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201606170

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Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Madison Surgery Center

MSC - Anesthesiology - Pediatric - Recovery/Pacu [5070]

MSC - Anesthesiology - Pediatric - Recovery/Pacu [5070] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Madison Surgery Center


MSC - Anesthesiology - Pediatric - Recovery/Pacu [5070]
Intended for PediatricPatients Only
Patient Care Orders
Non-Categorized Patient Care Orders [135450]
Cardiovascular Parameters to Notify Anesthesiologist
[NURCOM0022]
CONTINUOUS, Starting today For Until specified, Call
Anesthesiologist if stystolic BP falls below (70+2*Age) or if
HR falls below 60 bpm, PACU
Pulse Oximetry per MSC protocol [NURMON0009] CONTINUOUS, Starting today For 1 Days, Routine, PACU
Cardio-Respiratory Monitor - Pediatric - Without Rhythm
per MSC protocol [139420]
Cardio-Respiratory Monitor - Pediatric - Without Rhythm
[NURMON0074]
CONTINUOUS, Routine, Please complete the Notify
Provider order below, including specification for apnea >
*** seconds. If indicated, order pulse oximetry separately.
Device Present:
Device Mode:
Device Low Rate Limit (BPM):
Notify Provider:
PACU
Notify [NURCOM0001] Provider to Notify: Provider
Notify based on:
Notify provider for apnea > 20 seconds, PACU
Accucheck glucose - Immediately Post-Op [HCMGLUC] ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
PACU
Accucheck glucose - Conditional - RN Collect
[HCMGLUC]
ONCE, Starting today For 1 Occurrences, Routine
If Conditional, What Condition?
PACU
Follow PACU Pain and Sedation Score Protocol
[NURMON0080]
CONTINUOUS, Routine, PACU
Please Call Anesthesia Before Giving Any IV
Medications in Phase II [NURCOM0022]
ONCE, Post-Op/Phase II
Do NOT Discharge Patient From MSC Unless
Anesthesiologist Gives a Specific, Separate Discharge
Order. [NURCOM0022]
ONCE For 1 Occurrences, PACU
Respiratory [135474]
Oxygen Therapy - Blow-By [RT0032] CONTINUOUS, Starting today For Until specified, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Blow-By
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Nasal Cannula [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Nasal Cannula
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Nasal Cannula with humidifer
[RT0032]
CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device:
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Venti Mask [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Page 1 of 6
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:50 PM

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Venturi mask
Attempt to Wean Off Oxygen?
PACU
Oxygen Therapy - Non-Rebreather [RT0032] CONTINUOUS, Starting today, Routine
FiO2 (%):
Liter Flow:
Titrate oxygen to maintain O2 sat at (%):
O2 Delivery Device: Non-rebreather mask
Attempt to Wean Off Oxygen?
PACU
Medications
Parenteral Opioid Analgesic - First Line Rescue Therapy (Single Response) [135364]
MORPHine PF injection RANGE [750057] 0.025-0.1 mg/kg, Intravenous, EVERY 6 MINUTES PRN, pain
Administer up to *** mg.
First Line Parenteral Analgesic Agent - Give if unable to
tolerate oral opioids or rapid response required (if for rapid
response, may give parenteral and oral pain meds
concurrently). If insufficient pain relief, give Second Line
Parenteral Therapy or notify provider if no second line therapy
is ordered.
for 4 Minutes, PACU
HYDROmorphone PF (DILAUDID) injection RANGE
[750050]
0.0025-0.01 mg/kg, Intravenous, EVERY 6 MINUTES PRN,
pain
Administer up to *** mg.
First Line Parenteral Analgesic Agent - Give if unable to
tolerate oral opioids or rapid response required (if for rapid
response, may give parenteral and oral pain meds
concurrently). If insufficient pain relief, give Second Line
Parenteral Therapy or notify provider if no second line therapy
is ordered.
for 3 Minutes, PACU
FENTanyl (SUBLIMAZE) injection RANGE [750047] 0.5 mcg/kg, Intravenous, EVERY 6 MINUTES PRN, pain
Administer up to *** micrograms.
First Line Parenteral Analgesic Agent - Give if unable to
tolerate oral opioids or rapid response required (if for rapid
response, may give parenteral and oral pain meds
concurrently). If insufficient pain relief, give Second Line
Parenteral Therapy or notify provider if no second line therapy
is ordered.
for 1 Minutes, PACU
Parenteral Opoiod Analgesic - Second Line (Single Response) [137139]
MORPHine PF injection RANGE [750057] 0.025-0.1 mg/kg, Intravenous, EVERY 6 MINUTES PRN, pain
Administer up to *** mg.
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral Therapy.
Give if unable to tolerate oral opioids or rapid response
required (if for rapid response, may give parenteral and oral
pain meds concurrently)
for 4 Minutes, PACU
HYDROmorphone PF (DILAUDID) injection RANGE
[750050]
0.0025-0.01 mg/kg, Intravenous, EVERY 6 MINUTES PRN,
pain
Administer up to *** mg.
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral Therapy.
Give if unable to tolerate oral opioids or rapid response
Page 2 of 6
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:50 PM

