ࡱ> Z\Ya *&bjbj *FF\F\ , , 8,T'4pp(sss3333333$683sssss33}}}s3}s3}}1r3<z!.f2330'42_9O._94r3_9r3 ss}sssss33}sss'4ssss_9sssssssss, > j: Consider using therapeutic normothermia for all patients who are neurologically impaired, mechanically ventilated, and have a core body temperature greater than 37.80 C (1000 F). All patients must be admitted to the Neuro Critical Care Unit (NCCU) Patient resources include: Essential Standard ICU monitoring Salem sump tube Foley catheter Medi-therm III Hypothermia machine with 2 sets of hoses and one set of Rapr-Round wraps (Torso and Legs x 2) T/Pad and T/Pump Foley with termister or Esophageal temperature probe BIS monitor Optional CVP or PA catheter (preferably positioned in the Subclavian Vein) Arterial pressure line Patient monitoring Continuous Cardiac monitor Oxygen saturation BIS monitor Blood pressure via arterial line (optional) Every 1 hour Core temperature Shiver assessment (see protocol below) Every 2 hours Finger stick glucose If glucose > 140 mg/dl, initiate IV insulin protocol and convert to hourly finger stick glucose monitoring Surface Cooling for intubated patients Endotracheal intubation and mechanical ventilation Assure appropriate endotracheal tube placement per standard protocol Ventilator setting as appropriate for the patients presenting condition Induction of shivering suppression protocol Shiver is a MAJOR clinical issue in active normothermia maintenance. Each patient should be observed closely for shiver. In addition to visual monitoring, the nurse should gently palpate the patients masseters (jaw), pectoralis, and deltoids every 30 to 60 minutes. In addition, fine fluctuations on the patients cardiac rhythm tracing may also indicate shiver. Subsequent shiver suppression should be based on the Columbia Shiver Assessment Scale (CSAS). Assess and record the patients CSAS every 30 60 minutes and prn. Palpate the following muscle groups massiters (jaw), pectoralis, deltoids, and quadriceps. 0 no shiver 1 MILD = shiver in jaw and/or pectoralis, or cardiac rhythm tracing 2 MODERATE = shiver in jaw and/or pectoralis AND deltoids 3 SEVERE = intermittent generalized shiver of > 2 extremities Interventions for shiver suppression should be step-wise and based on the CSAS 0 No Shiver Optimize sedation and analgesia Propofol (Diprivan) drip Fentanyl drip Alter shiver threshold Buspirone (BusPar) by gastric tube 1 MILD Optimize sedation and analgesia Propofol (Diprivan) drip Fentanyl drip Alter shiver threshold Buspirone (BusPar) by gastric tube Vasodilatation Magnesium drip Increased comfort measures Hand and feet warmers 2 MODERATE Optimize sedation and analgesia Propofol (Diprivan) drip Fentanyl drip Alter shiver threshold Buspirone (BusPar) by gastric tube Meperidine (Demerol) IV bolus Vasodilatation Magnesium drip Increased comfort measures Hand and feet warmers 3 SEVERE Optimize sedation and analgesia Propofol (Diprivan) drip Fentanyl drip Alter shiver threshold Buspirone (BusPar) by gastric tube Meperidine (Demerol) IV bolus Vasodilatation Magnesium drip Neuromuscular blockade Vecuronium (Norcuron) intermittent boluses Increased comfort measures Hand and feet warmers Specific instructions for the interventions above Propofol (Diprivan) (to provide shiver suppression and continuous sedation) Continuous infusion at 20 mcg/kg/min Titrate by 5-10 mcg/kg/min every 10 minutes Maintain BIS reading of 40 60 Fentanyl (adjunctive therapy for shiver suppression and sedation) Bolus 50 mcg IV push and repeat every 30 minutes until the continuous infusion is initiated Continuous infusion at 2 mcg/kg/hour Buspirone (BusPar) (pharmacologically lowers the shiver threshold) Initial dose 30 mg by gastric tube Then, 15 mg by gastric tube every 8 hours until rewarmed to 360 C (96.80 F) Meperidine (Demerol) (pharmacologically lowers the shiver threshold and is synergistic with buspirone) 25 mg IV bolus x 1, then 12.5 mg IV bolus every 30 minutes PRN Magnesium drip (vasodilatation improves efficacy of cooling and increases patient comfort) Prepare 12 grams Magnesium Sulfate in 250 mL of normal saline Continuous infusion at 10 mL/hr (0.5 g/hr) Titrate to maintain a serum magnesium level of 3 4 mg/dL Monitor serum magnesium levels every 6 to 12 hours