Position: HOB Flat, Can sit up for meals and restroom. Up Ad Lib/Activity as Tolerated Assist as Needed, Cervical Collar: Patient to wear brace at all times including while sleeping. Can remove brace for showering only. Up Ad Lib/Activity as Tolerated Assist as Needed, TLSO/LSO Brace: Patient to wear brace at all times except while laying flat in bed (i.e., sleeping). Can remove brace for showering and sleeping. Up Ad Lib/Activity as Tolerated Assist as Needed, Cervicothoracic Brace (CTO): Patient to wear brace at all times except while laying flat in bed (i.e., sleeping). Can remove brace for showering and sleeping. While sleeping patient should wear cervica Daily Weight Set Up for Arterial Line Placement Central Venous Pressure Monitoring (CVP Monitoring) Activity Precautions (Spinal Precautions) Maintain External Ventricular Drain 10 cm H2O, Zero At: Opening of Ear (EAC). ICP Monitoring Record Hourly. Transduce ICP off closed ventricular drain every hour. Strict Intake and Output Per Unit Standards q1h q2h q4h q12h Urinary Catheter Care Maintain Gastric Tube Maintain Nasogastric - NG, Low Intermittent Suction Maintain Orogastric - OG, Low Intermittent Suction Maintain Surgical Drain Measure Output q2h, Recharge/Strip q2h and PRN Measure Output q4h, Recharge/Strip q2h and PRN Wound Care by Nursing Accucheck q6h, DC if glucose is less than 150 for 24hrs. Page: 1 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

NEUROSURGERY ICU PLAN POC Urinalysis Dipstick w/o Microscopy (POC Urinalysis Automated w/o Microscopy) q1h for specific gravity. q2h for specific gravity. q4h for specific gravity. Communication Notify Provider of VS Parameters Temp Greater Than 101.5, RR Greater Than 24, RR Less Than 10, SpO2 Less Than 92, HR Greater Than 120, HR Less Than 60, ICP Greater Than 20 cmh2o (sustained more than 5 min) Notify Provider (Misc) Reason: Urine output less than 30 ml/hr averaged over 4 hours. Notify Nurse (DO NOT USE FOR MEDS) For Temp greater than 101.4 obtain UA, UA C&S, Sputum C&S, and Blood Cultures X 2. Dietary NPO Diet NPO, Except Meds NPO, Except Ice Chips TPO After Midnight Oral Diet Clear Liquid Diet Regular Diet Clear Liquid Diet, Advance as tolerated to Regular Continuous/Cyclic Tube Feeding IV Solutions NS + 20 meq KCl/L IV, 100 ml/hr IV, 75 ml/hr IV, 125 ml/hr IV, 150 ml/hr NPO NPO, Except Meds, Except Ice Chips KCl 20 meq + thiamine 100 mg + folic aci (NS + KCl 20 meq + thiamine 100 mg + folic acid 1 mg + MVI/100 ml) IV, ml/hr 20 meq, Every Bag 100 mg, Every Bag 1 mg, Every Bag 10 ml, Every Bag Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. dexamethasone 10 mg, IVPush, inj, q6h mg, IVPush, inj 10 mg, PO, tab, q4h Administer with meals and nightly. Page: 2 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

