/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/,

/clinical/cckm-tools/content/order-sets/inpatient/cardiologyct-surgery/name-98400-en.cckm

20180104

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Cardiology/CT Surgery

IP – Dofetilide (TIKOSYN) – Adult – Supplemental [3117]

IP – Dofetilide (TIKOSYN) – Adult – Supplemental [3117] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Dofetilide (TIKOSYN) - Initiation - Adult - Supplemental [3117]
Prior to Initiation of Dofetilide (TIKOSYN)
Patient Monitoring [96259]
Cardiac Rhythm Monitoring - Adult
[NURMON0010]
CONTINUOUS, Starting today, Routine
Indication:
Notify Provider: Symptomatic Change in
Rhythm,Serious Arrhythmia
Functional Cardiac Defibrillator Present:
Laboratory - Baseline [96260]
POTASSIUM [K] COLLECT UPON ADMISSION, 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?
MAGNESIUM [MAG] COLLECT UPON ADMISSION, 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?
CREATININE [CRET] COLLECT UPON ADMISSION, 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?
PROTHROMBIN TIME/INR [PT] COLLECT UPON ADMISSION For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL [HEMO] COLLECT UPON ADMISSION For 1 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Diagnostic Tests and Imaging - Baseline [96261]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: Other (enter comments)
Comment: Dofetilide initiation
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Medications
Dofetilide (TIKOSYN) [96264]
clearance of less than 20 mL/cmDofetilide is contraindicated in patients with calculated creatinine NOTE:
dofetilide (TIKOSYN) cap - NOTE: Order 500 mcg
for patients with calculated creatinine clearance
greater than 60 mL/min [63440]
500 mcg, Oral, 2 X DAILY
NOTE: Order 500 mcg for patients with calculated
creatinine clearance greater than 60 mL/min
Page 1 of 5
Printed by LIND, JANNA S [JSL237] at 1/4/2018 10:06:22 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

dofetilide (TIKOSYN) cap - NOTE: Order 250 mcg
for patients with calculated creatinine clearance
40-60 mL/min [63439]
250 mcg, Oral, 2 X DAILY
NOTE: Order 250 mcg for patients with calculated
creatinine clearance 40-60 mL/min
dofetilide (TIKOSYN) cap - NOTE: Order 125 mcg
for patients with calculated creatinine clearance
20-39 mL/min [63438]
125 mcg, Oral, 2 X DAILY
NOTE: Order 125 mcg for patients with calculated
creatinine clearance 20-39 mL/min
NOTE: Prior to administering scheduled dose,
verify documented QT assessment from progress
note since last dose. If unable to verify QT, page
provider. [950018]
2 X DAILY
Prior to administering scheduled dose, verify
documented QT assessment from progress note since
last dose. If unable to verify QT, page provider.
Note: Obtain ECG 2-3 hours after each dofetilide
(TIKOSYN) dose [950018]
EVERY 12 HOURS
Note: Supplement potassium and magnesium as
needed prior to initiation of dofetilide (TIKOSYN)
[950018]
ONCE For 1 Doses
Dofetilide Patient Information Packet [950031] ONCE For 1 Doses
Anti-coagulants [144823]
Note: Warfarin Dosing Per Pharmacy [950044] 1 X DAILY (HS)
Medications - Potassium Supplementation
Oral - PRN [95544]
potassium chloride ER cap [49087] 20-60 mEq, Oral, PRN, potassium supplmentation -
See Admin Inst
For serum K 4.0-4.2 mmol/L give 20 mEq x1;
For serum K 3.7-3.9 mmol/L give 40 mEq x1;
For serum K 3.5-3.6 mmol/L give 60 mEq x1 (give in
divided doses of 40 mEq x1, followed in 1 hour by 20
mEq x1)
Swallow whole; do not break, chew, or open capsule
Oral - PRN - Renal Dosing [95545]
potassium chloride ER cap [49087] 10-30 mEq, Oral, PRN, potassium supplementation -
See Admin Instructions
For serum K 4.0-4.2 mmol/L give 10 mEq x1;
For serum K 3.7-3.9 mmol/L give 20 mEq x1;
For serum K 3.5-3.6 mmol/L give 30 mEq x1 (give in
divided doses of 20 mEq x1, followed in 1 hour by 10
mEq x1)
Swallow whole; do not break, chew, or open capsule
Medications - Magnesium Supplementation
Magnesium Sulfate (Single Response) [102289]
Page 2 of 5
Printed by LIND, JANNA S [JSL237] at 1/4/2018 10:06:22 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED,
magnesium supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Magnesium Supplemental Scale - NOTE: Order in
patients with RENAL impairment (CrCl < 30
mL/min) [950039]
PRN - NOTIFY PHARMACY WHEN NEEDED,
magnesium supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.025 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.05 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.075
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
NOTE: Order in patients with RENAL impairment
(CrCl < 30 mL/min)
Laboratory
Daily Labs [99561]
POTASSIUM [K] NEXT AM, Starting tomorrow For 3 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
MAGNESIUM [MAG] NEXT AM, Starting tomorrow For 3 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM, Starting tomorrow For 3 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PROTHROMBIN TIME/INR [PT] NEXT AM, Starting tomorrow For 3 Occurrences,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Conditional Labs [97030]
Page 3 of 5
Printed by LIND, JANNA S [JSL237] at 1/4/2018 10:06:22 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

