/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-98205-en.cckm

201606179

page

100

UWHC,UWMF,

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

IP - ECMO Initiation - Pediatric - Procedure [2214]

IP - ECMO Initiation - Pediatric - Procedure [2214] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - ECMO Initiation - Pediatric - Procedure [2214]
Patient Care Orders
Respiratory [31427]
Circuit Critical Care Package Extracorporeal Membrane
Oxygenation (ECMO) Circuit [NURCOM0022]
ONCE, Starting today For 1 Occurrences
Medications
Medications [30841]
heparin 1000 units/mL vial - NOTE: Suggested dose
100 units/kg [45303]
100 Units/kg, Intravenous, ONCE For 1 Doses
Administer prior to cannulation for ECMO
NOTE: Suggested dose 100 units/kg
Medications - Anesthesia [121298]
FENTanyl (SUBLIMAZE) injection [37424] 1-2 mcg/kg, Intravenous, PRN For 6 Hours, Sedation and
Sedation for intubation induction
Slow IV push. Maximum dose for sedation
for 1-2 Minutes
midazolam (VERSED) injection [760167] 0.1 mg/kg, Intravenous, PRN For 6 Hours, sedation, sedation
for intubation induction.
To be given only with physician confirmation that PRN criteria
have been met. Can administer 2 doses in 2 hours
MORPHine PF injection - NOTE: Suggested dose 0.05-
0.1 mg/kg (Maximum of 2 mg/dose) [800122]
Intravenous, PRN For 6 Hours, pain
To be given only with physician confirmation that PRN criteria
have been met. Can administer 2 doses in 2 hours
vecuronium (NORCURON) injection - Maximum Dose =
10 mg [760250]
0.1 mg/kg, Intravenous, PRN For 6 Hours, muscle relaxation
for intubation
To be given only with physician confirmation that PRN criteria
have been met. Can administer 2 doses in 2 hours
Medications - Resuscitation [121302]
atropine injection - Minimum dose = 0.1mg Maximum
dose = 1 mg [760016]
20 mcg/kg, Intravenous, ONCE PRN For 24 Hours,
bradycardia, bradycardia (symptomatic or below the lower
heart rate limit for age)
To be given only with physician confirmation that PRN criteria
have been met. Administer 1 dose within 2 hours
for 1 Minutes
albumin human 5% infusion [44038] 0.5 g/kg, Intravenous, PRN For 3 Doses, emergency
resuscitation. To be given only with physician confirmation
that PRN criteria have been met
calcium CHLOride injection 20 mg/kg [800104] 20 mg/kg, Intravenous, PRN For 24 Hours, resuscitation
*FOR CENTRAL LINE ONLY* To be given only with
physician confirmation that PRN criteria have been met Can
administer 2 doses in 2 hours
epINEPHrine (CARDIAC 1:10,000) 0.1 MG/ML injection
[760293]
10 mcg/kg, Intravenous, PRN For 24 Hours, hypotension
(symptomatic or below the lower blood pressure for age),
bradycardia (symptomatic or below the lower heart rate limit
for age), or cardiac arrest.
To be given only with physician confirmation that PRN criteria
have been met. Maximum dose 1 mg.
sodium bicarbonate 8.4 % injection - NOTE: For
children less than 30 days of age dilute 1:1 with sterile
water prior to administration [760224]
1 mEq/kg, Intravenous, PRN For 24 Hours, metabolic
acidosis (symptomatic or pH less than 7.2 due to metabolic
cause)
To be given only with physician confirmation that PRN criteria
have been met. For children less than 30 days of age dilute
1:1 with sterile water prior to administration. Can administer 2
doses in 2 hours Maximum dose 100 mEq.
for 1 Minutes
Laboratory
Laboratory (If Not Drawn in the Last 4 Hours) [31429]
Page 1 of 4
Pr i nt ed by SPENCER, L I NDSEY M [LMS033] at 3/17/2014 4:41:06 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