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01/2016Lee Vermeulen, CCKM@uwhealth.org

required (if for rapid response, may give parenteral and oral
pain meds concurrently)
for 3 Minutes, PACU
FENTanyl (SUBLIMAZE) injection RANGE [750047] 0.5 mcg/kg, Intravenous, EVERY 6 MINUTES PRN, pain
Administer up to *** micrograms.
Second Line Parenteral Analgesic Agent - Give if
unresponsive to maximum First Line Parenteral Therapy.
Give if unable to tolerate oral opioids or rapid response
required (if for rapid response, may give parenteral and oral
pain meds concurrently)
for 1 Minutes, PACU
Parenteral Opioid Antishivering - Meperidine [124167]
meperidine (DEMEROL) injection RANGE [750055] 0.25 mg/kg, Intravenous, ONCE PRN For 1 Doses, shivering,
for 4 Minutes, PACU
Oral Opioid Analgesic (Single Response) [135365]
Hyperlink to Pain Fast Fact - Multimodal Analgesia URL: https://uconnect.wisc.edu/clinical/references/pain-
management/references-guidelines/resources/name-
29968-en.file
oxycodone tab RANGE - (Maximum 10 mg/dose)
[750032]
5-10 mg, Oral, EVERY 1 HOUR PRN For 2 Doses, pain
Give parenteral opioid if patient unable to tolerate oral meds
or if rapid response required, may give parenteral and oral
pain meds concurrently. If patient cannot swallow tablets, use
oral solution. If giving oral med, and patient does not have
relief in 1 hour, titrate dose up to maximum dose. If no benefit
after 2 doses, call provider.
PACU
oxycodone soln - (Maximum 10 mg/dose) [750031] 0.05-0.15 mg/kg, Oral, EVERY 1 HOUR PRN For 2 Doses,
pain
Give solution if patient unable to swallow tablet. Give
parenteral opioid if patient unable to tolerate oral meds or if
rapid response required, may give parenteral and oral pain
meds concurrently. If giving oral med, and patient does not
have relief in 1 hour, titrate dose up to maximum dose. If no
benefit after 2 doses, call provider
PACU
NSAID Analgesics Note: May only select one NSAID Analgesic (Single Response) [135366]
URL:
ibuprofen (MOTRIN) susp - (Maximum 600 mg/dose)
[45376]
10 mg/kg, Oral, ONCE For 1 Doses, PACU
ketOROLAC (TORADOL) injection - (Maximum 15
mg/dose) [58693]
0.5 mg/kg, Intravenous, ONCE For 1 Doses
Administer IV push over 15-30 seconds
PACU
Other Analgesics Note: Do not order if within 6 hours of parenteral acetaminophen administration (Single Response)
[135368]
URL:
acetaMINOPHEN alcohol free (TYLENOL) 160 MG/5ML
susp - Note: Do not order if within 6 hours of parenteral
acetaminophen administration. (Maximum of 650
mg/dose) [43991]
10 mg/kg, Oral, ONCE For 1 Doses, PACU
acetaMINOPHEN alcohol free (TYLENOL) 160 MG/5ML
susp - Note: Do not order if within 6 hours of parenteral
acetaminophen administration. (Maximum of 650
mg/dose ) [43991]
15 mg/kg, Oral, ONCE For 1 Doses, PACU
acetaMINOPHEN (TYLENOL) disintegrating tab -
NOTE: Do not order if within 6 hours of parenteral
acetaminophen administration. (Maximum of 650
mg/dose) [64412]
Oral, ONCE For 1 Doses
NOTE: Do not order if within 6 hours of parenteral
acetaminophen administration. (Maximum of 650 mg/dose)
PACU
Page 3 of 6
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:50 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

