Order Set_HNC Free Flap_Pathway Day 0 UAH ICU Apr 2015

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Major Head and Neck Resection/Free Flap Reconstruction
Day 0 orders: Admission Burns ICU/GSICU
E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART
All orders to be reassessed daily and with extubation.
1. Check Caution Sheet for any allergies before ordering.
2. Medication orders must include drug, dose, route, frequency and, if applicable, duration.
3. If medication order is STAT or URGENT, notify RN and place a large X
in the STAT/URGENT box at right.
4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking out.
Order
STAT / URGENT
Use STAT box for medication orders ONLY
Rationale
This order set is to be used ONLY for patients with Head and Neck Cancer, who have undergone major surgery with Free Flap reconstruction. The aim
is for patient to be ready for transfer to ward by morning following surgery. Day 0 is day of surgery; Day 1 (post-surgery) commences when ICU care
team assesses patient as “ready for transfer” to the ward. Day 1 orders are for either Ward or ICU use, when patient has progressed appropriately.
Admission Checklist:
Admitting Physician and Charge nurse aware
Admission Orders.
Goals of Care Designation Orders completed
Admission History.
Medication Reconciliation initiated on BPMH form.
Admit GSICU under:
Dr Djogovic
Dr Meier
Dr Bagshaw
Dr Brindley
Dr Brisebois
Dr Cheung
Dr Chin
Other:
Dr Gibney
Dr Hudson
Dr Jacka
Dr Karvellas
Dr Khadaroo
Dr Romanovsky
Dr Sligl
Dr Townsend
Dr Widder
Dr Zygun
Admission requires notification of Attending staff and charge nurse,
completion of Admitting Orders, History and initiation of Medication
Reconciliation. Goals of Care to be determined on admission and to
be reviewed/signed by attending staff within 24 hours of admission.
Resident staff must notify admitting Intensivist or ICU Fellow of
any admission to ICU service AT ANY TIME.
ICU charge nurse MUST be contacted for bed availability and
assignment and PRIOR to physical transfer of patient to GSICU.
Primary Head and Neck Surgeon: ……………………………..
Goals of Care:
Goals of Care order sheet to be completed by attending physician within 24
hours of admission to GSICU. If prior Care Designation Orders available, these
can be used. Changes to Level of care are to be documented on tracking sheet.
Quality Improvement Goals for Head and Neck Cancer Surgery
1. Initiation of spontaneous breathing trials at conclusion of surgery.
2. Limiting mechanical ventilation and sedation during ICU admission.
3. Limiting ICU admission duration.
4. Early mobilization within 12 hours of ICU admission.
5. Early discharge from Hospital.
Patient Vitals and Monitoring:
Routine ICU vitals and monitoring
Foley catheter to urometer. Notify resident if output is less than 30mL/h or
greater than 300 mL/h for 2 hours.
Blood pressure monitoring
Notify resident if systolic BP less than 90mmHg or greater than 180mmHg
Notify resident if MAP less than 60mmHg or greater than 120mmHg
No inotropes or blood transfusions unless approved by head and neck staff
ICU care is an option (if medically indicated) for patients with
Goals of Care Designations consistent with that level of care.
This would include Care levels R1, R2, R3.
Quality Improvement Targets
1. 70% of patients spontaneously breathing on ICU arrival.
2. 70% of patients remaining spontaneously breathing in ICU.
3. 80% of patients transferred from ICU within 24hours.
4. 100% of patients mobilized within 12hours of surgery.
5. 100% of patients discharged from hospital within 10 days.
Routine ICU monitoring includes
-Continuous ECG monitoring and pulse oximetry
-Recording of vitals Q1H
-Intake and output Q1H
-Temperature Q4H
-Sedation Agitation Scale (RASS) Q4H.
Ranges for BP systolic and MAP varies according to different
patients and disease states.
Primary Survey on Arrival including Initial Flap Assessment
Free Flap location and Flap donor site with Surgeon:
Flap Donor Site………………………………………………………………………
Skin Donor Site………………………………………………………………………
Other (specify) ……………………………………………………………………....
Identify frequency of Doppler checks: ……………………………………………
Check color, drainage and suture lines …………………..……………………..
Identify if implanted Doppler ………………………………. ……………………..
Identify where to check Doppler for pulse ………………………………………..
Medication Reconciliation:
Summary of outpatient/ward medications with dose and frequency from prior to
admission to GSICU. Record on BPMH form.