NEUROSURGERY ICU PLAN levetiracetam 500 mg, IVPB, ivpb, q12h 500 mg, PO, tab, BID 500 mg, per tube/po, liq, BID mannitol 25 g, IVPush, inj, q6h, PRN other PRN Intracranial pressure greater than. ***Hold for serum sodium greater than 150 or serum osmolarity greater than 320.*** 50 g, IVPush, inj, q6h, PRN other PRN Intracranial pressure greater than. ***Hold for serum sodium greater than 150 or serum osmolarity greater than 320.*** phenytoin 100 mg, IVPush, inj, q8h 100 mg, per tube/po, liq, TID 125 mg, per tube/po, liq, TID 100 mg, PO, cap sa, BID 100 mg, PO, cap sa, TID 200 mg, PO, cap sa, BID methocarbamol 500 mg, IVPB, ivpb, q8h, x 72 hr, Infuse over 30 min 500 mg, PO, tab, TID tizanidine 2 mg, PO, tab, q8h, PRN muscle spasms diazepam 10 mg, PO, tab, q8h, PRN muscle spasms 5 mg, PO, tab, q8h, PRN muscle spasms Respiratory albuterol (albuterol 2.5 mg/3 ml (0.083%) inhalation solution) 2.5 mg, inhalation, soln, q4h, PRN shortness of breath 2.5 mg, inhalation, soln, q6h, PRN shortness of breath ipratropium (ipratropium (Atrovent) 0.02% inhalation solution) 2.5 ml, inhalation, soln, q6h, PRN shortness of breath or wheezing Analgesics acetaminophen 650 mg, PO, tab, q6h, PRN pain/fever Do not exceed 4000 mg of acetaminophen per day from all sources. HYDROcodone-acetaminophen (HYDROcodone-acetaminophen 5 mg-325 mg oral tablet) 2 tab, PO, q4h, PRN pain Do not exceed 4g/day of acetaminophen. 1 tab, PO, q4h, PRN pain Do not exceed 4g/day of acetaminophen. Page: 3 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

NEUROSURGERY ICU PLAN morphine 2 mg, IVPush, q1h, PRN pain-severe 1 mg, IVPush, q1h, PRN pain-severe 2 mg, IVPush, q2h, PRN pain-severe 1 mg, IVPush, q2h, PRN pain-severe fentanyl 50 mcg, IVPush, q1h, PRN pain-severe 25 mcg, IVPush, q1h, PRN pain-severe 50 mcg, IVPush, q2h, PRN pain-severe 25 mcg, IVPush, q2h, PRN pain-severe Antibiotics cefazolin 1 g, IVPB, ivpb, q6h, Infuse over 30 min vancomycin 1000 mg, IVPB, ivpb, q12h, Infuse over 90 min 1000 mg, IVPB, ivpb, q24h, Infuse over 90 min GI Prophylaxis esomeprazole 40 mg, IVPush, inj, q24h 40 mg, IVPush, inj, q12h Antiemetics ondansetron 4 mg, IVPush, soln, q6h, PRN nausea/vomiting Gastrointestinal Agents docusate 100 mg, PO, cap, Nightly, PRN constipation *****IF docusate is contraindicated or ineffective after 12 hours, USE bisacodyl***** bisacodyl 10 mg, rectally, supp, Daily, PRN constipation *****IF bisacodyl is contraindicated or ineffective after 6 hours, USE Fleet Enema***** senna 8.6 mg, PO, tab, Nightly, PRN constipation Antacids Al hydroxide-mg hydroxide-simethicone (aluminum hydroxide-magnesium hydroxide-simethicone 200 mg-200 mg-20 mg/5 ml oral suspension) 30 ml, PO, susp, q4h, PRN indigestion Administer 1 hour before meals and nightly. Blood Pressure Management hydralazine 10 mg, IVPush, inj, q30min, PRN hypertension Give if Systolic BP is greater than 160 or Diastolic greater than 100. ***Do NOT give if heart rate is greater than 130*** labetalol Page: 4 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

