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PHYSICIANS ORDERS

TIME

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SIGN, DATE AND

TIME ALL ENTRIES

Post OP CABG
Dr. Crocker

Admit to Cardiothoracic Service: Dr. Crocker.

Inform Cardiologist and patients Primary Care Physician of arrival to CVICU.
Daily Weight and Record
VITAL SIGNS:
a. Every 15 minutes until stable and while weaning vasoactive drips, then Q 1 hour.
b. Patient warming unit with blanket for core temperature less than 95 F
c. Blood warmer for transfusions until normothermic.
d. POD #2 may obtain BP q 4 hours
LAB STUDIES:
a. On arrival to unit: ABG, Hct, Hgb, Na, Potassium, Ica, per ISTAT. PT, PTT, Mg, per Lab
b. If Glucose greater than 121 follow Post Operative Cardiac Surgery Insulin Protocol
c. In 4 hours repeat CBC, BMP, Magnesium
d. BMP, CBC, Magnesium, Ionized Calcium Q day until discharge.
e. For temp greater than 102F: Get blood cultures times 2, different sites, UA and C & S., Sputum C & S.
f. ABG in a.m.
g. Hct/Hgb, Ica, KCL, Na Q 1-2 hours per ISTAT until pt is hemodynamically stable and PRN.
DIAGNOSTIC TESTING:
a. Portable Chest X-Ray on arrival to unit and daily
b. EKG in AM and PRN
HEMODYNAMIC:
a. Maintain Systolic BP greater than 100 and CI greater than 2. Call surgeon if titration is needed.
b. CARDIAC OUTPUT WITH PROFILE:
Continuous cardiac output record immediately Q 15 minutes until stable and while weaning vasoactive drips.
c. Pulmonary Artery Wedge on admission and PRN.
e. INOTROPES (titrate for above hemodynamic parameters) HAVE AVAILABLE AT BEDSIDE
Dopamine 400mg in 250ml of D5W or Normal Saline start at ________ micrograms per kilogram per minute
Dobutamine 500 mg in 250 ml of D5W or Normal Saline start at 3 - 5 micrograms per kilogram per minute
Epinephrine 2.5 mg and Calcium Chloride 1 gram in 250 ml D5W or Normal Saline start at 0.02 - 0.05 micrograms per
kilogram per minute
f. VASODILATORS:
If Systolic BP greater than 160 begin Nitroglycerin drip 50 mg in 250cc of D5W initiate at 5 micrograms per min and titrate
not to exceed 100 micrograms per min (30 ml per hour)
If Systolic BP remains greater than 160 with titrated Nitroglycerin drip at 5 Micrograms per kilogram per minute (100
micrograms per minute) start Nitroprusside (Nipride) drip 100 mg in 250 ml D5W initiate at 0.1 0.3 micrograms per
kilogram per minute not to exceed 10 micrograms per kilogram per minute.

Physician Signature________________________________________________________ Date/Time_ _________________________________

Addressograph / Patient Label

POST-OPERATIVE CARDIAC SURGERY - DR. CROCKER

Form #18-114.51 (7/09) Page 1 of 4

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DATE
ORDERED
DATE

PHYSICIANS ORDERS

TIME

8.

SIGN, DATE AND

TIME ALL ENTRIES

Post OP CABG
Dr. Crocker

g. VOLUME REPLACEMENT: (notify surgeon with the intervention)

1. If Systolic BP less than 90 and the PAD less than 12 or CVP less than 6
Infuse Hespan 250 ml bolus or 5% Albumin 250 ml bolus
MEDICATIONS:
a. ELECTROLYTE REPLACEMENT THERAPY:
1. Supplemental Potassium Chloride:
a. If Potassium level less than 3.5 give 60 mEq IVPB, infuse over 1 hours
b. If Potassium level is between 3.5 and 4.0 give 40 mEq IVPB, infuse over 1 hour.
c. Repeat Potassium level in 1 hour post infusion.
2. Supplemental Magnesium:
a. Mix 2 grams Magnesium Sulfate in 100 ml D5W
1. If Magnesium level is less than or equal 2 mg per dl give 2 grams over 30 minutes
2. Repeat Magnesium level in 1 hour post infusion
3. Supplemental Calcium Chloride:
a. If Ionized Calcium level less than 4.5 mg/dl give 1 gram Calcium Chloride in 50 ml D5W over 1 hour
b. Repeat Calcium level in 1 hour post infusion
b. ANTIBIOTICS:
1. Antibiotics: Cefazolin (Ancef )2 grams IV Q 8 hours x 5 doses
2. Antibiotics: If allergic to Ancef give Vancomycin _________ gms Q ________ hours
c. IV FLUIDS:
a. IV fluids of NS + 20 meq KCL/hr at 50 ml/hour.
b. Discontinue IV fluids when patient taking PO liquids.
d. AGITATION:
1. Midazolam (Versed) 1 mg IV push every 30 minutes as needed; may repeat times 1 dose; not to exceed 2 mg in 1
hour. Discontinue Versed order after patient is extubated.
e. COUPLED OR MULTIFOCAL PVCs OR 6 PVCs PER MINUTE:
1. Lidocaine (Xylocaine) Bolus 100 mg IV push as needed. May repeat times 1
2. Notify surgeon after first Xylocaine Bolus
f. PAIN (caution use if attempting to wean):
1. Morphine Sulfate 1 mg IV push every 15 minutes as needed for pain until extubated; may repeat times 4 doses; not
to exceed 4 mg in 1 hour
2. Meperidine 5 mg IV push every 15 minutes as needed for pain until extubated (if allergic to Morphine Sulfate) may
repeat times 4 doses. Not to exceed 20 mg in 1 hour.
WHEN PATIENT EXTUBATED CHANGE TO PO PAIN MEDS.
3. Acetaminophen (Tylenol) 650mg by mouth every 4 hours as needed for mild pain.
4. Acetaminophen 325mg/Codeine 30mg (Tylenol #3), 1 tab by mouth every 3 hours as needed for pain rate 1-3, if

patient not allergic to Codeine

Physician Signature________________________________________________________ Date/Time_ _________________________________