Antiemetics - First Line Rescue Therapy [135370]
If the patient received a single prophylactic antiemetic agent during the procedure, select an agent with a different
mechanism of action for rescue therapy in the anesthesia recovery period (e.g., if ondansetron was given prophylactically,
rescue with prochlorperazine). If two - three agents are ordered within a 1st, 2nd, or 3rd Line Panel, these should be
considered as concurrent administration orders.
droperidol (INAPSINE) injection - NOTE: Suggested
dose 10 mcg/kg (Maximum 0.625 mg/dose) [36952]
10 mcg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. If two - three first line agents are ordered,
these should be considered as concurrent administration
orders.
for 2 Minutes, PACU
promethazine (PHENERGAN) injection - NOTE: Do
NOT Order for patients less than 2 years (Maximum
12.5 mg/dose) [41412]
0.25 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. Administer dose in a free flowing IV.
Suggest dilution in 10-20 mL of sodium chloride 0.9% and
administration over 10 minutes if given IV push. Alternatively,
when administered by a CENTRAL LINE may be diluted in a
50 mL sodium chloride 0.9% mini-bag and administered over
at least 10 minutes. Do NOT use hand or wrist veins. If two -
three first line agents are ordered, these should be
considered as concurrent administration orders.
NOTE: Do NOT Order for patients less than 2 years
PACU
metoclopramide (REGLAN) injection - (Maximum 10
mg/dose) [39626]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. Administer over 2 minutes. If two - three
first line agents are ordered, these should be considered as
concurrent administration orders.
PACU
ondansetron (ZOFRAN) injection - (Maximum 4
mg/dose) [132824]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses
First Line Agent. If two - three first line agents are ordered,
these should be considered as concurrent administration
orders
for 3 Minutes, PACU
diphenhydramine (BENADRYL) injection - (Maximum
12.5 mg/dose) [36790]
0.5 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
First Line Agent. If two - three first line agents are ordered,
these should be considered as concurrent administration
orders.
for 1 Minutes, PACU
Antiemetics - Second Line Rescue Therapy [135371]
If the patient received a single prophylactic antiemetic agent during the procedure, select an agent with a different
mechanism of action for rescue therapy in the anesthesia recovery period (e.g., if ondansetron was given prophylactically,
rescue with prochlorperazine). If two - three agents are ordered within a 1st, 2nd, or 3rd Line Panel, these should be
considered as concurrent administration orders.
droperidol (INAPSINE) injection - NOTE: Suggested
dose 10 mcg/kg (Maximum 0.625 mg/dose) [36952]
10 mcg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders.
for 2 Minutes
NOTE: Suggested dose 10 mcg/kg (Maximum 0.625
mg/dose)
PACU
promethazine (PHENERGAN) injection - NOTE: Do
NOT Order for patients less than 2 years (Maximum
12.5 mg/dose) [41412]
0.25 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. Administer dose in a free flowing IV.
Suggest dilution in 10-20 mL of sodium chloride 0.9% and
Page 4 of 6
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:50 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

