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Medication Ordering by Perfusionists for Cardiopulmonary Bypass – Adult/Pediatric – Inpatient [69]

Medication Ordering by Perfusionists for Cardiopulmonary Bypass – Adult/Pediatric – Inpatient [69] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols




Delegation Protocol Number: 69

Delegation Protocol Title:
Medication Ordering by Perfusionists for Cardiopulmonary Bypass – Adult/Pediatric – Inpatient

Delegation Protocol Applies To:
UWHC Inpatients: Adult and pediatric patients on cardiopulmonary bypass.

Target Patient Population:
Surgical adult and pediatric patients managed by perfusionists during cardiopulmonary bypass procedures.

Delegation Protocol Champion:
Shahab Akhter, MD - Department of Surgery, Cardiothoracic Surgery

Delegation Protocol Reviewers:
Petros Anagnostopoulos, MD, Chief of Pediatric Cardiothoracic Surgery - Department of Surgery - Cardiothoracic
Tom Steffens, LP, CCP - UWHC Perfusion Manager
Joshua Sebranek, MD - Department of Anesthesia

Responsible Party:
Department of Surgical Services

Purpose Statement:
To delegate from the attending surgeon to certified perfusionists the authority to place orders for medications,
including fluids and cardioplegia solutions, required to regulate the patient's oxygenation, anticoagulation and
extracorporeal circulation. The protocol is triggered when a surgeon decides to place a patient on
cardiopulmonary bypass.

Who May Carry Out This Delegation Protocol:
Perfusionists licensed in the state of Wisconsin with American Board of Cardiovascular Perfusion certification as
a clinical perfusionist and have been trained in the use of this delegation protocol.

Prior to operating under this protocol, the perfusionist must complete a 3-6 month mentoring program,
demonstrate clinical proficiency in cardiopulmonary bypass and be approved for clinical competency by the
Perfusion Manager.

Guidelines for Implementation:
1. The protocol is initiated by the decision of the surgeon to place the patient on cardiopulmonary bypass.
2. The perfusionist will use Health Link to place orders for and document medications, including fluids and
cardioplegia solutions, given during bypass. Only medications explicitly listed in this protocol are authorized
for delegated action.
3. All other medications must be ordered by a provider.
4. Any changes to the perfusionist medication preference list will require Pharmacy and Therapeutics (P&T)
committee approval.
5. Pediatric Medications
5.1. Multiple Electrolyte Injection, Type I (PLASMA-LYTE A)
5.A.1. Stock: 1000 mL bags
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

5.A.2. Indications: Priming of the CPB circuit, volume replacement during Cardiopulmonary Bypass
(CPB).
5.A.3. Dose: 100 – 2000 mL
B. 0.9% Sodium Chloride
5.B.1. Stock: 1000 mL bags
5.B.2. Indications: Priming of the CPB circuit, volume replacement during CPB.
5.B.3. Dose 100 – 1000 mL
C. Heparin
5.C.1. Stock: 1000 units/mL (10 mL vial)
5.C.2. Concentration: 1000 units/mL
5.C.3. Indication: CPB circuit prime for ACT management due to circulatory dilution.
5.C.3.1. Dose 1500 - 5000 units
5.C.4. Indication: For Activated Clotting Time (ACT) < 480 seconds.
5.C.4.1. Dose: 500-5,000 units to maintain ACT > 480 seconds while on cardiopulmonary bypass
(CPB).
D. Aminocaproic acid (AMICAR)
5.D.1. Stock: 5 gm/ 20 mL
5.D.2. Concentration: 250 mg/mL
5.D.3. Indication: Priming of the CPB circuit, fibrinolysis.
5.D.4. Dose: 150 mg/kg – maximum 5 grams
E. Phenylephrine 1%
5.E.1. Stock: 10 mg/mL vial
5.E.2. Concentration: 1 mg/mL (Prepare by adding 1 mL of 10 mg/mL stock solution to 9 mL sterile 0.9%
NaCl)
5.E.3. Indication: For mean Arterial Blood Pressure (ABP) < 50 mmHg.
5.E.4. Dose: 10-200 mcg to maintain ABP > 50 mmHg
F. Mannitol 25%
5.F.1. Stock: 12.5 gm/50 mL vial.
5.F.2. Concentration: 0.25 gm/mL.
5.F.3. Indication: Administered prior to aortic cross clamp removal for oxygen free radical scavenging.
5.F.4. Dose: 0.5 gm/kg - maximum 25 grams
G. Sodium bicarbonate 8.4%
5.G.1. Stock: 50 mEq/50 mL vial
5.G.2. Concentration: 1 mEq/mL
5.G.3. Indication: CPB circuit prime for pH balance.
5.G.4. Dose 10-50 mEq
5.G.5. Indication: Base excess (BE) > -5.
5.G.6. Dose: (calculation) 0.2 x wt.(kg) x BE
H. Calcium Chloride 10%
5.H.1. Stock: 1 gm/10 mL
5.H.2. Concentration: 100 mg/mL
5.H.3. Indication: Normalization of ionized calcium levels when utilizing a blood prime and after aortic
cross clamp removal and normalization of ECG.
5.H.4. Dose: 50 – 1000 mg
I. Albumin 5%
5.I.1. Stock: 12.5 grams/250 mL
5.I.2. Concentration: 50 mg/mL
5.I.3. Indication: Volume replacement, excessive hemodilution and/or reduced colloid osmotic pressure
5.I.4. Dose: 12.5 – 25 grams
J. Albumin 25%
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

