Standing orders



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STANDING ORDERS

ADMIT – Unstable Angina/Non–ST-Elevation MI (NSTEMI)



Based on ACC/AHA 2007 Class I Recommendationsa


Patient ________________________­­___ ______________________ _______

(LAST NAME) (FIRST NAME) (MI)


Age: ___________ years Weight: __________ kg  Male  Female

Admit to: Cardiology

Condition:_______________________________________________________

Diagnosis:  Unstable angina  NSTEMI
Medication allergies: ______________________________________________
________________________________________________________________


NURSING




Check/Initial/Date

 _____/_____ Activity: bed rest

 _____/_____ Cardiac monitor

 _____/_____ Vital signs q4h x 24 h then q8h

 _____/_____ Diet: house/no added salt/low saturated fat; low cholesterol

 _____/_____ Call house officer for T >101, SBP >190 mm Hg or SBP <90 mm Hg, HR >120 bpm or HR <50 bpm, RR >30 or RR <10


 _____/_____ Guaiac ALL stools while on UFH, LMWH, GP IIb/IIIa inhibitor

 _____/_____ Supplemental O2 to keep arterial saturation >90%

Nasal prongs (cannula) 2 L/min

PLEASE CALL HOUSE OFFICER FOR O2 SAT <90%

 _____/_____ ORDER FOR RESPIRATORY CARE O2 SAT CHECK q8h


DIAGNOSTIC STUDIES



Check/Initial/Date

 _____/_____ ECG ON ADMISSION

 _____/_____ ECG for recurrent chest pain
C
LABORATORY STUDIES
heck/Initial/Date


CARDIAC MARKERS

 _____/_____ Troponin T/Troponin I: NOW AND EVERY _____hrs  ___ times

 _____/_____ CK-MB: NOW AND EVERY _____ hrs  ___ times
CHEMISTRY PANEL

 _____/_____ CBC, Lipid Profile, PTT, Chemistry (7) panel in AM – FASTING


MEDICATIONS

Check/Initial/Date

 _____/_____ Aspirin 162-325 (__________ insert dose) mg po chewed (loading dose) now, then 75-162 mg/d po (or 162-325 mg/d after stent implantation) daily maintenance dose


 _____/_____ If aspirin intolerant, use clopidogrel 300-600 (_________
insert dose) mg po x 1(loading dose),b then 75 mg/d po

 _____/_____ Stop all NSAIDs except aspirin


C
MEDICATIONS cont
heck/Initial/Date


-BLOCKER

Hold if signs of HF, evidence of a low-output state, increased risk for cardiogenic shock (age >70 y, SBP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, increased time since onset of UA/NSTEMI symptoms), or other relative contraindications to β-blockade (PR interval >0.24 s, second- or third-degree heart block, active asthma, or reactive airway disease).


Choose one:
IV -Blocker (optional; reserved for patients with refractory tachycardia or refractory hypertension; otherwise, oral β-blockade is sufficient)

 _____/_____ Drug: _____________________________ _______ mg IV every ____ hrs



Oral -Blocker

 _____/_____ METOPROLOL TARTRATE 50-200 mg bid

 _____/_____ ATENOLOL 50-200 mg/d

 _____/_____ CARVEDILOL 6.25 mg bid, uptitrated to max. 25 mg bid



NITROGLYCERIN

 _____/_____ NITROGLYCERIN 1/150 (0.4 mg) 1 TAB SL q5min x 3 prn chest pain; HOLD IF: SBP <100 mm Hg

 _____/_____ NITROGLYCERIN 5-200 µg/min IV in D5W continuous IV

 _____/_____ NITROGLYCERIN, transdermal, 0.2 to 0.8 mg/h q12h, tolerance in 7 to 8 h




C
EARLY RISK STRATIFICATION
heck/Initial/Date

 _____/_____  High risk  Intermediate risk  Low risk

High risk: elevated cardiac biomarkers, ST depression, transient ST elevation, >20 min of rest pain, hemodynamic instability, signs of CHF INITIAL INVASIVE STRATEGY (Diagnostic angiography with intent to revascularize)

Intermediate risk: no high-risk features, prior MI, prior CABG, T-wave inversions, rest angina <20 min relieved promptly with nitroglycerin, age >70 years EITHER INITIAL INVASIVE OR INITIAL CONSERVATIVE STRATEGY

Low risk: No high- or moderate-risk features, progressive angina without prolonged rest pain, normal cardiac markers, normal ECG with pain INITIAL CONSERVATIVE STRATEGY
 _____/_____  Invasive strategy

 Conservative strategy


Selection of Initial Treatment Strategy: Patient Characteristics

Invasive Strategy Preferred

  • Recurrent angina or ischemia at rest or with low-level activities

  • Elevated cardiac biomarkers (TnT or TnI)

