Unique Plan Description: CT Surg Cardiac Surgery, ERA (MH) Pre-op admit day of OR
Plan Selection Display: CT Surg Cardiac Surgery, ERA (MH) Pre-op admit day of OR
PlanType: Medical                                 
Version: 1          
Begin Effective Date: 2012-11-04 20:47:32
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2023-11-15 12:21:20
Available at all facilities: Yes

CT Surg Cardiac Surgery, ERA (MH) Pre-op admit day
Admit/Discharge/Transfer
	Admit to Inpatient Status
		T;N, Anticipated LOS 2 midnight or more
Vital Signs
	BP
		measure and document BP right and left arm pre op
Diet
	NPO
		After Midnight
Laboratory
	Type and Screen (No Product on hold)
		Stat, spec type = Blood
	Crossmatch Red Blood Cells
		Stat, spec type = Blood, 2, No Requirements, Open Heart
	Basic Metabolic Panel
		Stat, spec type = Blood
	CBC with Diff
		Stat, spec type = Blood
	Hemoglobin A1C
		Stat, spec type = Blood
	PF4 Assay Platelet Antibody Heparin Dependent
		Stat, spec type = Blood
	UA (Culture if Positive)
		Stat, Stat, spec type = Urine
	Lipid Panel
		Stat, spec type = Blood
	INR - MH/WH/JE
		Stat, spec type = Blood
	Iron Panel - MH/WH/JE
		Stat, spec type = Blood
Diagnostic Tests
	Chest AP & Lat
		angina, Stat, Angina
			Comment: If not done in last 30 days
	Spirometry
		T;N
			Comment: If patient current smoker, has a history of smoking, or has a history of asthma or COPD, perform spirometry pre and post. If non smoker do sipometry pre op.
	Spirometry with diffusion study
		T;N
			Comment: If patient current smoker, has a history of smoking, or has a history of asthma or COPD, perform spirometry pre and post. If non smoker do spirometry pre op.
	ECG
		Routine, Indication: Pre-op Release
			Comment: to be done in POH
IV Solutions
	Lactated Ringers Injection
		1,000 mL, IV, PRN, see comment, 2 Dose(s)/Time(s), 125 ml/hr
			Comment: Fluid replacement
	sodium bicarbonate 150 mEq/D5W 1000 mL
		1,000 mL, IV, 1 Dose(s)/Time(s), 0.5 mL/kg/hr
			Comment: (Maximum dose 50 mL/hr). continue until hanging IV solution is completed. DO NOT GIVE IF EF <30%, PATIENT ON DIALYSIS OR VALVE PATIENT. Begin infusion in POH.
		150 mEq, EVERY BAG
Medications
	Ancef (MH/WH)
		2,000 mg, Syringe, IV Push, PREOP, Surgical prophylaxis, NOW
			Comment: Within 30 minutes of incision
		2,000 mg, Syringe, IV Push, Q3H, Surgical prophylaxis, T;N+180, 1 Dose(s)/Time(s)
			Comment: During surgery.
		For patients with severe penicillin allergy(NOTE)*
	vancomycin IVPB
		1,000 mg, Injection-Premix, IVPB, PREOP, Indication: Surgical prophylaxis
			Comment: For patients <80kg; infuse over 1 hour. If allergic to other antibiotic options or documented reason for use.
		1,500 mg, Injection-Premix, IVPB, PREOP, Indication: Surgical prophylaxis
			Comment: For patients 80-120kg; infuse over 90 minutes. If allergic to other antibiotic options or documented reason for use.
		2,000 mg, Injection-Premix, IVPB, PREOP, Indication: Surgical prophylaxis
			Comment: For patients >120kg; infuse over 90 minutes. If allergic to other antibiotic options or documented reason for use.
	aztreonam
		1,000 mg, INT, IVPB, PREOP, Indication: Surgical prophylaxis, 1 Dose(s)/Time(s)
			Comment: For patients with severe penicillin allergy
	aspirin
		81 mg, Tablet-Chew, BY MOUTH, PREOP
			Comment: If patient has not taken within 24 hours
	mupirocin 2% topical ointment
		1 appl, Ointment, NARE, EACH, PREOP
	Pacerone
		600 mg, Tab, BY MOUTH, PREOP
			Comment: Give with sips of water. If patient has not taken amiodarone within 24 hours of admission and admitted morning of surgery.
	Toprol-XL
		25 mg, Tablet-Extended-Release, BY MOUTH, PREOP
			Comment: Give if patient has not taken a beta blocker within 24 hours of surgery.
