DRUG AND TREATMENT Intubation Phase Notify Therapy for STAT intubation Medications SUB Rapid Sequence Induction (SUB)* ***Reminder: Order SUB Rapid Sequence Induction (SUB) on a separate form*** lidocaine 100 mg inj IV PUSH ONCE, Clinical Instructions: for Mechanical Ventilator Intubation Radiology XR Chest *1 view AP Portable Post intubation, Stat, Pending Discharge - No, ONCE, Wet read immediately to be called to nurse Stat, 30 minutes post intubation Ventilator Initial Setup Ventilator Maintenance Phase Ventilator Weaning Assessment DAILY06 Initiate Precautions to Prevent Ventilator Associated Pneumonia Sedation Vacation: Hold all analgesics and sedations daily at 0800 until Ramsay of 2 Enteral Tube Insertion Enteral Tube Type: Orogastric, Tube Drainage Method: Low Intermittent Suction, Additional Instructions: As needed Please obtain STAT ABG draw, PRN, for oxygen saturation LESS than 92% and call results to physician Medications GEN Venous Thromboembolism Prophylaxis (VTE) (SUB)* ***Reminder: Order GEN Venous Thromboembolism Prophylaxis (VTE) (SUB) on a separate form*** Chlorhexidine 0.12% Vent Oral Care Kit 1 dose PO mouthwash BID Comments: For oral cleaning if patient is intubated. Protonix 40 mg inj IV PUSH DAILY Prevacid Solu Tab 30 mg tab soluble OG TUBE DAILY Diprivan 1000mg/100 ml premix bottle IV bottle Rate: 10 Rate: Titrate mcg/hour Comments: Start at 10 mcg/hr and titrate in increments of 10 mcg/kg every five minutes to Ramsay scale of 4 up to maximum of 80 mcg/hr (check lipids). Assess sedation level Q4H and Page 1 of 6
DRUG AND TREATMENT 30 minutes after each dose change Ativan 100 mg/d5w 100 ml IV drip IV bag Rate: 2 mg/hour Comments: Start at 2 mg/hr and titrate in increments of 2 mg every 10 minutes to Ramsay scale of 3 up to maximum of 8 mg/hr. Assess sedation level Q4H and 30 minutes after each dose change Fentanyl 2,500 mcg / 250 ml IV Set (IVS)* Sodium Chloride 0.9% IV bag Rate: Starting Rate 25 mcg/hour Comments: Start at 25 mcg/hr and titrate to Ramsay scale of 3 up to maximum of 100 mcg/hr. Assess sedation level Q4H and 30 minutes after each dose change fentanyl IV drip 2,500 mcg Versed 100 mg/ns 100 ml IV drip 100 ml IV bag Rate: 2 mg/hour Comments: Start at 2 mg/hr and titrate in increments of 2 mg every 10 minutes to Ramsay scale of 3 up to maximum of 8 mg/hr. Assess sedation level Q4H and 30 minutes after each dose change Precedex 200 mcg/ns 50 ml IV Set (IVS)* Sodium Chloride 0.9% IV iv Rate: 0.2 mcg/kg/hr Comments: Start at 0.2 mcg/kg/hr and titrate in increments of 0.1 mcg/kg every 15 minutes to Ramsay scale of 3 up to maximum of 0.7 mcg/kg/hr. Assess sedation level Q4H and 30 minutes after each dose change dexmedetomidine IV drip 200 mcg Precedex 200 mcg / 50 ml premix IV premix Rate: 0.2 mcg/kg/hr Comments: Start at 0.2 mcg/kg/hr and titrate in increments of 0.1 mcg/kg every 15 minutes to Ramsay scale of 3 up to maximum of 0.7 mcg/kg/hr. Assess sedation level Q4H and 30 minutes after each dose change morphine 2 mg inj IV PUSH Q2H, PRN Pain Moderate Comments: Titrate to Ramsay scale of 3. Assess sedation level Q4H and 30 minutes after each dose Ativan 1 mg inj IV PUSH Q4H, PRN Agitation Comments: Titrate to Ramsay scale of 3. Assess sedation level Q4H and 30 minutes after each dose Versed 2 mg inj IV PUSH Q2H, PRN Agitation Comments: Titrate to Ramsay scale of 3. Assess sedation level Q4H and 30 minutes after each dose NEURO Neuromuscular Blockade (SUB)* ***Reminder: Order NEURO Neuromuscular Blockade (SUB) on a separate form*** Radiology XR Chest *1 view AP Portable Page 2 of 6