POTASSIUM [K] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement and 4 hours after oral replacement
MAGNESIUM [MAG] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw one hour after IV
replacement
Diagnostic Tests and Imaging
To Be Completed 2-3 Hours After Each Dofetilide (TIKOSYN) Dose [96265]
ECG - 12 Lead [EKG0008] PRN, Starting today, Routine
Reason for exam:
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
To be completed 2-3 hours after each dofetilide
(TIKOSYN) dose.
Cardiac Procedures [144928]
Heart And Vascular Care Procedure - EP
[CARD0007]
ONCE For 1 Occurrences, Routine,
Procedure:
Special Procedures:
Reason for EP Procedure:
Provider to Perform Procedure:
Does the patient have a pacemaker or ICD?
Last INR value? (will auto pull in date and value in
comment):
Last Ejection Fraction value? (will auto pull in date and
value in comment):
Assess patient for Cardiovascular Lab Ankle Brachial
Index? Yes
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE For 1 Occurrences, Routine
Reason for exam:
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Page 4 of 5
Printed by LIND, JANNA S [JSL237] at 1/4/2018 10:06:22 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

Transesophageal Echocardiogram [ECH0008] ONCE For 1 Occurrences, Routine
Indication:
Name and pager number of the physician to contact
the day of the procedure:
Can the patient provide consent?
If not is the POA aware of the procedure and available
to provide consent the day of the procedure?
List the name and the primary telephone number of
the POA (indicate N/A if not needed):
Does the patient have positive blood cultures?
Does the patient have a history of esophageal varices,
strictures or dysphagia?
Does the patient have a history of cervical spine
deformity or cervical collar that can not be removed?
Has the patient been NPO for at least 8 hours prior to
the procedure?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Do you want Agitated Bubble Study?
Does patient use CPAP?
Transesophageal Echocardiogram with
Cardioversion [ECH0001]
ONCE For 1 Occurrences, Routine
Indication:
Name and pager number of the physician to contact
the day of the procedure:
Can the patient provide consent?
If not is the POA aware of the procedure and available
to provide consent the day of the procedure?
List the name and the primary telephone number of
the POA (indicate N/A if not needed):
Does the patient have positive blood cultures?
Does the patient have a history of esophageal varices,
strictures or dysphagia?
Does the patient have a history of cervical spine
deformity or cervical collar that can not be removed?
Has the patient been NPO for at least 8 hours prior to
the procedure?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Do you want Agitated Bubble Study?
Does patient use CPAP?
Page 5 of 5
Printed by LIND, JANNA S [JSL237] at 1/4/2018 10:06:22 AM
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org