Surgical team must provide information regarding surgery and
wound care required and this must be documented by the ICU
team, as part of the transfer of care process from OR to ICU.
MUST use Medication reconciliation (Best Possible
Medication History) form. Information to be updated as
received by Pharmacist, Nurse, Physician team.
Physician Signature (Surgical Team): ……………………………………… Date/Time: ……………………………………………………..
Physician Signature (Critical Care Team): ………………………………… Date/Time: ……………………………………………………..
Critical Care Orders: GSICU/Burns University of Alberta site.
April 2015 revision
PAGE 1 OF 6
Critical Care/Head and Neck Surgery Protocol
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Major Head and Neck Resection/Free Flap Reconstruction
Day 0 orders: Admission Burns ICU/GSICU
E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART
All orders to be reassessed daily and with extubation.
1. Check Caution Sheet for any allergies before ordering.
2. Medication orders must include drug, dose, route, frequency and, if applicable, duration.
3. If medication order is STAT or URGENT, notify RN and place a large X
in the STAT/URGENT box at right.
4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking out.
Patient Care and Safety:
Elevate head of bed 30 degrees or higher as tolerated.
Soft restraints to extremities as required for patient safety. Assess q30min. If
4-point restraints used, assess Q15min. Release restraints Q2h and prn
Gentle mouth care with Normal saline, PRN, by nurse or RT with soft cath.
Active ankle dorsi-flexion and plantar flexion (10 times) when awake.
Wound Care:
Neck incision line care with Normal Saline followed by Polysporin ointment BID.
Empty and re-prime Jackson-Pratt Drains Q…..H and prn.
All head and neck drains and sutures to be removed by head and neck team.
No tracheostomy ties.
No oral suctioning.
Maintain head in neutral position.
Flap donor site:
Leave dressings intact until post op day #7, then remove.
Other:……………………………………………………………………………
Skin donor site:
Skin donor site (e.g., thigh) – on Post Op Day 1, remove outer dressing to
TM
expose Xeroform
Other:……………………………………………………………………………
Flap Assessments:
Monitor free flap Q1 hour for: Color, Pulses (Doppler), Capillary refill.
Monitor flap donor site Q1 hour for: Color, Pulses, Capillary refill,
Temperature, Movement, Sensation.
Activity (for specific donor sites):
Bed rest upon arrival to GSICU. Up in chair POD#1 with affected limbs
elevated.
Thigh: If primary closure flap: weight bearing as tolerated to affected leg, no
knee flexion >30⁰ Thigh: If free flap with skin graft: weight bearing as tolerated to affected leg Fibula: weight-bearing as tolerated
Forearm: may move upper arm & fingers
Scapula: keep in arm sling until POD#7, may move fingers Deep Vein Thrombosis prophylaxis:
Heparin 5000 units subcutaneously Q8H (standard)
Pneumatic compression stockings.
NO HEPARIN due to patient coagulopathy or possible HITT
Acetylsalicylic acid 325 mg feeding tube / PO Q12 hours
Gastrointestinal mucosal protection:
FamoTIDine 20 mg IV (Standard GI prophylaxis)
Q12H (standard)
Daily (renal impairment)
Ranitidine 150 mg feeding tube
BID (standard)
Daily (renal impairment)
Pantoprazole 40 mg IV daily.
Lansoprazole 30 mg feeding tube daily.
Venous Access and Maintenance:
Saline lock peripheral venous lines with 5 mL and central venous lines with 5
mL of preservative-free normal saline every 12 hours and PRN.
Saline lock PICC lines with 10-20 mL of preservative-free normal saline every
12 hours and PRN.
STAT / URGENT
Use STAT box for medication orders ONLY
Elevation of head of bed reduces likelihood of subclinical
aspiration and ventilator associated pneumonia, reduces edema
to surgical site.
Need for restraints will be reassessed daily at bedside rounds
Early detection of free flap compromise has been shown to
greatly increase free flap salvage rates and reduce requirement
for re-operative procedures.
DVT prophylaxis is standard of care for ALL ICU patients.
Pneumatic compression indicated when heparin is
contraindicated due to active or high risk of bleeding,
coagulopathy or heparin induced thrombocytopenia and
thrombosis (HITT).
H2 receptor antagonist for acid reduction and prophylaxis of
stress mucosal ulceration in all patients unless on therapeutic
proton pump inhibitor or post total gastrectomy.
Dosage reduction for H2 receptor antagonist is required in
renal dysfunction or failure (on dialysis or Cr clearance less than
50ml/min).