NEUROSURGERY ICU PLAN 5 mg, IVPush, inj, q15min, PRN hypertension Give if Systolic BP is greater than 160 or Diastolic greater than 100. ***Do NOT give if heart rate is less than 60*** metoprolol 5 mg, IVPush, inj, q10min, PRN hypertension Give if Systolic BP is greater than or Diastolic greater than. ***Do NOT give if heart rate is less than 60*** nicardipine 25 mg/250 ml NS IV Final concentration = 0.1 mg/ml (100 mcg/ml). Usual Dose Range is 5-15 mg/hr. Notify physician if administered dose (rate) is greater than the usual dose range. Start at rate: mg/hr DOPamine 400 mg/250 ml D5W Start at rate: mcg/kg/min IV norepinephrine 4 mg/250 ml D5W Start at rate: mcg/min IV Sedatives propofol 1,000 mg/100 ml IV Final concentration = 10 mg/ml (10,000 mcg/ml). Do not use filter < 5 microns for administration. Max rate 100 mcg/kg/min. Titrtate to a RASS of 3. (See Richmond Agitation-Sedation Scale) Start at rate: mcg/kg/min fentanyl 1000 mcg/100 ml NS IV Final concentration = 10 mcg/ml. Start at rate: mcg/hr Laboratory CBC with Differential Basic Metabolic Panel Comprehensive Metabolic Panel Prothrombin Time with INR PTT Phosphorus Level Magnesium Level Arterial Blood Gas Alcohol Level Page: 5 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

NEUROSURGERY ICU PLAN Sed Rate C Reactive protein Phenytoin Level Total Sodium Level Osmolality Culture Blood Culture Sputum with Gram Stain Urinalysis Culture Urine Urine Random Drug Screen Diagnostic Tests DX Chest Portable CT Head w/o Respiratory Respiratory Care Plan Protocol Chest Physiotherapy q4h, as needed for pulmonary congestion. Incentive Spirometry q1h for 24 hr, Instruct patient to use 10 time each hour while awake. q1h for 48 hr, Instruct patient to use 10 time each hour while awake. Notify RT (Keep PCO2 less than 35) Keep PCO2 less than 35 Notify RT (NO ARDSnet Protocol) NO ARDSnet Protocol Physical Medicine and Rehab Consult PT Mobility for Eval & Treat Consult Occ Therapy for Eval & Treat Consult Speech Therapy for Eval & Treat Consults/Referrals Consult Dietician (Nutrition Consult by Dietitian) Social Services for Assessment and Eval Clergy Consult (Pastoral Care) Consult MD Service: MICU Team, Reason: Ventilator Management...Additional Orders Page: 6 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

NEUROSURGERY ICU PLAN Page: 7 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

VTE PROPHYLAXIS PLAN Patient Care VTE Guidelines See Reference Text for Guidelines ***If VTE Pharmacologic Prophylaxis not given, choose the Contraindications for VTE below and complete reason contraindi cated*** Contraindications VTE Patient low risk for VTE Patient is ambulatory Patient Refusal Family/Caregiver Refusal Cont IV heparin day of/after admission Anticoag therapy not warfarin for Afib Warfarin prior to admit; on hold r/t INR Risk of Bleeding Thrombocytopenia Active Bleeding Alteplase Administered w/in 24 hrs IV Heparin w/in 24 hrs of Surgery Apply Elastic Stockings Apply to: Bilateral Lower Extremities, Length: Knee High Apply to: Left Lower Extremity (LLE), Length: Knee High Apply to: Right Lower Extremity (RLE), Length: Knee High Apply to: Bilateral Lower Extremities, Length: Thigh High Apply to: Left Lower Extremity (LLE), Length: Thigh High Apply to: Right Lower Extremity (RLE), Length: Thigh High Apply Sequential Compression Device Apply to Bilateral Lower Extremities Apply to Left Lower Extremity (LLE) Apply to Right Lower Extremity (RLE) Apply Pedal Pump Apply to Bilateral Feet Apply to Left Foot Apply to Right Foot Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ***Recommended Trauma Dose = 30 mg, subcut, q12h*** ***Recommended Dose for Morbidly Obese Patients = 40 mg, subcut, q12h*** enoxaparin 40 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q24h 30 mg, subcut, syringe, q12h 40 mg, subcut, syringe, q12h heparin 5,000 units, subcut, inj, q12h 5,000 units, subcut, inj, q8h fondaparinux 2.5 mg, subcut, syringe, Daily ***If you order RIVAROXABAN for your patient, please indicate the reason below*** Page: 8 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

VTE PROPHYLAXIS PLAN Reason for Oral Factor Xa Inhibitor Reason: Atrial fibrillation Reason: Persistent atrial fibrillation Reason: Paroxysmal atrial fibrillation Reason: Atrial flutter Reason: Hx Afib/flutter - NA w/in 8wks post CABG Reason: Partial hip arthroplasty Reason: Total hip arthroplasty Reason: Total hip replacement Reason: Total knee arthroplasty Reason: Total knee replacement rivaroxaban 10 mg, PO, tab, In PM warfarin 5 mg, PO, tab, QPM aspirin 81 mg, PO, tab, Daily 325 mg, PO, tab, Daily Page: 9 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

PCA MED PLAN UMC Health System IV Solutions ***CAUTION*** Ordering a continuous rate (Basal Dose), should be reserved for opioid tolerant patients who require high dose therapy. ***DOSING NOTES***: 1. Initial doses are for opioid naive patients. Chronic pain patients may require higher doses. 2. Decrease initial starting dose by 25-30% in patients > 65 yrs, or patients with renal, hepatic, or pulmonary impairment. 3. Hydromorphone and fentanyl are recommended for patients with renal impairment or those intolerant of morphine. 4. Avoid meperidine use in patients > 65 yrs, renal impairment, seizure disorders, MAO inhibitors, or duration > 72 hrs. Reserve meperidine use for patients intolerant to all other opioids. morphine (morphine 30 mg/30 ml PCA) Start date/time Dose (mg) = 1, Lock-out Interval (min) = 8, 4-hour Limit (mg) = 20, Start date/time Dose (mg) = 1, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 20, Start date/time Dose (mg) = 2, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 40, Start date/time HYDROmorphone (HYDROmorphone 6 mg/30 ml PCA) Start date/time Dose (mg) = 0.1, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 2, Start date/time Dose (mg) = 0.2, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 4, Start date/time Dose (mg) = 0.3, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 6, Start date/time fentanyl (fentanyl 300 mcg/30 ml PCA) Start date/time Dose (mcg) = 10, Lock-out Interval (min) = 10, 4-hour Limit (mcg) = 100, Start date/time Dose (mcg) = 10, Lock-out Interval (min) = 10, 4-hour Limit (mcg) = 150, Start date/time Dose (mcg) = 10, Lock-out Interval (min) = 10, 4-hour Limit (mcg) = 200, Start date/time meperidine (meperidine 300 mg/30 ml PCA) Start date/time Dose (mg) = 10, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 100, Start date/time Dose (mg) = 10, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 150, Start date/time Dose (mg) = 10, Lock-out Interval (min) = 10, 4-hour Limit (mg) = 200, Start date/time If no IV Fluid is currently infusing, start 0.9% sodium chloride at KVO for duration of PCA NS (Normal Saline) 1,000 ml final vol, IV, KVO Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ACUTE MANAGEMENT OF RESPIRATORY DEPRESSION If respiratory rate is less than 10 breaths/min or patient is unresponsive 1. Stop PCA Pump 2. Dilute naloxone (Narcan) 0.4 mg / 1 ml in 9 ml NS and administer 0.1 mg (2.5 ml) by IVP every 2-3 minutes until respiratory rate is greater than 10 breaths/min. 3. Notify Physician Page: 10 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

PCA MED PLAN UMC Health System naloxone (naloxone 0.4 mg/ml injectable solution) 0.1 mg, IVPush, inj, q2min, PRN bradypnea Dilute in 0.4 mg in 9 ml NS and administer 0.1 mg (2.5 ml) every 2-3 minutes until respiratory rate is greater than 10 breaths/ min. Respiratory Continuous Pulse Oximetry Page: 11 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