  • New or presumably new ST-segment depression

  • Signs or symptoms of HF or new or worsening mitral regurgitation

  • High-risk findings from noninvasive testing

  • Hemodynamic instability

  • Sustained ventricular tachycardia

  • PCI within 6 months

  • Prior CABG

  • High risk score (eg, TIMI, GRACE)

  • Reduced LV function (LVEF <40%)

Conservative (Selectively Invasive) Strategy Preferred

  • Low risk score

  • Patient or physician preference in absence of high-risk features

It is reasonable for initially stabilized high-risk patients with UA/NSTEMI* (GRACE risk score >140) to undergo an early invasive strategy within 12 to 24 hours of admission. For patients not at high risk, an early invasive approach is also reasonable (Class IIa, LOE: B).c


*Immediate catheterization/angiography is recommended for unstable patients.

C
INITIAL INVASIVE STRATEGY (High- or Intermediate-Risk Patients)
heck/Initial/Date

Initiate at least one (Class I, LOE: A) or both (Class IIa, LOE: B) of the following:
 _____/_____ Clopidogrel 300-600 (__________ insert dose) mg po x 1 (loading dose),b then 75 mg/d po. Withhold for 5 days if CABG is planned.
OR
 _____/_____ Prasugrel (at the time of PCI) 60 mg po x 1 (loading dose),c then 10 mg/d po. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients ≥75 years of age, prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit, except in high-risk situations (patients with diabetes or a history of prior MI) for which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to undergo urgent CABG. When possible, discontinue prasugrel at least 7 days before any surgery.



AND/OR
GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY (choose one):

 _____/_____ Eptifibatide 180 µg/kg IV bolus x 2, 10 min apart, followed by IV infusion of 2.0 µg/kg/min, reduce to 1.0 µg/kg/min if CrCl <50 mL/min. Continue for 18 to 24 hours post-PCI.



OR

 _____/_____ Tirofiban IV infusion of 0.4 µg/kg/min for 30 min, reduce to 0.2 µg/kg/min for CrCl <30 mL/min, followed by IV infusion of 0.1 µg/kg/min, reduce to 0.05 µg/kg/min if CrCl <30 mL/min. Continue for 18 to 24 hours post-PCI.



OR

 _____/_____ Abciximab 0.25 mg/kg IV bolus administered 10-60 min before the start of PCI, followed by IV infusion of 0.125 µg/kg/min (to a maximum of 10 μg/min). Continue for 12 hours post-PCI. Indicated only if there is no appreciable delay to angiography and PCI is likely to be performed. Reserve only for patients with planned PCI within 24 hours.


INITIAL INVASIVE STRATEGY (High- or Intermediate-Risk Patients) cont

Either an IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban; Class I, LOE: A) or clopidogrel (loading dose followed by daily maintenance dose; Class I, LOE: A) should be added to aspirin and anticoagulant therapy before diagnostic angiography.


For UA/NSTEMI patients in whom an initial invasive strategy is selected, it is reasonable to initiate antiplatelet therapy with both clopidogrel (loading dose followed by daily maintenance dose) and a GP IIb/IIIa inhibitor (Class IIa, LOE: B).
Factors favoring administration of both clopidogrel and a GP IIb/IIIa inhibitor include delay to angiography, high-risk features, and early recurrent ischemic discomfort.
Check/Initial/Date
ANTICOAGULANT THERAPY (choose one):

(A) or (B) denotes level of evidence designation.


 _____/_____ Unfractionated Heparin (A) (for 48 hours) 60 U/kg IV bolus (not to exceed 4000 U), followed by IV infusion of 12 U/kg/h (not to exceed 1000 U/h) to achieve goal aPTT 1.5 to 2.0 times control (approximately 50 to 70 s); check aPTT in 6 h and adjust heparin as indicated (see appendix for titration nomogram)

OR

 _____/_____ Enoxaparind (A) 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1 mg/kg every 24 h). Continue for the duration of hospitalization, 8 days, or until PCI or CABG is performed.



OR

 _____/_____ Fondaparinux (B) 2.5 mg SC once daily (avoid if CrCl <30 mL/min). Continue for the duration of hospitalization, 8 days, or until PCI or CABG is performed. UFH, per institutional practice, should be administered for any PCI procedure.



OR

 _____/_____ Bivalirudin (B) 0.1 mg/kg IV bolus, then IV infusion of 0.25 mg/kg/h (use with caution if CrCl <30 mL/min). Continue until PCI is performed or for up to 4 h post-PCI. Discontinue 3 h before CABG and dose with UFH per institutional practice.