Saline lock peripheral IVs and central lines not currently in use.
Physician Signature (Surgical Team): ……………………………………… Date/Time: ……………………………………………………..
Physician Signature (Critical Care Team): ………………………………… Date/Time: ……………………………………………………..
Critical Care Orders: GSICU/Burns University of Alberta site.
April 2015 revision
PAGE 2 OF 6
Critical Care/Head and Neck Surgery Protocol
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+
Affix patient label within this box.
Major Head and Neck Resection/Free Flap Reconstruction
Day 0 orders: Admission Burns ICU/GSICU
E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART
All orders to be reassessed daily and with extubation.
1. Check Caution Sheet for any allergies before ordering.
2. Medication orders must include drug, dose, route, frequency and, if applicable, duration.
3. If medication order is STAT or URGENT, notify RN and place a large X
in the STAT/URGENT box at right.
4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking out.
On Admission to ICU:
Arterial blood gas.
Complete blood count and differential (CBC and differential count)
Serum electrolytes (Na+, K+, Cl-, CO2)
Serum glucose
Renal function (Creatinine, Blood urea nitrogen)
Secondary electrolytes (Mg+, iCa++, PO4-)
Coagulation profile (INR, PTT)
Liver function (AST, ALT, LDH, Total Bili, Alk Phos)
Troponin
Troponin Q8H x 3 (acute coronary syndrome)
Creatine Kinase (CK)
Lactate
12 lead EKG
Chest X-ray, AP UPRIGHT portable
Urinalysis
Schedule for further investigations (Daily, to be sent before 06:00):
Arterial blood gas (with electrolytes/glucose/lactate) (prn with vent changes)
Complete blood count and differential (CBC and diff.)
Renal function (Creatinine, Blood Urea Nitrogen)
Coagulation profile (INR, PTT)
Liver function (AST, ALT, LDH, Total Bili, Alk Phos)
Secondary electrolytes (Mg+, iCa++, PO4-)
Other:.………………………………………………………………………
………………………………………………………………………………….
Microbiological Cultures and Precautions
Blood cultures with temperature greater than 38.5 degrees (if not previously
cultured during that episode).
MRSA/VRE screening AND Isolation for patients from a health care facility
outside of Canada/hospitalized in Canada with prior transplant/for transplant.
MRSA/VRE screening on admission and MRSA, screening on the first Monday
of each month.
Significant organism isolation, if prior positive culture or high risk of colonization
with significant organism (MRSA, VRE, C. difficile)
Fluid Therapy:
Maintenance IV fluid (signify one) at ………………….mL/hour.
Total IV+PO fluid intake =………………………mL/hour
Plasma-Lyte A (Standard IV fluid)
Ringers Lactate (no added potassium CHLORIDE)
0.9% NaCl (Normal Saline) (no added potassium CHLORIDE)
Additional IV fluids:
Rehabilitation (Occupational and Physical therapy):
Occupational Therapy consult and assessment for potential pressure ulcer
prevention, splinting, relaxation therapy, fine motor exercises.
Physical Therapy consult for chest physiotherapy, range of motion exercises
and for patient mobilization.
STAT / URGENT
Use STAT box for medication orders ONLY
Admission bloodwork to be obtained on all new ICU
admissions unless obtained in the previous 6 hours on ward
or in Emergency department.
Point of Care Arterial Blood Gas Machine in GSICU provides
ABGs, Glucose, Hemoglobin, serum electrolytes, ionized
calcium and lactate. Hb and Lactate results from ABG are valid
only if sample analyzed thirty minutes of sample draw. (RN to
collaborate with RT on draw time).
Chest X-ray to confirm position of feeding tube.
Contact Head and Neck surgery team for repositioning of
feeding tubes, if required.
Except in specific circumstances, bloodwork is sent once daily
and is available prior to morning rounds. Reassess need daily.
Point of Care Arterial Blood Gas Machine in GSICU provides
ABGs, Glucose, Hemoglobin, serum electrolytes, ionized
calcium and lactate. Hb and Lactate results from ABG valid only
if sample analyzed within 30 minutes of sample draw.
Routine Chest x-rays are of limited value. Chest x-rays to be
ordered as required.
Patients previously positive for MRSA or VRE remain on
precautions and do not require reculture on admission. Isolation
continues until patient is OFF antibiotics and three negative
cultures at one-week intervals are obtained.
MRSA screening, one nasal swab (both nares) one groin swab,
(both groins), ETT suction and any significant drainage.
