CHN2412 Continuous Renal Replacement Therapy ... - Carondelet

PHYSICIAN‘SORDERUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSCONTINUOUS RENAL REPLACEMENT THERAPY - CSMSTAT/NOW(Check Box to Left)* LIST ALL ALLERGIES: (Medication, food, latex and/or Contrast Dye) * Required on Admission OrdersPATIENT STATUS: Inpatient1. SCUF CVVH (pre filter) CVVHD2. Cartridge: CAR 5003. CRRT System Anticoagulation:None OR Heparin (DO NOT use if patient is receiving systemic, therapeutic Heparin)4. Circuit Priming: use 1000 mL 0.9% Sodium Chloride5. Therapy Fluid:RFP 400 (2/3)Final Concentration:Potassium* ______mEq/L (max: 4 mEq/L)(Already contains 2 mEq/L Potassium)Calcium** ______mEq/L (max: 4 mEq/L)RFP 402 (0/3)Final Concentration:Potassium* ______mEq/L (max: 4 mEq/L)Calcium** ______mEq/L (max: 4 mEq/L)*Potassium to be added as potassium chloride. **Calcium to be added as calcium gluconate6. ALWAYS ASPIRATE DWELL PRIOR TO INITIATION OF THERAPYNx Stage Solutions—5 Liter BaseRFP400RFP402Calcium (mEq/L) 3 3Potassium (mEq/L) 2 0Magnesium (mEq/L) 1 1Sodium (mEq/L) 140 140Chloride (mEq/L) 111 109Bicarbonate (mEq/L) 35 35Glucose (mg/dL) 100 1007. Settings:Blood flow rate (mL/minute): ____________ (Note: maximum is 600 mL/minute)Therapy Fluid rate (mL/hour): ___________ (Maximum 12,000 mL/hour).Administer only through a dialysis catheterNet fluid removal (goal), titrate based on: CHOOSE ONEPulmonary Artery Catheter present:PAOP greater than 20, goal = ______ mL/hrPAOP 18-20, goal = ______ mL/hrPAOP 16-18, goal = ______ mL/hrPAOP 12-16, goal = ______ mL/hrCentral Venous Pressure monitoring present:CVP greater than 18, goal = _____ mL/hrCVP 16-18, goal = _____ mL/hrCVP 14-16, goal = _____ mL/hrCVP 12-14, goal = _____ mL/hrSystolic Blood Pressure:SBP greater than 110, goal = _____ mL/hrSBP 90-110, goal = _____ mL/hrSBP less than 90, goal = _____ mL/hrPhysician Signature: Date Signed: Time Signed:Physician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSM – 12/7/12CHN2412 Expires – 12/2015Copy 04.23.14 Page 1 of 2UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED

PHYSICIAN‘SORDERUSE BALL POINT PEN – PRESS FIRMLYCARONDELET HEALTH NETWORKHOSPITAL PROVIDED PRE-PRINTED PHYSICIAN’S ORDERSSTAT/NOW(Check Box to Left)CONTINUOUS RENAL REPLACEMENT THERAPY - CSM8. Heparin Anticoagulation: (attach pre filter)Heparin Bolus (1000 unit/mL vial): ________ or 40 units/kg IV Push once, administer at the pre pump portRound dose to the nearest tenth, MAX DOSE 3000 unitsThen start Heparin infusion (50 units/mL premix bag) at 400 units/hr, connect to the pre-pump port.Adjust heparin bolus/infusions using PTT levels and the table below:PTT 20-35 Rebolus 40 units/kg (MAX DOSE 3000 units) and increase heparin by400 units/hourPTT 36-49 Increase heparin by 200 units/hourPTT 50-70 Target Range – no changePTT 71-90 Decrease heparin by 200 units/hourPTT 91-120 Decrease heparin by 400 units/hourPTT 121-150 Hold heparin for 30 minutes and decrease heparin by 600units/hourPTT over 150 Hold heparin and call physicianRecirculate: If off CRRT for 0-2 hours resume Heparin at prior rateRecirculate: If off CRRT for 2-4 hours rebolus with ½ of the original doseRecirculate: If off CRRT for 4 or more hours re-bolus with the whole dose9. Nursing: Call physician for clotting, bleeding, excessive or low fluid removal10. Labs:Basic Metabolic Panel every ________Magnesium every ________Phosphorus every ________Comprehensive Metabolic Panel every _________CBC without diff every ________PT/INR every _________For Heparin Anticoagulation: Draw PTT post filter• PTT STAT, then every 6 hours after Heparin Bolus or any change in Heparin Rate• After two consecutive PTT values within target range, change to daily PTT drawn from patient• If filter clots, draw a PTT post filter11. For circuit change, insert dwell in the appropriate limb of the catheter as follows:• If patient is disconnected less than 30 min, use 0.9% normal saline in the volume recommended• If patient is disconnected more than 30 min, use Heparin 5000 units/mL in the volume recommended12. For patient transport:1. Perform Blood Recirculation2. Dwell appropriate limb of the catheter with Heparin 5000 units/mL in the volume recommended3. Perform Saline Recirculation with 1000 mL of 0.9% Sodium Chloride4. Resume CRRT when patient returns to unit13. Call Nx Stage information hotline for any technical problems at 1-866-697-824314. Other Orders:Physician Signature: Date Signed: Time Signed:Physician Printed Name / License # / Telephone #:PATIENT IDENTIFICATIONMEC Approval CSM – 12/7/12CHN2412 Expires – 12/2015Copy 04.23.14 Page 2 of 2UNLESS NOTED AS PBO (PRESCRIBED BRAND ONLY), A FORMULARY EQUIVALENT MEDICATION MAY BE DISPENSED