Vecuronium (Norcuron) (only AFTER adequate sedation achieved BIS < 60) Bolus 0.1 mg/kg x 1 Re-bolus Vecuronium prn shivering Hand and feet warmers (improves subjective patient comfort) Hand Place one warm compress (chemical pack) in each hand. Secure to hand with stockinette if needed Change prn Feet Place T/Pad over and around feet Connect to T/Pump Set T/Pump to 380 C (100.40 F) Normothermia induction and maintenance see below Normothermia induction and maintenance Place esophageal or bladder continuous temperature probe Torso wrap Apply Torso wrap directly on the patient Place a patient gown OVER the body wrap Leg wraps Apply leg wraps to the patients legs Place SCDs over the wraps Therapy induction If initial core temperature > 390 C (102.20 F) Infuse cold NS (40 60 C / 390 430 F) 1000 mL x 2 over 10 minutes each (use a pressure bag) If core temperature reaches 370 C (98.60 F), discontinue cold NS infusion If after the second bolus of cold NS, the core temperature remains > 370 C (98.60 F) Give an additional volume of cold saline, also on a pressure bag, to make a final volume of 40 mL/kg If initial core temperature > 37.80 and < 390 C (100 - 102.20 F) Infuse cold NS (40 60 C / 390 430 F) 1000 mL x 1 over 10 minutes (use a pressure bag) If core temperature reaches 370 C (98.60 F), discontinue cold NS infusion If after initial 1000 mL bolus, the core temperature remains > 370 C (98.60 F) administer an additional 1000 mL cold NS x 1 over 10 minutes (use a pressure bag) If after the second bolus of cold NS, the core temperature remains > 370 C (98.60 F) Give an additional volume of cold saline, also on a pressure bag, to make a final volume of 40 mL/kg Interrupt cold NS infusion if CVP increases greater than 5 mmHg over 5 minutes. Restart when volume status stabilizes. Connect the temperature probe to the Medi-therm III Cooling Machine and set on AUTO RAPID Mode and the Set-Point = 360 C (96.40 F) Therapy maintenance Maintain the set-point setting of 360 C (96.40 F) until clinical concern for fever has resolved Termination of active normothermia Once the clinical concern for fever has resolved Set the machine to monitor Leave the wraps on the patient Continuously monitor temperature for at least 24 hours If core temperature exceeds 380 C (100.40 F), resume active normothermia protocol as above Columbia Shiver Assessment Scale (CSAS) 0 no shiver 1 MILD = shiver in jaw and/or pectoralis, or cardiac rhythm tracing 2 MODERATE = shiver in jaw and/or pectoralis AND deltoids 3 SEVERE = intermittent generalized shiver of > 2 extremities Interventions based on CSAS 0 No Shiver Optimize sedation and analgesia Propofol (Diprivan) drip Fentanyl drip Alter shiver threshold Buspirone (BusPar) by gastric tube 1 MILD all interventions above and ADD Vasodilatation Magnesium drip Increased comfort measures Hand and feet warmers 2 MODERATE all interventions above and ADD Alter shiver threshold Meperidine (Demerol) IV bolus 3 SEVERE all interventions above and ADD Neuromuscular blockade Vecuronium (Norcuron) intermittent boluses     Protocol for Therapeutic Normothermia with Rapr-Round Wraps DECEMBER 2007  PAGE 1 of  NUMPAGES 1 Joseph Haymore, RN, MS, CNRN, CCRN, ACNP jhaymore@onebox.com NeuroCare Associates - 2101 Medical Park Drive, Suite 305 - Silver Spring, Maryland 20902 (301) 754-0833 l m SUVde'(z{"#$%8;o´}p}p}p}p}p}p}p}pph|rhhUCJOJQJh|rhhU5CJOJQJh7fhhUCJOJQJ^Jh!hhUCJOJQJhhhUCJOJQJhhhU5CJOJQJhhhUCJOJQJ^Jh|rhhU>*CJOJQJ^Jh|rhhUCJH*OJQJ^Jh|rhhUCJOJQJ^J( " : J Z   % g ~    =  & F & FgdhU & F & F= L a ( m STUcd(*8^8gdhUp^pgdhU^gdhU & FgdhU & F^ & FgdhU & F & F*yz"C^n5P`xp^pgdhU8^8gdhU & FgdhU$E`p 8Wo? & FgdhU & FgdhU & FgdhU & FgdhU8^8gdhUp^pgdhU_g"4d:z-.Ci#$-.hvgWhhUhhU5CJOJQJ^JhhUhhUCJOJQJ^JhhUhhU5CJOJQJ^Jh|rhhUCJOJQJh|rhhU5CJOJQJh|rhhU>*CJOJQJ^Jh|rhhUCJH*OJQJ^Jh|rhhUCJOJQJaJh|rhhU5CJOJQJaJh|rhhUCJOJQJ^Jh|rhhU5CJOJQJ^J"?_"e;Tz@{ .jo2 & FgdhU & FgdhU & FgdhU23fh$.Tn & F $IfgdhUl  & F $IfgdhUl  & F $IfgdhUl  & F $IfgdhUl $$Ifa$gdhUl  & FgdhUgdhU,-56./45>?NORefjkrsxy9:BCE F N O !!!!!hhUhhUCJH*OJQJ^J"hhUhhU5CJH*OJQJ^J"hhUhhU5>*CJOJQJ^JhhUhhU5CJOJQJ^JhhUhhUCJOJQJ^JCXT}US g ! & F $IfgdhUl  & F $IfgdhUl  & F $IfgdhUl  & F $IfgdhUl  & F $IfgdhUl !6!U!!!!!"" 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