5.J.1. Stock: 12.5 grams/50mL
5.J.2. Concentration: 0.25 gm/mL
5.J.3. 5.J.3. Indication: Priming of the CPB circuit to maintain colloid osmotic pressure.Dose: 12.5 - 25
grams
K. Cefazolin (ANCEF)
5.K.1.Stock: 1 gm lyophilized powder.
5.K.2.Concentration: 50 mg/mL (Dilute 1 gm in 20 mL sterile 0.9% NaCl solution.)
5.K.3.Indication: Priming of the CPB circuit, prophylaxis.
5.K.4.Dose: 25mg/kg – maximum 1 gm
L. Methylprednisolone sodium succinate (SOLU-MEDROL)
5.L.1. Stock: 500 mg lyophilized powder
5.L.2. Concentration: 25 mg/mL (Dilute 500 mg in 20 mL sterile 0.9% NaCl solution)
5.L.3. Indication: Priming of the CPB circuit, reduce inflammatory response due to CPB
5.L.4. Dose: 30 mg/kg – maximum 2 grams

M. Phentolamine (REGITINE)
5.M.1. Stock: 5 mg lyophilized powder
5.M.2. Concentration: 0.5 mg/mL (Prepare by reconstituting 5 mg with 10 mL sterile 0.9% NaCl
solution)
5.M.3. Indication: Given at the onset of cooling for deep hypothermia circulatory arrest procedures to
aid in systemic cooling.
5.M.4. Dose: 0.2 mg/kg
N. Furosemide (LASIX)
5.N.1. Stock: 100 mg/10 mL
5.N.2. Concentration: 10 mg/mL
5.N.3. Indication: Given at the onset of cooling for deep hypothermia circulatory arrest procedures to
aid urine output.
5.N.4. Dose: 0.25 mg/kg
O. Cardioplegia Solutions
5.O.1. Pediatric
5.O.1.1. Stock: 255 mL
5.O.1.2. Concentration: see pharmacy label
5.O.1.3. Indication: For induction of diastolic arrest.
5.O.1.4. Dose: 10-30 mL/kg at 4-8°C
5.O.1.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
5.O.2. Induction
5.O.2.1. Stock: 465 mL
5.O.2.2. Concentration: see pharmacy label
5.O.2.3. Indication: For induction of diastolic arrest.
5.O.2.4. Dose: 500 – 2000 mL at 4-8°C
5.O.2.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
5.O.3. Maintenance
5.O.3.1. Stock: 575 mL
5.O.3.2. Concentration: see pharmacy label
5.O.3.3. Indication: For maintenance of diastolic arrest.
5.O.3.4. Dose: 200 – 1000 mL, at 4-8°C, in 10 – 30 minute intervals after induction dose
5.O.3.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