Blood cultures should be drawn from peripheral sites, new
central lines are acceptable.
Plasma-Lyte A= Na+140, K+5, Mg++3, Cl-98, Gluconate
23mEq/L, Acetate 27 mEq/L with pH 7.4. Magnesium may
precipitate with medications and blood products. Plasma-Lyte A
is preferred IV maintenance and resuscitation fluid in ICU.
Ringers Lactate=Na+130, K+4, Mg++2, Lactate 28mEq/L,
Ca+3 with pH 6.5. Calcium may precipitate with medications and
blood products. Caution in renal failure due to K+ content for
both Ringers Lactate and Plasma-Lyte.
Normal saline=Na+154, Cl-154 with pH 5.5.
Patients may be referred to Occupational Therapy with the
following concerns: pressure ulcers, fragile skin (pressure ulcer
risk), persistent edema, decreased ROM, physical
deconditioning, anxiety or neurologic impairment.
Physiotherapy in the ICU plays an important role in maintaining
strength, coordination, preventing patient delirium and reducing
ventilator days and length of ICU stay.
Physician Signature (Surgical Team): ……………………………………… Date/Time: ……………………………………………………..
Physician Signature (Critical Care Team): ………………………………… Date/Time: ……………………………………………………..
Critical Care Orders: GSICU/Burns University of Alberta site.
April 2015 revision
PAGE 3 OF 6
Critical Care/Head and Neck Surgery Protocol
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Affix patient label within this box.
Major Head and Neck Resection/Free Flap Reconstruction
Day 0 orders: Admission Burns ICU/GSICU
E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART
All orders to be reassessed daily and with extubation.
1. Check Caution Sheet for any allergies before ordering.
2. Medication orders must include drug, dose, route, frequency and, if applicable, duration.
3. If medication order is STAT or URGENT, notify RN and place a large X
in the STAT/URGENT box at right.
4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking out.
Antimicrobial Therapy:
Cefazolin 1 gram IV Q8H
and
Metronidazole 500 mg IV Q12H x 4 doses.
or
Ciprofloxacin 400 mg IV Q12H x 4 doses.
and
Clindamycin 600 mg IV Q8H x 6 doses.
Nutritional Support:
Feeding tube position has been confirmed in OR
SAFE START tube feeds with Peptamin AF 1.2 with Prebio at 25mL/h, advance
to goal rate of 50 mL/h as tolerated.
Do not begin tube feeding until ordered by ENT physician and chest x-ray has
been done and reviewed for verification of tube placement.
Consult Dietician for nutritional assessment and suggestions.
Metoclopramide for initiation of enteral feeding or PRN for nausea.
10mg IV Q6H
5mg IV Q6H (Renal Impairment)
10mg IV Q6H PRN for nausea.
Docusate SODIUM 100mg via feeding tube BID once tube feeds initiated.
Sennosides 17mg via feeding tube QHS once tube feeds initiated.
Metabolic support:
Insulin infusion Novolin Toronto (100 units/100mL Normal Saline), titrate to
maintain range of 6.0mmol/L to 10.0mmol/L
Check serum glucose while receiving insulin by infusion, every 4 hours
and 1 hour after each change in insulin infusion rate,.
Notify resident if glucose less than 4 or greater than 16 mmol/L
Thyroid hormone replacement with …………………………………………….
Electrolyte replenishment:
Maintain serum Potassium between 3.5 – 5.0 mmol/L. For Potassium less than
3.5 mmol/L, give Potassium Chloride 20 mmol IV in 100ml Sterile Water for
Injection over 1 hour (Central Line). Repeat serum electrolytes 1 hour post
completion of infusion.
Maintain serum Magnesium between 0.7 – 1.2 mmol/L. For Magnesium less
than 0.7 mmol/L, give Magnesium Sulfate 4 grams IV in 100mL Normal Saline over
4 hours. Repeat Mg+ level 1 hour post completion of infusion.
Maintain serum ionized Calcium between 0.9 – 1.25 mmol/L. For Calcium less
than 0.9 mmol/L, give Calcium Gluconate 2 grams IV in 100mL Normal Saline over
1 hour. Repeat serum ionized Ca+ 1 level 1 hour post completion of infusion.
Maintain serum Phosphorus between 0.8 – 1.45 mmol/L. For Phosphorus less
than 0.8 mmol/L give either….
Sodium 20 mmol plus Phosphate 15 mmol IV in 250mL Normal Saline over
4hours.
OR
Potassium phosphate 15 mmol (as phosphate) IV in 250 mL Normal Saline
over 4 hours
Repeat serum PO4- level 6 hours post completion of infusion.
Oxygenation and Ventilation Goals:
Maintain O2 saturation greater than 94% or PO2 greater than 65mmHg
(standard)
Maintain pH of 7.35-7.45 (standard)
Notify resident if pH less than 7.20.
Tracheostomy site care by Respiratory Therapy, assess site Q shift.
STAT / URGENT
Use STAT box for medication orders ONLY
The optimum duration of prophylaxis has not been determined.
Prophylactic perioperative antibiotics should be started prior to
skin incision for maximal benefit. No advantage to continuation
of perioperative antibiotics beyond 24 to 48 hours postop has
ever been demonstrated.
Feeding tube position can be confirmed in OR by placement of
feeding tube beyond 50 cm, with freely mobile wire and
bronchoscopic examination of the airway. Chest x-ray must be
reviewed when endoscopic examination not completed.
Consider of discontinuation of Metoclopramide once enteral
feeds at goal and tolerated. Dosage reduction for
Metoclopramide in renal failure to 5mg IV Q6H. Be aware of the
adverse effects of Metoclopramide in elderly (extra pyramidal
side effects) and in combination with Haldol (QT prolongation).
Early enteral feeding has been shown to improve patient
outcomes.
Do not use electrolyte orders if creatinine is
greater than 150 mmol/L, urine output less than
250 mL in last 24 hours, or patient requires
dialysis.
Electrolyte orders to be reassessed daily and
reordered using Daily Rounds and Goals
Check-list.
Usual Goals for oxygenation and ventilation are saturations
over 94% and normal pH (PCO2 approximately 40mmHg).
Overall hospital and Critical Care length of stay
are significantly reduced if mechanical
ventilation is not required.
Physician Signature (Surgical Team): ……………………………………… Date/Time: ……………………………………………………..
Physician Signature (Critical Care Team): ………………………………… Date/Time: ……………………………………………………..
Critical Care Orders: GSICU/Burns University of Alberta site.
April 2015 revision
PAGE 4 OF 6
Critical Care/Head and Neck Surgery Protocol
+
+
Affix patient label within this box.
Major Head and Neck Resection/Free Flap Reconstruction
Day 0 orders: Admission Burns ICU/GSICU
E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART
All orders to be reassessed daily and with extubation.
1. Check Caution Sheet for any allergies before ordering.
2. Medication orders must include drug, dose, route, frequency and, if applicable, duration.
3. If medication order is STAT or URGENT, notify RN and place a large X
in the STAT/URGENT box at right.
4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking out.
STAT / URGENT
Use STAT box for medication orders ONLY
Ventilated Patient: Mode of ventilation
Wean to Pressure Support (PSV) as tolerated with goal of early CPAP trial.
Tracheostomy cuff to remain inflated
No tracheostomy ties, as these may damage surgical flap site.
PEEP at 5cm H2O (standard) Increase, as required to maximum of 12cm H20
for air trapping and dynamic airway collapse.
Other:
Spontaneous Breathing Trial for weaning from mechanical ventilation:
Trial of CPAP x 30 minutes when criteria met.
Trach cradle or T-piece as soon as clinically appropriate
Criteria for Readiness for potential extubation
•FIO2 less than 0.40 with O2 saturations greater than 90%
•PEEP requirement of 8cm H2O or less
•Hemodynamically stable, OFF vasopressors
•No or minimal sedation and GCS 15/15
•Awake and cooperative
•Cuff leak on endotracheal tube.
Goal is to wean patient from mechanical ventilation as rapidly as
possible. Minimal or rapid weaning from sedation and
spontaneous breathing trials as soon as clinically appropriate
Bronchodilator therapy: (for patients with COPD/Asthma)
Salbutamol inhalor 6 puffs (100mcg each) by metered dose inhaler (MDI)
while on Ventilator and 2 puffs (100mcg each) while spontaneously breathing.
Q4H PRN for bronchospasm
Q6H regular dosing
Ipratropium bromide inhaler 6 puffs MDI while on Ventilator and 2 puffs while
spontaneously breathing.
Q4H PRN for bronchospasm
Q6H regular dosing
Patient Delirium Management:
Delirium score measurement (ICDSC) each shift
Q6H
regular less
dosing.