ELECTROLYTE MED PLAN Communication When placing the protocol order, do NOT order any meds unless you need IMMEDIATE electrolyte replacement therapy. Electrolyte Replacement Protocol ***See Reference Text*** Electrolyte Replacement Protocol (IV Potassium Replacement) Electrolyte Replacement Protocol (IV Sodium Phosphates Replacement) Electrolyte Replacement Protocol (IV Potassium Phosphates Replacement) Electrolyte Replacement Protocol (IV Magnesium Replacement) Electrolyte Replacement Protocol (Oral Potassium Replacement) Electrolyte Replacement Protocol (Oral Phosphates Replacement) Electrolyte Replacement Protocol (Oral Magnesium Replacement) Electrolyte Replacement Protocol (Aggressive Treatment Option) IV Solutions Replacement orders should only be used in patients with a serum creatinine less than 2 mg/dl, BUN less than 30 mg/dl, and urinary output greater than 30 ml/hr An infusion pump is required for all electrolyte infusions Only the selected electrolytes will be replaced per protocol IV POTASSIUM REPLACEMENT: *****Central line administration***** 20 meq, IVPB, ivpb, ONE TIME, Infuse over 1 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check magnesium levels if potassium does not respond after 2 doses. CENTRAL LINE 20 meq/hr - [Serum Potassium 3.6-3.9 mmol/l] 40 meq, IVPB, ivpb, ONE TIME, Infuse over 2 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check magnesium levels if potassium does not respond after 2 doses. CENTRAL LINE 20 meq/hr - [Serum Potassium 3.1-3.5 mmol/l] 60 meq, IVPB, ivpb, ONE TIME, Infuse over 3 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check magnesium levels if potassium does not respond after 2 doses. CENTRAL LINE 20 meq/hr - [Serum Potassium 2.6-3 mmol/l] 80 meq, IVPB, ivpb, ONE TIME, Infuse over 4 hr, [Notify Physician if Serum Potassium < 2.6 mmol/l] **Repeat serum KCL level 2 hrs after the total replacement is completed. **ECG monitoring required for infusion rates > 10 meq/hr. **Check CENTRAL LINE 20 meq/hr - [Serum Potassium less than 2.6 mmol/l - notify physician] *****Peripheral line administration***** Page: 12 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

ELECTROLYTE MED PLAN 20 meq, IVPB, ivpb, ONE TIME, Infuse over 2 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check magnesium levels if potassium does not respond after 2 doses. PERIPHERAL LINE 10 meq/hr - [Serum Potassium 3.6-3.9 mmol/l] 40 meq, IVPB, ivpb, ONE TIME, Infuse over 4 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check magnesium levels if potassium does not respond after 2 doses. PERIPHERAL LINE 10 meq/hr - [Serum Potassium 3.1-3.5 mmol/l] 60 meq, IVPB, ivpb, ONE TIME, Infuse over 6 hr, *Repeat serum potassium level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check magnesium levels if potassium does not respond after 2 doses. PERIPHERAL LINE 10 meq/hr - [Serum Potassium 2.6-3 mmol/l] 80 meq, IVPB, ivpb, ONE TIME, Infuse over 8 hr, [Notify Physician if Serum Potassium < 2.6 mmol/l] *Repeat serum KCL level 2 hours after the total replacement is completed. *ECG monitoring required for infusion rates > 10 meq/hr. *Check Mg l PERIPHERAL LINE 10 meq/hr - [Serum Potassium less than 2.6 mmol/l - Notify Physician] IV SODIUM PHOSPHATES REPLACEMENT: *****Use when only phosphorus needs replacement***** sodium phosphate 15 mmol, IVPB, ivpb, ONE TIME, Infuse over 2 hr, Repeat serum phosphorus level 6 hours after infusion is completed. [serum phosphorus 2-2.5 mg/dl] sodium phosphate 30 mmol, IVPB, ivpb, ONE TIME, Infuse over 4 hr, Repeat serum phosphorus level 6 hours after infusion is completed. [serum phosphorus 1-1.9 mg/dl] sodium phosphate 45 mmol, IVPB, ivpb, ONE TIME, Infuse over 6 hr, [Notify physician if serum phosphorus less than 1 mg/dl] *Repeat serum phosphorus level 6 hours after infusion is completed. [serum phosphorus less than 1 mg/dl - notify physician] IV POTASSIUM PHOSPHATES REPLACEMENT: *****Use when phosphorus AND potassium need replacement***** potassium phosphate 15 mmol, IVPB, ONE TIME, Infuse over 2 hr, **Repeat serum phosphorus level 6 hours after infusion is completed. **Each 15 mmol of phosphorus contains 22 meq of potassium. [serum phosphorus 2-2.5 mg/dl] potassium phosphate 30 mmol, IVPB, ONE TIME, Infuse over 4 hr, **Repeat serum phosphorus level 6 hours after infusion is completed. **Each 15 mmol of phosphorus contains 22 meq of potassium. [serum phosphorus 1-1.9 mg/dl] Page: 13 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