DRUG AND TREATMENT failure, Routine, Pending Discharge - No, DAILY, Daily while intubated for respiratory failure Mode; AC, Rate; 10, Fi02; 1, PEEP; 5, Tidal Volume: 8 ml/kg of ideal body wt (DEF)* Mode; PRVC, Rate; 10, Fi02; 1, PEEP; 5, Tidal Volume: 8 ml/kg of ideal body wt Routine, Daily while intubated Consults Nutrition Consult TPN (DEF)* Tube Feeding Weaning & Extubation Phase ASDIR, Q5MINS x 4, then Q15MINS x 2, then Q30MINS x 2. See Order Comments for additional instructions Comments: During weaning process: monitor and document HR, rhythm, BP, respiratory rate, level of consciousness, tidal volume, oxygen saturation, and signs of intolerance (see Ventilator Weaning Intolerance Criteria-Reference Text order) If patient meets pre wean criteria (Wean Assessment Score greater than 17 and Ramsay score less than 4) coordinate for mechanical vent weaning with RT. Confirm cuff leak test greater than 110 ml (predeflation VTe - post-deflation VTe) prior to extubation Ventilator Weaning Intolerance Criteria-Reference Text Notify Provider Routine, Must call physician prior to ventilator extubation Hold IV sedation except Precedex (unavailable at Baptist Beaches and Baptist Nassau) (DEF)* For Baptist Beaches and Nassau, see Order Comments Comments: Reduce Propofol by 5 mcg/kg/min every 5 minutes until off. Restart Propofol if patient becomes agitated (to level necessary to sedate to Ramsey Level II). When Ramsey Level II achieved, Check NIF, and respiratory rate. Once NIF greater than 20, FVC greater than 8 ml/kg and respiratory rate less than 30, place patient on : Pressure Support 0 cm, CPAP 5 cm, and FIO2 50% for a 30 minute breathing trial Extubate Patient Extubate to venti mask at current FIO2 if patient meets pre wean criteria Extubate Patient Extubate to Bipap 12/5 setting if patient meets pre wean criteria Extubate Patient Extubate to room air if patient meets pre wean criteria Routine, May increase FiO2 to maintain O2 sat greater than 92% but not to exceed FiO2 of 50%. If ph less than 7.35 and/or PO2 less than 60, resume previous ventilator settings for next 24 hours Page 3 of 6
DRUG AND TREATMENT Routine, Obtain ABG 30 minutes post mechanical ventilator wean or sooner if patient exhibits signs of intolerance. Call results to physician (DEF)* Results of ABG study obtained post mechanical ventilator wean or sooner if patient exhibits intolerance Trache Weaning Phase ASDIR, Q5MINS x 4, then Q15MINS x 2, then Q30MINS x 2. See Order Comments for additional instructions Comments: During weaning process: monitor and document HR, rhythm, BP, respiratory rate, level of consciousness, tidal volume, oxygen saturation, and signs of intolerance (see Ventilator Weaning Intolerance Criteria-Reference Text order) Hold IV sedation except Precedex during ventilator weaning (unavailable at Baptist Beaches and Baptist Nassau) (DEF)* For Baptist Beaches and Nassau, see Order Comments. Comments: Reduce Propofol by 5 mcg/kg/min every 5 minutes until off. Restart Propofol if patient becomes agitated (to whatever level necessary to sedate to Ramsey Level II). When Ramsey Level II achieved, Check NIF, and respiratory rate. Once NIF greater than 20, FVC greater than 8 ml/kg and respiratory rate less than 30, place patient on : Pressure Support 0 cm, CPAP 5 cm, and FIO2 50% for a 30 minute breathing trial Ventilator Weaning Intolerance Criteria-Reference Text Notify Physician If weaning intolerance and patient placed back on ventilator at PRE Weaning settings Notify Physician If weaning intolerance and patient placed back on ventilator at PRE Weaning settings or if ph is LESS than 7.34 or PaO2 of LESS than 60mmHg. Radiology XR Chest *1 view AP Portable Early AM, Pending Discharge - No, STAT in AM for post discontinuation of mechanical ventilator see order comment Comments: Therapy to conduct T-piece trial at current Fi02. If tolerated, ABG in 30mins and call results to physician. For any respiratory signs of weaning intolerance (see criteria) place patient back on ventilator at PRE WEANING settings and call physician. see order comment Comments: Therapy to place patient on VOLUME TARGETED Pressure Support with target goal of 240 ml Vte. Call physician if Vte is LESS than 280ml. Place back on PRE WEANING ventilator settings for signs of ventilator weaning intolerance (see criteria). ABG after 30mins of volume targeted pressure support and call physician with results if ph is LESS than 7.34 or PaO2 of LESS than 60mmHg Page 4 of 6
DRUG AND TREATMENT Once patient meets extubation criteria and physician approval obtained, discontinue Mechanical Ventilator and place on trach collar to equal O2 used during Mechanical Ventilator use. No neck rotation or movement x 4 hours O2 Therapy. 92, Titrate to O2 sat of 92% with heated humidification (post mechanical ventilator extubation) (DEF)* 92, Titrate to O2 sat of 92% with cooled humidification (post mechanical ventilator extubation) Routine, Obtain ABG 30 minutes post discontinuation of mechanical ventilator or sooner if patient exhibits signs of intolerance. Call results to physician +120 Hours Remove sutures 5 days post tracheostomy Post-Extubation Phase ASDIR, Q5MINS x 4, then Q15MINS x 2, then Q30MINS x 2, then Q1H. See Order Comments for additional instructions Comments: Post Extubation: monitor and document HR, rhythm, BP, respiratory rate, level of consciousness, tidal volume, oxygen saturation, and signs of intolerance (see Ventilator Weaning Intolerance Criteria-Reference Text order), and stridor. Diet NPO NPO times 4 hours then clear liquids and advance as tolerated post mechanical ventilator extubation Diet Order. NPO, For 4 hours then clear liquids and advance as tolerated post mechanical ventilator extubation Notify Physician If patient exhibits signs/symptoms of aspiration while eating/drinking, make NPO and notify physician Notify Provider ABG Results Special Instructions: Call physician for PaO2 LESS than 60 mmhg; ph LESS than 7.34 Medications Proventil Neb 0.083% 2.5 mg neb inh NEB Q4H RT, Duration: 72 hour DuoNeb 3 ml NEB neb inh Q4H RT, Duration: 72 hour (DEF)* 3 ml INHALE neb inh Q4H RT, Duration: 72 hour Incentive Spirometry Routine, Q1H while awake. Therapy to initiate and perform patient education first Routine, 30 minutes post mechanical ventilator extubation or sooner if stridor or patient exhibits signs of intolerance. Call physician for PaO2 LESS than 60 mmhg; ph LESS than 7.34 Page 5 of 6
DRUG AND TREATMENT O2 Therapy. Venti Mask, Equal to current FiO2 (DEF)* Nasal Cannula, Titrate FiO2 to maintain oxygen saturation greater than or equal to 92% Oxygen Mask, Titrate FiO2 to maintain oxygen saturation greater than or equal to 92% BIPAP Consults Consult Speech Therapy for post mechanical ventilator extubation swallow evaluation Page 6 of 6