/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/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98204-en.cckm

201711332

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - ECMO - Adult Pre-Cannulation [2458]

IP - ECMO - Adult Pre-Cannulation [2458] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - ECMO - Adult - Pre-Cannulation [2458]
for Adult Patients OnlyIntended
Patient Care Orders
Respiratory [80147]
Circuit Critical Care Package Extracorporeal
Membrane Oxygenation (ECMO) Circuit
[NURCOM0022]
ONCE, Starting today For 1 Occurrences
Non-Categorized Patient Care Orders [80148]
For Patients With Nasogastric Tube
[NURTAD0046]
ONCE, Starting today For 1 Occurrences, Remove
Nasogastric tube and insert and maintain orogastric
tube
OG Tube Placement - Adult [120995]
Insert and Maintain Orogastric Tube
[NURTAD0015]
CONTINUOUS, Routine
Options:
Flush with:
Flush Frequency: EVERY 8 HOURS
Check Residual:
Does this need to be inserted/placed? Yes
Device Status:
Refer to Policy 2.20AP Care & Maintenance of
Enteral Tubes (Adult & Pediatric)
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Orogastric tube
placement
What specific question(s) would you like answered
by this exam? Evaluate orogastric tube placement
Relevant recent/past history? Cardiac Surgery
Is patient pregnant?
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate orogastric
tube placement. The location of orogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Site Care [109462]
If Patient's Chest Open, MD Must Clean Cannula
Site [NURWND0018]
CONTINUOUS, Starting today
Medications
Prior to Cannulation [80353]
heparin 1000 units/mL vial [45303] 100 Units/kg, Intravenous, ONCE For 1 Doses
Administer prior to cannulation for ECMO
cisatracurium (NIMBEX) injection [156566] 0.15 mg/kg, Intravenous, ONCE For 1 Doses
Administer prior to cannulation for ECMO
Page 1 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

vecuronium (NORCURON) vial [46843] 0.1 mg/kg, Intravenous, ONCE For 1 Doses
Administer prior to cannulation for ECMO
MORPHine 2 mg PF injection [800122] 2 mg, Intravenous, ONCE For 1 Doses
Administer prior to cannulation for ECMO
Laboratory
Laboratory (If Not Drawn in the Last 4 Hours) [80149]
LD, TOTAL [LDH] NEXT DRAW, 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?
ALT/SGPT [ALT] NEXT DRAW, 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?
AST/SGOT [AST] NEXT DRAW, 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?
BILIRUBIN, TOTAL [TBIL] NEXT DRAW, 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?
GGT [GGT] NEXT DRAW, 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?
ELECTROLYTES [LYTE] NEXT DRAW, 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?
GLUCOSE [GLU] NEXT DRAW, 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?
BUN [BUN] NEXT DRAW, 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] NEXT DRAW, 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?
Page 2 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

CALCIUM [CA] NEXT DRAW, 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] NEXT DRAW, 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?
PHOSPHATE [PHOS] NEXT DRAW, 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?
CBC WITH DIFFERENTIAL [CBC] NEXT DRAW, 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] NEXT DRAW, 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?
FIBRINOGEN [GM1320] NEXT DRAW, 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?
LACTATE [GM2255] NEXT DRAW, Starting today For 1 Occurrences,
STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BLOOD GASES AND O2 SATURATION
[HCBGASOS]
NEXT DRAW, Starting today For 1 Occurrences,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URIC ACID [URIC] NEXT DRAW, 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?
HEMOGLOBIN, PLASMA [HCPHGB] NEXT DRAW, 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?
Cultures (If Not Previously Drawn in the Last 24 Hours) [31430]
CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [116728]
.Practices for Blood Culturing Best This order equals 2 sites (4 bottles). See link below for
Best Practices for Blood Culturing URL:
Page 3 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

https://uconnect.wisc.edu/clinical/references/laboratory-
services/blood/
Lab Test Directory URL: https://uconnect.wisc.edu/clinical/tools-
resources/lab-test-directory/microbiology/name-
67798-en.labtest
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
ONCE, Starting today For 1 Occurrences, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures
on subsequent days are of minimal diagnostic
value. Culture detects bacteria, Candida and
Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
ONCE, Starting today For 1 Occurrences, Routine,
For optimum diagnosis of sepsis, sample 3-4 sites
only on the first day of a septic episode. Cultures
on subsequent days are of minimal diagnostic
value. Culture detects bacteria, Candida and
Cryptococcus. If filamentous fungi are suspected
see Culture, Blood, Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, FUNGAL, WITH SMEAR
[HCFCULTS]
ONCE, Starting today For 1 Occurrences, Routine,
Smears not routinely performed on CSF. If CSF,
order Culture, Fungal.
Indicate source if other:
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE, Starting today For 1 Occurrences, Routine,
For patients with an ET tube or tracheostomy,
quantitative mini-BAL by RT or bronchoscopic BAL
are the preferred methods of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, URINE [URC] ONCE, Starting today For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter?
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Blood Bank
Tests [145005]
Page 4 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