ELECTROLYTE MED PLAN potassium phosphate 45 mmol, IVPB, ONE TIME, Infuse over 6 hr, [Notify Physician if serum phosphorus < 1 mg/dl] **Repeat serum phosphorus level 6 hours after infusion is completed. **Each 15 mmol of phosphorus contains 22 meq of potassium. [Notify Physician if serum phosphorus less than 1 mg/dl] IV MAGNESIUM REPLACEMENT: magnesium sulfate 2 g, IVPB, ivpb, ONE TIME, Infuse over 60 min, Repeat serum magnesium level 2 hours after the infusion is completed. [serum magnesium level 1.3-1.6 mg/dl] magnesium sulfate 3 g, IVPB, ivpb, ONE TIME, Infuse over 90 min, Repeat serum magnesium level 2 hours after the infusion is completed. [serum magnesium level 1-1.2 mg/dl] magnesium sulfate 4 g, IVPB, ivpb, ONE TIME, Infuse over 120 min, [Notify Physician if serum magnesium level less than 1 mg/dl] **Repeat serum magnesium level 2 hours after the infusion is completed. [serum magnesium level < 1 mg/dl - notify physician] Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. ORAL POTASSIUM REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** 20 meq, PO, tab sa, ONE TIME, *Repeat serum potassium level 4 hours after the total replacement is completed. *Check magnesium levels if potassium does not respond after total replacement completed. [Serum Potassium 3.6-3.9 mmol/l] 20 meq, PO, tab sa, q2h, x 2 dose, *Repeat serum potassium level 4 hours after the total replacement is completed. *Check magnesium levels if potassium does not respond after total replacement completed. [Serum Potassium 3.1-3.5 mmol/l] 20 meq, PO, tab sa, q2h, x 3 dose, *Repeat serum potassium level 4 hours after the total replacement is completed. *Check magnesium levels if potassium does not respond after total replacement completed. [Serum Potassium 2.6-3 mmol/l] 20 meq, PO, tab sa, q2h, x 4 dose, [Notify Physician if Serum Potassium less than 2.6 mmol/l] **Repeat serum potassium level 4 hours after the total replacement is completed. **Check magnesium levels if potassium does not respond after total replaceme [Notify Physican if Serum Potassium <2.6 mmol/l] ORAL PHOSPHATE REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** Page: 14 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

ELECTROLYTE MED PLAN potassium phosphate-sodium phosphate (potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg oral powder for reconstitution) 2 packet, PO, BID, x 6 dose [serum phosphorus 2-2.5 mg/dl] ORAL MAGNESIUM REPLACEMENT: *****For asymptomatic patients able to take ORAL supplementation***** magnesium lactate 168 mg, PO, tab, BID, x 6 dose, Repeat serum magnesium level with AM labs. [serum magnesium 1.3-1.6 mg/dl] Laboratory Potassium Level Phosphorus Level Magnesium Level Page: 15 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