5.O.4. Warm Induction
5.O.4.1. Stock: 82 mL
5.O.4.2. Concentration: see pharmacy label
5.O.4.3. Indication: For induction of diastolic arrest in patients with acute myocardial infarctions.
5.O.4.4. Dose: 200 – 400 mL, delivered at 37°C
5.O.4.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
5.O.5. Warm Reperfusate
5.O.5.1. Stock: 240 mL
5.O.5.2. Concentration: see pharmacy label
5.O.5.3. Indication: For reperfusion prior to aortic cross clamp removal in patients with acute
myocardial infarctions.
5.O.5.4. Dose: 200 – 1000 mL, delivered at 37°C
5.O.5.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
5.O.6. Cardioplegia Solution (PLEGISOL)
5.O.6.1. Stock: 1000 mL Baxter Healthcare Corp NDC 0338-0341-04
5.O.6.2. Concentration: see package insert. Addition of 10 mL of 8.4% Sodium Bicarbonate
solution to 1000 mL bag required prior to use.
5.O.6.3. Indication: For patients with cold agglutinins (see cold agglutinin clinical practice
guideline).
5.O.6.4. Dose: 500-2000 mL delivered at 4-8°C
5.O.6.5. Note: Do not dilute with whole blood. Use as a crystalloid only solution

5.O.7. Cardio del Nido
5.O.7.1. Stock: 1046.3 ml
5.O.7.2. Concentration: see pharmacy label
5.O.7.3. Indication: For induction and maintenance of diastolic arrest
5.O.7.4. Dose: 10-30 ml/kg at 4-8°C
5.O.7.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 1:4 blood to
cardioplegia ratio

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

6. Adult Medications
A. Multiple Electrolyte Injection, Type I (PLASMA-LYTE A)
6.A.1. Stock: 1000 mL bags
6.A.2. Indications: Priming of the CPB circuit, volume replacement during CPB.
6.A.3. Dose: 100 – 2000 mL
B. Sodium Chloride 0.9% solution
6.B.1. Stock: 1000 mL bags
6.B.2. Indications: Priming of the CPB circuit, volume replacement during CPB.
6.B.3. Dose 100 – 1000 mL
C. Heparin
6.C.1. Stock: 1000 units/mL (10 mL vial).
6.C.2. Concentration: 1000 units/mL.
6.C.3. Indication: CPB circuit prime for activated clotting time (ACT) management due to circulatory
dilution.
6.C.4. Dose: 10,000 units
6.C.5. Indication: ACT < 480 seconds.
6.C.6. Dose: 5,000-10,000 units to maintain ACT > 480 seconds while on cardiopulmonary bypass
(CPB).
D. Phenylephrine 1%
6.D.1. Stock: 10 mg/mL vial.
6.D.2. Concentration: 1 mg/mL (Add 1 mL of 10 mg/mL stock to 9 mL sterile 0.9% NaCl for a final
concentration of 1 mg/mL).
6.D.3. Indication: For mean Arterial Blood Pressure (ABP) < 50 mmHg.
6.D.4. Dose: 50-200 mcg to maintain ABP > 50 mmHg.
E. Mannitol 25%
6.E.1. Stock: 12.5 gm/50 mL vial.
6.E.2. Concentration: 0.25 gm/mL.
6.E.3. Indication: CPB circuit prime for dieresis management.
6.E.4. Dose: 25 grams
6.E.5. Indication: Administered prior to aortic cross clamp removal for oxygen free radical scavenging.
6.E.6. Dose: 12.5 grams.
F. Sodium bicarbonate 8.4%
6.F.1. Stock: 50 mEq/50 mL vial
6.F.2. Concentration: 1 mEq/mL.
6.F.3. Indication: CPB circuit prime for pH balance.
6.F.4. Dose 50 mEq
6.F.5. Indication: Base excess > -5.
6.F.6. Dose: (calculation) 0.2 x wt.(kg) x BE
G. Calcium Chloride 10%
6.G.1. Stock: 1 gm/10 mL
6.G.2. Concentration: 100 mg/mL
6.G.3. Indication: Normalization of ionized calcium levels after aortic cross clamp removal and
normalization of ECG.
6.G.4. Dose: 1-2 grams
H. Albumin 5%
6.H.1. Stock: 12.5 grams/250 mL
6.H.2. Concentration: 50 mg/mL
6.H.3. Indication: Volume replacement, excessive hemodilution and/or reduced colloid osmotic
pressure.
6.H.4. Dose: 12.5 – 25 grams
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