administration over 10 minutes if given IV push. Alternatively,
when administered by a CENTRAL LINE may be diluted in a
50 mL sodium chloride 0.9% mini-bag and administered over
at least 10 minutes. Do NOT use hand or wrist veins. If two -
three second line agents are ordered, these should be
considered as concurrent administration orders.
NOTE: Do NOT Order for patients less than 2 years
PACU
metoclopramide (REGLAN) injection (Maximum 10
mg/dose) [39626]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. Administer over 2 minutes. If two -
three second line agents are ordered, these should be
considered as concurrent administration orders.
PACU
ondansetron (ZOFRAN) injection - (Maximum 4
mg/dose) [132824]
0.1 mg/kg, Intravenous, ONCE PRN For 1 Doses
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders
for 3 Minutes, PACU
diphenhydramine (BENADRYL) injection - (Maximum
12.5 mg/dose) [36790]
0.5 mg/kg, Intravenous, ONCE PRN For 1 Doses,
nausea/vomiting
Second Line Agent - Give if patient fails to respond to first line
agent after 30 minutes. If two - three second line agents are
ordered, these should be considered as concurrent
administration orders.
for 1 Minutes, PACU
Fluid Bolus for Hypotension [135373]
sodium chloride 0.9% BOLUS [730003] 10 mL/kg, Intravenous, ONCE For 1 Doses, PACU
lactated ringers BOLUS [730001] 10 mL/kg, Intravenous, ONCE For 1 Doses, PACU
Bradycardia [136007]
atropine injection - NOTE: Suggested dose 0.01 mg/kg
(Minimum 0.1 mg/dose; Maximum 0.4 mg/dose) [34843]
0.01 mg/kg, Intravenous, ONCE PRN For 1 Doses,
bradycardia, see Admin Instructions
Notify Anesthesiologist if any of the following symptoms
occur: decreased level of consciousness, nausea, and
decreased heart rate (less than *** bpm)
for 1 Minutes
NOTE: Suggested dose 0.01 mg/kg (Minimum 0.1 mg/dose;
Maximum 0.4 mg/dose)
PACU
IV Fluids [135374]
sodium chloride 0.9% infusion [64367] Intravenous, CONTINUOUS
Titrate rate to keep up with fluid loss
PACU
lactated ringers infusion [38890] Intravenous, CONTINUOUS
Titrate rate to keep up with fluid loss
PACU
Respiratory/Airway [135375]
albuterol 2.5 mg/3 mL neb soln [34314] 2.5 mg, Nebulization, ONCE For 1 Doses, PACU
racepinephrine 2.25 % neb soln [150812] 0.5 mL, Nebulization, ONCE For 1 Doses, PACU
Self-administered Medications [81248]
Note: Self Administered Medication Program
Documentation [950000]
ONCE For 1 Doses
Patient may self-administer and use own supply of the
following medications: ***
PACU
Spasms [105798]
diazepam (VALIUM) injection - NOTE: Suggested dose 0.1 mg/kg, Intravenous, ONCE For 1 Doses
Page 5 of 6
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:50 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org

0.1 mg/kg/dose (Maximum 5 mg/dose) [36675] NOTE: Suggested dose 0.1 mg/kg/dose (Maximum 5
mg/dose)
PACU
Laboratory
Labs - Immediately Post-Op [134762]
HEMOGLOBIN [HGB] ONCE, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PACU
PROTHROMBIN TIME/INR [PT] ONCE, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition?
PACU
Diagnostic Tests and Imaging
Studies [135466]
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms?
What specific question(s) would you like answered by this
exam?
Relevant recent/past history?
Is patient pregnant?
If being performed remotely, where? IP PACU
Transport Method: Floor Determined/Entered
PACU
Page 6 of 6
Printed by GUETZLAFF, SCOTT F [SFG091] at 1/14/2016 1:54:50 PM

Copyright © 2015 University of Wisconsin Hospital and Clinics Authority, University of Wisconsin Medical Foundation, Inc, UW-Madison
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:



















 
01/2016Lee Vermeulen, CCKM@uwhealth.org