SLIDING SCALE INSULIN PROTOCOL PLAN Patient Care Accucheck Per Sliding Scale Insulin Frequency AC & HS AC & HS 3 days TID BID q12h q6h q6h 24 hr q4h q2h Sliding Scale Insulin Protocol Follow SSI Reference Text Medications Medication sentences are per dose. You will need to calculate a total daily dose if needed. insulin regular (Low Dose Insulin Sliding Scale) 0-10 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale 111-150 - 0 units; 151-200 - 2 units subq; 201-250 - 3 units subq; 251-300 - 4 units subq; 301-350 - 6 units subq; 351-400 - 8 units subq; Greater than 400-10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, q6h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale 111-150 - 0 units; 151-200 - 2 units subq; 201-250 - 3 units subq; 251-300 - 4 units subq; 301-350 - 6 units subq; 351-400 - 8 units subq; Greater than 400-10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, q4h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale 111-150 - 0 units; 151-200 - 2 units subq; 201-250 - 3 units subq; 251-300 - 4 units subq; 301-350 - 6 units subq; 351-400 - 8 units subq; Greater than 400-10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... TO Read Back Scanned Powerchart Scanned PharmScan Page: 16 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

SLIDING SCALE INSULIN PROTOCOL PLAN 0-10 units, subcut, inj, q2h, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale 111-150 - 0 units; 151-200 - 2 units subq; 201-250 - 3 units subq; 251-300 - 4 units subq; 301-350 - 6 units subq; 351-400 - 8 units subq; Greater than 400-10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, TID, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale 111-150 - 0 units; 151-200 - 2 units subq; 201-250 - 3 units subq; 251-300 - 4 units subq; 301-350 - 6 units subq; 351-400 - 8 units subq; Greater than 400-10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. 0-10 units, subcut, inj, BID, PRN glucose levels - see parameters Low Dose Insulin Sliding Scale 111-150 - 0 units; 151-200 - 2 units subq; 201-250 - 3 units subq; 251-300 - 4 units subq; 301-350 - 6 units subq; 351-400 - 8 units subq; Greater than 400-10 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. Page: 17 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

SLIDING SCALE INSULIN PROTOCOL PLAN insulin regular (Moderate Dose Insulin Sliding Scale) 0-12 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale TO 111-150 - 2 units subq; 151-200 - 3 units subq; 201-250 - 4 units subq; 251-300 - 6 units subq; 301-350 - 8 units subq; 351-400 - 10 units subq; Greater than 400-12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, q6h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale 111-150 - 2 units subq; 151-200 - 3 units subq; 201-250 - 4 units subq; 251-300 - 6 units subq; 301-350 - 8 units subq; 351-400 - 10 units subq; Greater than 400-12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, q4h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale 111-150 - 2 units subq; 151-200 - 3 units subq; 201-250 - 4 units subq; 251-300 - 6 units subq; 301-350 - 8 units subq; 351-400 - 10 units subq; Greater than 400-12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, q2h, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale 111-150 - 2 units subq; 151-200 - 3 units subq; 201-250 - 4 units subq; 251-300 - 6 units subq; 301-350 - 8 units subq; 351-400 - 10 units subq; Greater than 400-12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... Read Back Scanned Powerchart Scanned. PharmScan Page: 18 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