If ICDSC
than 4, use PRN therapy for agitation
6 puffs Monitor
by MDI Q4H
QTc interval daily while using regular dose Haloperidol or
QUEtiapine and discontinue if QTc interval is greater than 500ms.
Haloperidol IV bolus……… (1-10mg) Q……h.
Haloperidol IV bolus……….. (1-10mg) Q15min prn to maximum of 40mg in
4 hours. Call resident if dosing limited reached.
If ICDSC greater than or equal to 4, use Delirium protocol.
• QUEtiapine 25 mg via feeding tube Q12h (08:00 and 20:00)
• At the beginning of each shift, IF ICDSC is greater than or equal to 4, or
two or more doses of prn Haloperidol have been given, increase dose of
QUEtiapine by 12.5 mg Q12h (to a maximum dose of 200 mg in 12 hours)
Patient Anxiety Treatment:
For Richmond Agitation Sedation Scale (RASS) score of +1 or more, assess and
treat pain first, if RASS remains +1 or greater give…….
Midazolam IV bolus 1-5mg Q15min prn. To maximum of 20mg in 12hours.
LORazepam IV bolus 1-2mg Q15min prn.
(Maximum dose Lorazepam 10mg in 12 hours as either prn or regular dosing)
Bronchodilator therapy is indicated for patients with
reactive airways or known asthma. They are not routinely
prescribed to intubated and ventilated patients.
Patient Analgesia: (choose ONE agent)
Critical-Care Pain Observation Tool (C-POT) Q4H and 1 hour after PRN
analgesic
morphine IV bolus 1-10mg Q15min prn. Maximum of 40mg in 12 hours.
FentaNYL IV bolus 25-100mcg Q15min prn. Maximum of 250mcg in 12 hours.
HYDROmorphone (Dilaudid) IV bolus 0.5-2mg Q15min prn for pain.
Maximum of 8mg in 12 hours.
Acetaminophen (Tylenol) 650 mg feeding tube Q6H prn (Maximum 4 grams
Acetaminophen in 24 hours)
Delirium: Always consider role of hypoxia or hypercarbia, pain,
withdrawal, electrolyte, metabolic abnormalities.
If Haloperidol greater than 40mg required for management of
delirium within a 4 hour period, patient should be reassessed
and consideration given to alternative agents.
Exclusion criteria for Delirium Protocol
•History of neuroleptic malignant syndrome
•Allergy to Quetiapine or olanzapine
•Already on antipsychotic medications
•known seizure disorder
• QTc interval greater than 500ms.
Accumulated sedation and analgesia prolong ventilator
dependency and potentially contribute to confusion,
delirium and prolong ICU stays.
For sedation, the target goal is RASS of -2 to 0
Physician Signature (Surgical Team): ……………………………………… Date/Time: ……………………………………………………..
Physician Signature (Critical Care Team): ………………………………… Date/Time: ……………………………………………………..
Critical Care Orders: GSICU/Burns University of Alberta site.
April 2015 revision
PAGE 5 OF 6
Critical Care/Head and Neck Surgery Protocol
+
+
Affix patient label within this box.
Major Head and Neck Resection/Free Flap Reconstruction
Day 0 orders: Admission Burns ICU/GSICU
E. G. King Critical Care Trauma Unit. DO NOT THIN FROM CHART
All orders to be reassessed daily and with extubation.
1. Check Caution Sheet for any allergies before ordering.
2. Medication orders must include drug, dose, route, frequency and, if applicable, duration.
3. If medication order is STAT or URGENT, notify RN and place a large X
in the STAT/URGENT box at right.
4. ALL Orders MUST be implemented by marking prompt box or DELETED by stroking out.
STAT / URGENT
Use STAT box for medication orders ONLY
Other Common Medications:
Thiamine 100mg IV daily x 3 days
Folate 5mg IV Daily
Multivitamin – 1 tablet via feeding tube, Daily
Stress tab – 1 tablet via feeding tube, Daily
Ondansetron 8mg IV q6hr PRN for nausea
Chlorhexidine 0.12% mouth wash, 30cc swish & spit BID and PRN
Date/Time
Additional Orders:
Use additional standard order sheets as required
Physician Signature (Surgical Team): ……………………………………… Date/Time: ……………………………………………………..
Physician Signature (Critical Care Team): ………………………………… Date/Time: ……………………………………………………..
Critical Care Orders: GSICU/Burns University of Alberta site.
April 2015 revision
PAGE 6 OF 6
Critical Care/Head and Neck Surgery Protocol