I. Antibiotics
6.I.1. Cefuroxime (ZINACEF)
6.I.1.1. Stock: 1.5 gm lyophilized powder
6.I.1.2. Concentration: 100mg/mL (Dilute 1.5 gm in 15 mL sterile 0.9% NaCl solution)
6.I.1.3. Dose: 1.5 gm (for patients who are 40-120 kg) or 3 g (for patients who are greater than 120
kg)
6.I.1.4. Indication: Given 4 hours after 1st dose (per anesthesia)
J. Vancomycin
6.J.1. Vancomycin
6.J.1.1. Stock: 1 gm lyophilized powder
6.J.1.2. Concentration: 50 mg/mL (Dilute 1 gm in 20 mL sterile 0.9% NaCl solution)
6.J.1.3. Dose: 1 gm
6.J.1.4. Indication: Given 6 hours after 1st dose (per anesthesia)
6.J.1.5. Note: Most often given in valve cases
K. Magnesium sulfate 50%
6.K.1.Stock: 1 gm/2 mL vial.
6.K.2.Concentration: 0.5gm/mL
6.K.3.Indication: Administered prior to aortic cross clamp removal for reduction of reperfusion
injury/arrhythmias.
6.K.4.Dose: 2 gm
L. Lidocaine 4%
6.L.1. Stock: 40 mg/mL in 5 mL vial
6.L.2. Concentration: 40 mg/mL
6.L.3. Indication: CPB circuit prime to reduce incidence of ventricular fibrillation at the onset of CPB.
6.L.4. Dose: 200 mg
6.L.5. Indication: Administered prior to aortic cross clamp removal to reduce incidence of reperfusion
arrhythmias.
6.L.6. Dose: 280 mg
M. Cardioplegia Solutions
6.M.1. Induction
6.M.1.1. Stock: 465 mL
6.M.1.2. Concentration: see pharmacy label
6.M.1.3. Indication: For induction of diastolic arrest.
6.M.1.4. Dose: 500 – 2000 mL at 4-8°C
6.M.1.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
6.M.2. Maintenance
6.M.2.1. Stock: 575 mL
6.M.2.2. Concentration: see pharmacy label.
6.M.2.3. Indication: For maintenance of diastolic arrest.
6.M.2.4. Dose: 200 – 1000 mL, at 4-8°C, in 10 – 30 minute intervals after induction dose
6.M.2.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
6.M.3. Warm Induction
6.M.3.1. Stock: 82 mL
6.M.3.2. Concentration: see pharmacy label
6.M.3.3. Indication: For induction of diastolic arrest in patients with acute myocardial infarctions.
6.M.3.4. Dose: 200 – 400 mL, delivered at 37°C
6.M.3.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

6.M.4. Warm Reperfusate
6.M.4.1. Stock: 240 mL
6.M.4.2. Concentration: see pharmacy label.
6.M.4.3. Indication: For reperfusion prior to aortic cross clamp removal in patients with acute
myocardial infarctions
6.M.4.4. Dose: 200 – 1000 mL, delivered at 37°C
6.M.4.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 4:1 blood to
cardioplegia ratio
6.M.5. Cardioplegia solution (PLEGISOL)
6.M.5.1. Stock: 1000 mL Baxter Healthcare Corp NDC 0338-0341-04
6.M.5.2. Concentration: see package insert
6.M.5.3. Indication: For patients with cold agglutinins (see cold agglutinin procedure).
6.M.5.4. Dose: 500-2000 mL delivered at 4-8°C
6.M.5.5. Note: Must add 10 mL of 8.4% sodium bicarbonate solution to 1000 mL bag prior to use
6.M.6. Cardio del Nido
6.M.6.1. Stock: 1046.3 ml
6.M.6.2. Concentration: see pharmacy label
6.M.6.3. Indication: For induction and maintenance of diastolic arrest
6.M.6.4. Dose: 500 – 2000mL at 4-8°C
6.M.6.5. Note: Must be diluted with oxygenated whole blood via the CPB circuit in a 1:4 blood to
cardioplegia ratio

References:
1. 8.17 Administration of Medications #13

Collateral Documents/Tools: N/A

Approved By:
UWHC Pharmacy & Therapeutics Committee: March 2012; *April 2014; *October 2015
UWHC Medical Board: March 2012; *April 2014; *October 2015

Effective Date: November 2015
Scheduled for Review: November 2018

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org