ELECTROLYTES [LYTE] STAT - RN COLLECT, 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?
GLUCOSE [GLU] STAT - RN COLLECT, 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?
BUN [BUN] STAT - RN COLLECT, 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?
CREATININE [CRET] STAT - RN COLLECT, 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?
CALCIUM [CA] STAT - RN COLLECT, 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?
MAGNESIUM [MAG] STAT - RN COLLECT, 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?
PHOSPHATE [PHOS] STAT - RN COLLECT, 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?
CBC WITH DIFFERENTIAL [CBC] STAT - RN COLLECT, 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?
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT, 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?
FIBRINOGEN [GM1320] STAT - RN COLLECT, 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?
LACTATE [GM2255] STAT - RN COLLECT, 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] STAT - RN COLLECT, Starting today For 1 Occurrences,
STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
Page 2 of 4
Pr i nt ed by SPENCER, L I NDSEY M [LMS033] at 3/17/2014 4:41:06 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


previous specimen?
If Conditional, What Condition?
HEMOGLOBIN, WHOLE BLOOD [HCWBHGB] STAT - RN COLLECT, 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?
ABG [HCBGAS] CONDITIONAL - RN COLLECT, Starting today, STAT
Indicate FIO2:
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? This is a pre-ECMO circuit
lab. It does not reflect any patient value. For circuit check
only
ELECTROLYTES, WHOLE BLOOD [HCWBLYTS] CONDITIONAL - RN COLLECT, Starting today, STAT
If add on test, what should lab do if unable to add test to
previous specimen?
If Conditional, What Condition? Over 24 hours
Blood Bank
Tests [138651]
TYPE AND SCREEN, NEONATAL [HCNTS] STAT - RN COLLECT, 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?
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
RBC's on all patients with antibodies. Do you want to opt out
of this automatic order for this patient? No
Blood Products [138652]
Red Blood Cells (Adult) [BLB0006] 4 UNITS, Starting today For 4 Occurrences, STAT
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):
Has consent been obtained?
Date Consent Obtained (Valid for 1 year):
Plasma (Adult) [BLB0003] 4 UNITS, Starting today For 4 Occurrences, STAT
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:
Has consent been obtained?
Date Consent Obtained (Valid for 1 year):
Platelets (Adult) [BLB0004] 4 RANDOM/1 SINGLE, Starting today For 1 Occurrences,
STAT
Page 3 of 4
Pr i nt ed by SPENCER, L I NDSEY M [LMS033] at 3/17/2014 4:41:06 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority


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:
Does patient require single donor platelets (If yes, Blood Bank
MD approval required): No
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):
Has consent been obtained?
Date Consent Obtained (Valid for 1 year):
Cryoprecipitate (Adult) [BLB0005] Starting today, STAT
Reason for Order: C2 Factor VIII, XIII or vWF deficiency
Blood Product Need (It will take approximately 30 to 60
minutes from the time nursing notifies the Blood Bank to
prepare the products): SURGICAL USE
Date Product Needed: 3/17/2014
Has consent been obtained? Emergent (Unable to Obtain)
Fibrin Glue, mLs Needed:
Date Consent Obtained (Valid for 1 year):
Transfusion [12028]
If ordering to transfuse a product, make sure the product is or has already been ordered.
Transfuse Red Blood Cells (Adult) [NURTRT0021] Starting today, Routine
Run Each Unit Over:
Transfuse Plasma (Adult) [NURTRT0031] Starting today, Routine
Run Each Unit Over:
Transfuse Platelets (Adult) [NURTRT0030] Starting today, Routine
Run Each Unit Over:
Transfuse Cryoprecipitate (Adult) [NURTRT0032] Starting today, Routine
Run Each Unit Over:
Fibrin Glue, mLs Needed:
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [31432]
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 (PEDS)
[ECH0012]
ONCE, 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?
To whom can we send the results of the study? (include
clinician and location):
Do you want Agitated Bubble Study?
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Indication: Pre-Extracorporeal Membrane Oxygenation
(ECMO): Rule out structural heart disease.
Page 4 of 4
Pr i nt ed by SPENCER, L I NDSEY M [LMS033] at 3/17/2014 4:41:06 PM
Copyright © 2014 University of Wisconsin Hospital and Clinics Authority