C
INITIAL CONSERVATIVE STRATEGY (Low- or Intermediate-Risk Patients)
heck/Initial/Date

 _____/_____ Clopidogrel 300 mg po x 1 (loading dose), b then 75 mg/d po
ANTICOAGULANT THERAPY (choose one):

(A) or (B) denotes level of evidence designation.


 _____/_____ Unfractionated Heparin (A) (for 48 hours) 60 U/kg IV bolus (not to exceed 4000 U), followed by IV infusion of 12 U/kg/h (not to exceed 1000 U/h) to achieve goal aPTT 1.5 to 2.0 times control (approximately 50 to 70 s); check aPTT in 6 h and adjust heparin as indicated.
OR
 _____/_____ Enoxaparinc (A) 1 mg/kg SC q12h (if CrCl <30 mL/min, give 1 mg/kg every 24 h)

OR

 _____/_____ Fondaparinux (B) 2.5 mg SC once daily (avoid if CrCl <30 mL/min). Preferred if high risk of bleeding.

Continue IV UFH for at least 48 h (Class I, LOE: A) or enoxaparin or fondaparinux for the duration of the hospitalization (Class I, LOE: A). Enoxaparin or fondaparinux is preferable to UFH as anticoagulant therapy, unless CABG is planned within 24 h (Class IIa, LOE: B).

For UFH, consult Unfractionated Heparin Dosing Chart.

 _____/_____ Schedule assessment of LVEF

 _____/_____ Schedule stress test

 _____/_____ Start early invasive strategy if patient has recurrent

symptoms/ischemia, HF, arrhythmias, positive cardiac biomarkers, or positive stress test


INITIAL CONSERVATIVE STRATEGY (Low- or Intermediate-Risk Patients) cont

GLYCOPROTEIN IIB/IIIA INHIBITOR THERAPY
For UA/NSTEMI patients in whom an initial conservative (ie, noninvasive) strategy is selected, it may be reasonable to add eptifibatide or tirofiban to anticoagulant and oral antiplatelet therapy (Class IIb, LOE: B).
 _____/_____ Eptifibatide 180 µg/kg IV bolus, followed by IV infusion of 2.0 µg/kg/min (reduce to 1.0 µg/kg/min if CrCl <50 mL/min)

OR

 _____/_____ Tirofiban IV infusion of 0.4 µg/kg/min for 30 min, reduce to 0.2 µg/kg/min for CrCl <30 mL/min, followed by IV infusion of 0.1 µg/kg/min, reduce to 0.05 µg/kg/min if CrCl <30 mL/min



C
AS-NEEDED MEDICATIONS
heck/Initial/Date

 _____/_____ DOCUSATE SODIUM 100 mg po bid

 _____/_____ MAALOX PLUS EX STR 15 mL po q6h prn indigestion

 _____/_____ OXAZEPAM 15-30 mg po qhs prn insomnia

 _____/_____ ACETAMINOPHEN 650 mg po q4h prn headache

 _____/_____ MAGNESIUM HYDROXIDE 30 mL po daily prn constipation

 _____/_____ MAGNESIUM SULFATE Sliding Scale IV daily

Call house officer if serum Mg <1.2; hold order for creatinine >1.9

If serum Mg <1.4 give 5 g MgSO4 IV

If serum Mg <1.6 give 4 g MgSO4 IV

If serum Mg <1.8 give 3 g MgSO4 IV

If serum Mg <2.0 give 2 g MgSO4 IV
 _____/_____ LAB, MG, K daily

 _____/_____ KCL IMMEDIATE REL Sliding Scale Target K >4.5 mg/dL po daily

Call house officer if K <3.4; hold order for creatinine >1.9

If K <3.7 give 60 mEq

If K <4.1 give 40 mEq

If K <4.6 give 20 mEq


Additional Orders:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________
 _____/_____ CHEST PAIN PROTOCOL

 _____/_____ ECG x 1 prn chest pain

 _____/_____ For CP: check VS, call house officer

 _____/_____ Mark if cardiac cath is planned: Time _________________

 _____/_____ NPO except meds  Now  After midnight

 _____/_____ LAB, TYPE AND HOLD NEXT AVAILABLE

 _____/_____ NUTRITION CONSULT

Patient admitted to cardiology ischemia pathway with known or suspected CAD. Please facilitate outpatient education in low-cholesterol, low-salt diet

 _____/_____ SOCIAL SERVICE CONSULT

Patient admitted to cardiology ischemia pathway with known

or suspected CAD. Please assess and assist in need for outpatient support (including VNA) services