	Peridex 0.12% oral rinse
		15 mL, Soln, MOUTHWASH, PREOP, 1 Dose(s)/Time(s)
			Comment: Swish and gargle for 30 seconds then spit, do not swallow.
	gabapentin
		300 mg, Capsule, BY MOUTH, PREOP
			Comment: Administer 1-2 hr prior to surgery; contact Anesthesia if not given. Give 300mg if patient < or = 60 years old and > or = 63.6kg (140 lbs); pharmacy to modify dose to 200mg if patient 61-70 years old or weighs 54.5-63.5kg (120-139 lbs); pharmacy to modify dose to 100mg if patient 71-75 years old or weighs < 54.5kg (< 120 lbs).  If patient 76 years old or older, discontinue order.
		200 mg, Capsule, BY MOUTH, PREOP
			Comment: If 61-70 years old or weighs 54.5-63.5kg (120-139 lbs); administer 1-2 hr prior to surgery; contact Anesthesia if not given.
		100 mg, Capsule, BY MOUTH, PREOP
			Comment: If 71-75 years old or weighs <54.4kg ( < 120 lbs); administer 1-2 	hr prior to surgery; contact Anesthesia if not given.
	acetaminophen
		1,000 mg, Tab, BY MOUTH, PREOP
			Comment: For case duration < 6 hrs.
	acetaminophen 10 mg/mL intravenous solution
		1,000 mg, Solution-Injection, IVPB, Once, PRN for see comment, duration: 1 Dose(s)/Time(s)
			Comment: Use only if strict NPO for all oral medications pre-op; Anesthesia to determine dose timing - pre-op or intra-op.
Patient Care
	No ACE (angiotensin converting enzyme) inhibitors
		Stop Nephrotoxic medications.
	No ARB (angiotensin receptor blocker)
		Stop Nephrotoxic medications.
	No NSAIDS (non steroidal anti-inflamatory)
		Stop Nephrotoxic medications
	Notify MD
		Notify surgeon if greater than 15mm difference between right and left BP
		Notify anesthesia of arrival to see pre op
	Notify MD of Lab results
		Abnormal lab results or diagnostic tests to surgeon.
	Notify
		ICD or Pacemaker device rep to change to appropriate device settings on day of surgery if patient has permanent pacemaker or ICD
	IV Insulin Parameters
		Initiate insulin drip 4 hours prior to surgery or as otherwise directed by physician
	Obtain Consent/Permit for:
		Coronary artery bypass.
		Aortic valve replacement
		Mitral Valve repair / replacement
		Tricuspid valve repair
		MAZE procedure
		Aneurysm repair
		Pericardial drainage / window
		Redo sternotomy
	Obtain Medical Records
		Verify that heart cath report is on chart pre op
Consults/Follow-up
	Consult Cardiac Rehab: Inpatient
		T;N, Indications CABG
			Comment: Pre op Indications CABG - do preop 5 meter walk

VTE Prophylaxis Pre Op
Medications
	HEParin 5000 units/mL SUBCUTANEOUS
		5,000 units, Injection, SUBCUTANEOUS, PREOP, T;N
	Lovenox
		40 mg, Syringe, SUBCUTANEOUS, PREOP, T;N
		30 mg, Syringe, SUBCUTANEOUS, PREOP, T;N
Patient Care
	Sequential Compression Device Pre Procedure
		T;N, Apply, Once
			Comment: knee high
	Anti Embolism Stockings Pre Procedure
		T;N, Apply, Once
			Comment: knee high

CT Surg Cardiac Surgery, ERA (MH) Regular Insulin
IV Solutions
	insulin regular 100 units/NS 100 mL Premix
		100 mL, IV, Routine, T;N, Total Volume = 100
			Comment: Concentration:1 unit/mL, Rate:  2 mL/hr = 2 units/hr, continuous if initial glucose greater than 150.Titration of regular insulin IV infusion:If glucose is: 1.)  Less than 70 discontinue infusion and follow hypoglycemia treatment parameters.2.)  70-99, decrease infusion by 1 unit/hour.3.)  100-150, no change4.)  Greater than 150, and is greater than or equal to the previous glucose, increase infusion by 1 unit/hour.5.)  Greater than 150, and is less than the previous glucose, maintain the same rate.6.)  Greater than 200, increase infusion by 2 units/hour. Initiate insulin drip 4 hours prior to surgery or as otherwise directed. Obtain glucose POC-RN q1hr starting with initiation of drip. Discontinue Regular Insulin Infusion 48 hours after surgery
		100 units, EVERY BAG, 2 units/hr
Medications
	Dextrose 50%
		25 mL, Injection, IV Push, Q15MIN, PRN for low blood sugar
			Comment: Give if blood glucose less than 60mg/dL or 60-70 mg/dL and patient unable to tolerate oral intake. Notify provider if given with corresponding POC glucose recheck value.
	glucagon
		1 mg, Injection, IV Push, Q15MIN, PRN for low blood sugar, Routine, T;N
			Comment: Give if blood glucose < 70mg/dL AND if dextrose 50% injectable unavailable OR inadequate response to IV dextrose 50%. May give SubQ or IM if patient does not have IV access. Notify provider if given with corresponding POC glucose recheck value.