TYPE AND SCREEN [HCTS] STAT - RN COLLECT, Starting today For 1
Occurrences, Routine, As good clinical practice and
for patient safety, the Transfusion Service will
automatically crossmatch 2 packed RBCs on all
patients with antibodies to ensure blood would be
available in the event it is needed. If you would like to
opt out of this automatic order for this patient please
contact the UWHC Blood Bank at (608) 263-8367 or
The American Center Lab at (608) 234-6600 as
appropriate.
TYPE AND SCREEN [HCTS] EVERY 72 HOURS, Starting today, Routine, As good
clinical practice and for patient safety, the Transfusion
Service will automatically crossmatch 2 packed RBCs
on all patients with antibodies to ensure blood would
be available in the event it is needed. If you would like
to opt out of this automatic order for this patient
please contact the UWHC Blood Bank at (608) 263-
8367 or The American Center Lab at (608) 234-6600
as appropriate.
Analgesics [81358]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Oral, ONCE For 1 Doses
Premedication for blood product
Blood Products [12026]
Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 5 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Blood Product [12027]
Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
Consent Status:
Plasma (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Page 6 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Platelets (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call
263-8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cryoprecipitate (Pediatric) [BLB0012] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Transfusion [12028]
been ordered.ordering to transfuse a product, make sure the product is or has already If
Transfuse Red Blood Cells (Adult)
[NURTRT0021]
TRANSFUSE 1 UNIT, Starting today For 1
Occurrences, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe)
1 Red Blood Cell Unit ~ 350 mL.
Run Each Unit Over:
Transfuse Plasma (Adult) [NURTRT0031] Starting today, Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
Transfuse Platelets (Adult) [NURTRT0030] TRANSFUSE 1 SINGLE, Starting today For 1
Occurrences, Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
Page 7 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Transfuse Cryoprecipitate (Adult) [NURTRT0032] Starting today, Routine, Patient Weight
No data found for Wt
Cryoprecipitate is stored frozen as 5 pooled units
(approx 120mL). Standard adult dose = 10 units.
Suggested dose = 1 unit/10 kg.
Individual cryoprecipitate units are also available for
fibrin glue (approx 10-15 mL each).
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to prepare
products.
Run Each Unit Over:
Fibrin Glue, mLs Needed:
Transfusion [12029]
been ordered.ordering to transfuse a product, make sure the product is or has already If
Transfuse Red Blood Cells (Pediatric)
[NURTRT0035]
TRANSFUSE 1 UNIT, Starting today For 1
Occurrences, Routine, Patient Weight
No data found for Wt
All cellular products are leukocyte-reduced (CMV
safe).
1 Red Blood Cell Unit ~ 350 mL. Suggested dose: 10
mL/kg body weight.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Transfuse Plasma (Pediatric) [NURTRT0037] Starting today, Routine, Patient Weight
No data found for Wt
1 Plasma Unit ~ 200 mL. Suggested dose: 10-15
mL/kg body weight.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Transfuse Platelets (Pediatric) [NURTRT0036] Starting today, Routine, Patient Weight
No data found for Wt
1 Single Donor Unit ~ 200-250 mL. Suggested dose
= 10-20 mL/kg body weight for neonatal and pediatric
patients. For patients greater than 60 kg, suggested
dose is 1 Single Donor Unit.
NURSING REMINDER: Complete request to
dispense 30-60 minutes before transfusion to prepare
products.
Run Over:
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Page 8 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org

Transfuse Cryoprecipitate (Pediatric)
[NURTRT0038]
Starting today, Routine, Patient Weight
No data found for Wt
1 Cryoprecipitate Unit ~ 10-20 mL. Suggested dose: 1
Unit/10 kg body weight. If patient weighs less than 10
kg give 1 unit.
NURSING REMINDER: Call Blood Bank at 263-8367
30-60 minutes before transfusion to prepare products.
Run Over:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [80150]
ECG - 12 Lead [EKG0008] ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Indication: Pre-Extracorporeal Membrane
Oxygenation (ECMO).
Transthoracic Resting Echocardiogram
[ECH0003]
ONCE, Starting today For 1 Occurrences, Routine
Reason for exam: OTHER (COMMENT)
Other (Comment): see comments
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Indication: Pre-Extracorporeal Membrane
Oxygenation (ECMO) - Rule Out Structural Heart
Disease.
Page 9 of 9
Printed by LIND, JANNA S [JSL237] at 6/27/2017 10:40:55 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2017CCKM@uwhealth.org