DAY 2 OR LATER: REMINDERS

Check/Initial/Date

 _____/_____ If on UFH (consult Unfractionated Heparin Dosing Chart)

_____________________________________________

 _____/_____ Calcium channel blocker (if β-blocker contraindicated)

Drug: _______________________ ___mg ____times/d
 _____/_____ ACE inhibitor or ARB; recommended if diabetic

Drug: _______________________ ___mg ____times/d


 _____/_____ Lipid-lowering therapy (statins) regardless of LDL; dose target to LDL <100 mg/dL (further reduction to <70 mg/dL reasonable)

Drug: ____________________________ ___mg once daily


 _____/_____ Echocardiography. FIRST 24 HR if evidence of CHF, hemodynamic instability, mechanical complication
 _____/_____ Warfarin: RECOMMENDED if LV thrombus, extensive wall dyskinesis, LVEF <20%-30%
C
PRIOR TO DISCHARGE
heck/Initial/Date

 _____/_____ Patient had stent implanted



OR

 _____/_____ Patient had medical therapy without stenting


MEDICATIONS

 _____/_____ Aspirin ________ mg/d for ___________________________


 _____/_____ Clopidogrel _________ mg/d for _______________________

OR

 _____/_____ Prasugrel 10 mg/d for ______________________________


 _____/_____ -blocker

Drug: __________________________________________

Dosage: ________________________________________
 _____/_____ ACE inhibitor or ARB

Drug: __________________________________________

Dosage: ________________________________________

 _____/_____ Aldosterone receptor blocker

Drug: __________________________________________

Dosage: ________________________________________


 _____/_____ Calcium channel blocker

Drug: ___________________________________________

Dosage: _________________________________________
 _____/_____ Statin

Drug: ___________________________________________

Dosage: _________________________________________
 _____/_____ Nitroglycerin

Drug: ___________________________________________

Dosage: _________________________________________
 _____/_____ Drug: ___________________________________________

Dosage: _________________________________________

 _____/_____ Drug: ___________________________________________

Dosage: _________________________________________


P
PRIOR TO DISCHARGE cont
ATIENT/FAMILY EDUCATION AND FOLLOW-UP INSTRUCTIONS

Check/Initial/Date

 _____/_____ Medication instructions/disease education


 _____/_____ Smoking cessation
 _____/_____ Diabetes management
 _____/_____ Nutrition, weight, and blood pressure management
 _____/_____ Exercise program
 _____/_____ Referral to cardiac rehab


Time: ______ Date: ______ Signature: ____________________________________
a Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of
patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing
Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable
Angina/Non­–ST-Elevation Myocardial Infarction) developed in collaboration with the American
College of Emergency Physicians, the Society for Cardiovascular Angiography and
Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of
Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency
Medicine. J Am Coll Cardiol. 2007;50(7):e1-e157.

b Some uncertainty exists about optimum dosing of clopidogrel. Randomized trials establishing its
efficacy and providing data on bleeding risks used a loading dose of 300 mg orally followed by a
daily oral maintenance dose of 75 mg. Higher oral loading doses such as 600 or 900 mg of
clopidogrel more rapidly inhibit platelet aggregation and achieve a higher absolute level of
inhibition of platelet aggregation, but the additive clinical efficacy and the safety of higher oral
loading doses have not been rigorously established.

c Kushner FG, Hand M, Smith SC Jr, et al. 2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2009;54(23):2205-2241.

d Limited data are available for the use of other LMWHs in UA/NSTEMI.



Heparin Adjustment Nomogram for Standard Laboratory Reagents
With a Mean Control aPTT of 26-36 s


aPTT (s)

Bolus Dose (U)

Stop Infusion (min)

Rate Change (mL/h)

Repeat aPTT

<40

3000

0

+2

6 h

40-49

0

0

+1

6 h

50-75

0

0

0 (no change)

Next am

76-85

0

0

–1

Next am

86-100

0

30

–2

6 h

101-150

0

60

–3

6 h

>150

0

60

–6

6 h

aPTT indicates activated partial thromboplastin time. Heparin infusion concentration = 50 U/mL. Target aPTT = 50-75 s.

For aPTTs obtained before 12 h after initiation of thrombolytic therapy:



  1. Do not discontinue or decrease infusion unless significant bleeding or aPTT >150 s.

  2. Adjust infusion upward if aPTT <50 s. For aPTTs obtained 12 h after initiation of thrombolytic therapy, use entire nomogram: Deliver bolus, stop infusion, and/or change rate of infusion based on aPTT, as noted on appropriate line of nomogram.

Adapted with permission from Hirsh J, Raschke R, Warkentin TE, Dalen JE, Deykin D, Poller L. Heparin: mechanism of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety. Chest. 1995;108(4 suppl):258S-275S.

Reprinted with permission from Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol. 1996;28(5):1328-1428.







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