	Moderate Dose NovoLOG
		4 - 24 units, Injection, SUBCUTANEOUS, Q6H-Sch, PRN, sliding scale
			Comment: Begin 48 hours after surgery<< Sliding Scale Comments >>Under 150, Do not give any insulin150 - 199 = 4 units,200 - 249 = 8 units,250 - 299 = 12 units,300 - 349 = 16 units,350 - 399 = 20 units.Over 399 = 24 units,<< Sliding Scale Comments >> Check  POC in 3 hours; notify physician if repeat POC  greater than or equal to 400mg or less than or equal to 100.  Do not give insulin based on repeat POC value.  RN may change sliding scale insulin order to before meals and at bedtime for patients on oral diet. Enter as QIDACHS PRN
Patient Care
	Glucose POC - RN
		Q1H
			Comment: After 24 hours, when glucose is in target range (100-150) for 4 hours, cancel q1h glucose order and enter order for q2h.
		T+1;0400, Q1H
			Comment: Start at 0400 or 4 hours prior to start of surgery. After 24 hours, when glucose is in target range (100-150) for 4 hours, cancel q1h glucose order and enter order for q2h.
		T;N+2880, QIDACHS
			Comment: Start 48 hrs after surgery
	Notify MD
		T;N, if glucose POC >200mg/dL for 2 consecutive checks
	Discontinue
		T;N, insulin drip protocol after 48hrs and begin Insulin Sliding Scale Novolog
	Notify MD
		T;N, for instructions if dietary change: abrupt change in oral intake, change to NPO status, tube feedings are held or discontinued, TPN held or discontinued.  (caloric intake necessary to prevent hypoglycemia)
		T;N, If insulin requirements > 10units/hr for further instruction
	Hypoglycemia Treatment Parameters
		T;N
			Comment: Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Blood glucose <40mg/dl (critical value), treat with Dextrose 50%, 25 mL, then immediately notify physician.  Repeat glucose in 15 minutes. Blood glucose 40-55 mg/dL give Dextrose 50% 25 mL. Repeat glucose 15 min after treatment. Notify physician after follow-up value is obtained. Blood glucose 56-70 mg/dL administer 4 oz apple juice.  If patient NPO or unable to tolerate oral intake, give Dextrose 50%, 25ml.  Repeat glucose in 15 minutes after treatment.  If repeat glucose 55-70, repeat apple juice or Dextrose. Obtain another glucose, Give 1 complex carb (15g) and 1 protein snack (7g) or patient meal if patient able to take orals any time hypoglycemia is treated.  When blood glucose >150mg/dl, restart infusion at ½ previous rate and change glucose checks to every hour until glucose is within target range (100-150) for 4 hours, then change to Q2H glucose checks.
		T;N, Hypoglycemia protocol initiated for patients with glucose <70mg/dl. Patient should have an IV while on Hypoglycemia protocol.
		T;N, glucose < 60mg/dL  treat with Dextrose 50% 25 mL.OR glucagon 1mg as per medication orders. Notify provider as per critical result protocol. Repeat treatment as outlined in hypoglycemia parameters.
			Comment: Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, glucose 60-70 mg/dL, administer 4 oz apple juice, 4 oz non-diet soda, or glucose gel.  If patient NPO or unable to tolerate oral intake, give Dextrose 50% 25ml , OR glucagon 1mg as per medication orders.
			Comment: Repeat treatment as outlined in hypoglycemia parameters. Notify provider of all treatments given and POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, After initial treatment of any glucose value </= 70 mg/dL, repeat POC glucose in 15 min; if result </= 70mg/dL continue treating as per protocol and rechecking glucose 15 min after treatment until glucose >70mg/dL.
			Comment: Notify provider of all treatments given and corresponding POC glucose recheck values. When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.
		T;N, Once glucose is within normal limits, give 1 complex carb and 1 protein source (such as ½ sandwich OR 1 individual container of peanut butter and 3 packs of crackers) or patient meal if patient able to take orals to prevent recurrent hypoglycemia.
			Comment: When notifying provider of hypoglycemic treatment, clarify with provider future instructions on diabetic medication therapy.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase