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OP - Glucagon Growth Hormone Stimulation Test Delegation Protocol - Pediatric Diagnostics - Supplemental [5993]

OP - Glucagon Growth Hormone Stimulation Test Delegation Protocol - Pediatric Diagnostics - Supplemental [5993] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Diagnostics/Sedation


SmartSet: OP - GLUCAGON GROWTH HORMONE STIMULATION TEST
DELEGATION PROTOCOL - PEDIATRIC DIAGNOSTICS - SUPPLEMENTAL
(ID:5993)
General Information
Display name: Arginine/Glucagon Growth Hormone Stimulation Test
Type: General
Merge priority:
Version comment:
Content source:
Synonyms: 1. Arginine/Glucagon Growth Hormone Stimulation Test
2. Day Treatment
3. Growth Hormone
4. AFCH
SmartSet notes:
Description:
Web information: Title URL
1.
Questionnaire:
Configuration
All Stimulation Test Patients
Premedications for Needle Insertion
Lidocaine
Page 1 of 4
Printed by STRAKA, KEVIN F [KFS1] at 10/3/2016 11:35:10 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2016CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit Topical, EVERY 1 HOUR PRN, prior to needle
sticks to reduce pain. See "LMX Use Instructions"
order in Active Orders report or the Admin
Instructions for application details
FOR PATIENTS 5 Kg OR LESS: Do NOT apply
to area greater than 100 square centimeters.
(maximum 1 g/site; maximum 1 site per hour, 6
times per day).
FOR PATIENTS 5.1-10 Kg: Do NOT apply to
area greater than 100 square centimeters.
(maximum 1 g/site; maximum 2 sites per hour, 6
times per day).
FOR PATIENTS GREATER THAN 10 Kg: Do
NOT apply to area greater than 200 square
centimeters. (maximum 2.5 g/site; maximum 4
sites per hour, 6 times per day).
For patients less than 1 year old do NOT leave on
longer than 1 hour. For patients 1 year or older do
NOT leave on longer than 2 hours
Peds Diagnostic
LMX Use Instructions for Premedication Prior to
Needle Insertion
Peds Diagnostic
Stimulation Test Orders
Arginine/Glucagon Growth Hormone Stimulation Test
Insert and Maintain Peripheral IV CONTINUOUS, Starting S, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed? Yes
Peds Diagnostic
sodium chloride flush 0.9% 10 mL injection Flush, PRN Starting S For 8 Hours, flush/line care,
Peds Diagnostic
Vital Signs - Baseline ONCE, Starting S For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Obtain once prior to test., Peds Diagnostic
Activity: Bedrest CONTINUOUS, Starting S For Until specified,
Routine
AD LIB:
AMBULATE:
CHAIR:
DANGLE:
BEDREST:
RESTRICTIONS:
UPPER LEFT EXTREMITY WEIGHT BEARING:
UPPER RIGHT EXTREMITY WEIGHT BEARING:
LOWER LEFT EXTREMITY WEIGHT BEARING:
LOWER RIGHT EXTREMITY WEIGHT BEARING:
Patient should remain recumbent throughout
stimulation testing. (May sleep during testing.), Peds
Diagnostic
Page 2 of 4
Printed by STRAKA, KEVIN F [KFS1] at 10/3/2016 11:35:10 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org

Notify Pediatric Endocrine Fellow Provider to Notify: Provider
Notify based on: Blood Pressure,Other
If systolic blood pressure > (mmHg): 20 mmHg below
baseline reading
If systolic blood pressure < (mmHg):
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
Other: Significant change in clinical status. Blood
sugar <45 mg/dL and/or change in mental status.
Peds Diagnostic
Glucose, POC STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine, Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Adult) panel.
If Conditional, What Condition?
Collect prior to test. If blood glucose less than 65
mg/dL, call physician before beginning test.
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia
management and monitoring as indicated in the
Hypoglycemia Management (Pediatric Panel), Peds
Diagnostic
IGF-1 (INSULIN-LIKE GROWTH) - BASELINE STAT - RN COLLECT, Starting S For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Obtain baseline IgF-1 level, Peds Diagnostic
GROWTH HORMONE CONDITIONAL - RN COLLECT, Starting S For 6
Occurrences, Routine, The reference laboratory has
patient preparation instructions. Refer to the ARUP
reference link below for more information on this test
and discuss with patient as appropriate.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Obtain 1st level 30
minutes after the start of the arginine administration
(prior to glucagon), subsequent levels should be
drawn at 30, 60, 90, 120, 150 & 180 minutes post
Glucagon,(i.e. 2nd level approximately 60 minutes
post start of arginine infusion).,Label time samples
with number of minutes post-administration of each
individual agent.
The reference laboratory has patient preparation
instructions. Refer to ARUP reference link below for
more information on this test and discuss with patient
as appropriate. Label timed samples with number of
minutes post-administration of each individual agent.,
Peds Diagnostic
CORTISOL SPECIFIC TIME - RN COLLECT For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw at 60 minutes post glucagon administration to
measure adrenal insufficiency., Peds Diagnostic
Page 3 of 4
Printed by STRAKA, KEVIN F [KFS1] at 10/3/2016 11:35:10 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org

CORTISOL SPECIFIC TIME - RN COLLECT For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw at 120 Minutes post glucagon administration to
measure adrenal insufficiency., Peds Diagnostic
arginine (R-GENE) infusion 500 mg/kg, Intravenous, ONCE Starting S For 1
Doses
Administer prior to glucagon via 0.2 or 0.22 micron in-
line filter over 30 minutes. Central line recommended.
Maximum dose = 22.5 grams. For any questions
regarding the dosing of arginine or glucagon please
call Endocrine RN on call if after 8 am, otherwise call
Pediatric Endocrine Fellow on call if before 8 am
for 30 Minutes, Peds Diagnostic
glucagon injection kit - Maximum Dose = 1 mg 0.03 mg/kg, Intravenous
Administer 30 minutes after the start of the arginine
infusion
Peds Diagnostic
Criteria
Suggestions: LOOKUP LOCATOR-PED ENDODIABETES[1260]
Filter: RESTRICTION LOCATOR - OP UWHC PEDIATRICS[1273]
Restrict SmartSet:
Settings
Discontinue action:
Deselect sections for
Pended/Held orders:
Pended/Held orders
display:
Release date: Use System Definitions Setting
Disallow user override:
Page 4 of 4
Printed by STRAKA, KEVIN F [KFS1] at 10/3/2016 11:35:10 AM
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
10/2016CCKM@uwhealth.org