SLIDING SCALE INSULIN PROTOCOL PLAN 0-12 units, subcut, inj, TID, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale 111-150 - 2 units subq; 151-200 - 3 units subq; 201-250 - 4 units subq; 251-300 - 6 units subq; 301-350 - 8 units subq; 351-400 - 10 units subq; Greater than 400-12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. 0-12 units, subcut, inj, BID, PRN glucose levels - see parameters Moderate Dose Insulin Sliding Scale 111-150 - 2 units subq; 151-200 - 3 units subq; 201-250 - 4 units subq; 251-300 - 6 units subq; 301-350 - 8 units subq; 351-400 - 10 units subq; Greater than 400-12 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300; then resume normal accucheck and sliding scale routine. Call physician. insulin regular (High Dose Insulin Sliding Scale) 0-14 units, subcut, inj, AC & nightly, PRN glucose levels - see parameters High Dose Insulin Sliding Scale 111-150 - 3 units subq; 151-200 - 4 units subq; 201-250 - 6 units subq; 251-300 - 8 units subq; 301-350 - 10 units subq; 351-400 - 12 units subq; Greater than 400-14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, q6h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; 111-150 - 3 units subq; 151-200 - 4 units subq; 201-250 - 6 units subq; 251-300 - 8 units subq; 301-350 - 10 units subq; 351-400 - 12 units subq; Greater than 400-14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician. Continued on next page... TO Read Back Scanned Powerchart Scanned Pharmscan Order Take By Signature: Page: 19 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

SLIDING SCALE INSULIN PROTOCOL PLAN 0-14 units, subcut, inj, q4h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; TO 111-150 - 3 units subq; 151-200 - 4 units subq; 201-250 - 6 units subq; 251-300 - 8 units subq; 301-350 - 10 units subq; 351-400 - 12 units subq; Greater than 400-14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, q2h, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; 111-150 - 3 units subq; 151-200 - 4 units subq; 201-250 - 6 units subq; 251-300 - 8 units subq; 301-350 - 10 units subq; 351-400 - 12 units subq; Greater than 400-14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, TID, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; 111-150 - 3 units subq; 151-200 - 4 units subq; 201-250 - 6 units subq; 251-300 - 8 units subq; 301-350 - 10 units subq; 351-400 - 12 units subq; Greater than 400-14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician 0-14 units, subcut, inj, BID, PRN glucose levels - see parameters High Dose Insulin Sliding Scale ; 111-150 - 3 units subq; 151-200 - 4 units subq; 201-250 - 6 units subq; 251-300 - 8 units subq; 301-350 - 10 units subq; 351-400 - 12 units subq; Greater than 400-14 units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG is less than 300, then resume normal accucheck and sliding scale routine. Call physician Continued on next page... Read Back Scanned Powerchart Scanned PharmScan Page: 20 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14

SLIDING SCALE INSULIN PROTOCOL PLAN insulin regular (Blank Insulin Sliding Scale) See Comments, subcut, inj, PRN glucose levels - see parameters Blood glucose is less than ; Initiate hypoglycemic protocol and Call physician; 70-110 - units; 111-150 - units subq; 151-200 - units subq; 201-250 - units subq; 251-300 - units subq; 301-350 - units subq; 351-400 - units subq; Greater than 400 - units IV now, repeat accucheck in 30 minutes; continue to repeat 10 units IV and accuchecks every 30 minutes until BG less than, then resume normal accucheck and sliding scale routine. Call physician HYPOglycemia Protocol HYPOglycemia Protocol If BS is less than 70 mg/dl, and patient SYMPTOMATIC, give 6 oz. of juice PO (if applicable) and/or follow HYPOglycemia Protocol meds. glucose (D50) 25 g, IVP, syringe, as needed, PRN glucose levels - see parameters Patient unable to swallow / NPO WITH IV access. Dextrose 50% 50 ml IV. Recheck BG in 15-20 minutes. Repeat treatment until blood glucose greater than 100 mg/dl. If not NPO provide additional snack once able to swallow. glucose 15 g, PO, gel, as needed, PRN glucose levels - see parameters glucagon 1 mg, IM, inj, as needed, PRN glucose levels - see parameters Patient UNABLE to swallow / NPO WITHOUT IV access. Administer Glucagon 1 mg IM or SubQ. Contact physician for further orders. Establish IV access with saline lock. Recheck BG every 15 to 20 minutes. Use aspiration precautions as glucagon may cause nausea and vomiting. Page: 21 of 21 Neurosurgery ICU Plan Version: 3 Effective on: 08/27/14