Addressograph / Patient Label

POST-OPERATIVE CARDIAC SURGERY - DR. CROCKER

Form #18-114.51 (7/09) Page 2 of 4

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ORDERED
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SIGN, DATE AND

TIME ALL ENTRIES

Post OP CABG
Dr. Crocker

5. Hydrocodone 7.5mg with Acetaminophen 500mg (Lortab 7.5mg) by mouth every 4 hours as needed for pain rate 4-6,
if patient not allergic to Codeine
6. Oxycodone 5mg / Acetaminophen 325mg (Percocet) 2 tabs by mouth every 4 hours as needed for pain rate 7-10.
g. NAUSEA and or VOMITING:
1. Prochlorperazine (Compazine) 10 mg IM or IV push every 4 hours as needed
2. Ondansetron (Zofran) 4 mg IV push every 6 hours PRN Nausea and Vomiting
h. OTHER MEDICATIONS:
1. Aspirin EC 325 mg by mouth daily begin evening of surgery
2. Mupirocin 2% (Bactroban) Nasal ointment to each nostril every 12 hours. Apply a liberal amount to a cotton swab
and use one to swab the inside of each nasal passage.
POST OP MEDICATIONS WHEN EXTUBATED
1. Metroprolol (Lopressor) 25 mg by mouth every 12 hours. Hold if Heart Rate less than 60 or SBP less than 110.
HOLD IF PACING THE PATIENT..
2. ACE inhibitor:_________________________________________________________________________________
3. Magnesium Sulfate 2 grams in 100 ml D5W over 30 minutes daily times 3 beginning the day of surgery and see
PRN order.
4. Multivitamins with minerals 1 tab by mouth every AM.
5. Acetaminophen (Tylenol) 650 mg by mouth or Rectal suppository every 4 hours as needed for temperature greater
than 100.5F
6. Temazepam (Restoril) 15mg by mouth at bedtime for sleep; may repeat times 1 if unable to sleep.
7. Aluminum and Magnesia Hydroxides 30ml PO PRN for Indigestion
8. Bisacodyl Supp one rectally PRN Constipation
9. Docusate (Colace )1 PO BID
10. Pantoprazole (Protonix )40 mg PO daily
11. Ask Dr. Crocker about home meds.
9. RESPIRATORY:

a. Ventilator: TV__________, IMV__________, PS__________, PEEP__________, SV__________ with 100% FI02 times
10 minutes then obtain an ABG

b. Follow Weaning Protocol

c. Monitor Pulse Oximetry

d. EZ PAP and aerosol therapy with Albuterol 0.5 ml of 0.5% solution in 2.5 ml 0.9 Normal Saline post extubation every 4 hrs.

e. Incentive Spirometry every hour by nurses or the respiratory tech while awake post extubation

f. Turn, cough and deep breath every 4 hours, from 7am to 11pm

g. 02 protocol to keep pulse oximetry greater than 92%
10. PACEMAKER:

a. If Heart Rate less than 60 attach pacemaker generator

b. Pacemaker settings: _______________________________________________________________________________

Physician Signature________________________________________________________ Date/Time_ _________________________________

Addressograph / Patient Label

POST-OPERATIVE CARDIAC SURGERY - DR. CROCKER

Form #18-114.51 (7/09) Page 3 of 4

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ORD
DATE
ORDERED
DATE

PHYSICIANS ORDERS

TIME

SIGN, DATE AND

TIME ALL ENTRIES

Post OP CABG
Dr. Crocker

11. TUBES AND DRAINS:

a. Mediastinal and pleural tubes to underwater seal at 20 cm H2 O suction.

b. Strip chest tubes with vital signs and as needed.

c. Nasal or Oral gastric tube to low continuous suction, irrigate as needed with 0.9 Normal Saline Solution.

d. May discontinue tube 30 minutes after extubation or with extubation for oral Gastric Tube

e. Indwelling catheter to gravity drainage with hourly urinary outputs
12. DIET:

a. NPO until extubated, then begin liquids by mouth 2 hours after extubation if no nausea

b. Regular diet after patient has tolerated clear liquid diet.
13. ACTIVITY:

a. May elevate head of bed when awake and vital signs stable

b. Dangle post extubation if stable

c. Out of bed to chair in a.m. if stable

d. Progressive ambulation per Physical Therapy and/or Nursing Staff

e. Up in chair for all meals

f. When in bed, elevate foot of bed one notch at all times.
14. NOTIFY DR. CROCKER OF THE FOLLOWING:

a. For Inotropes titration

b. Chest tube output greater than 200 ml per hour

c. Temp of greater than 102 F immediately post op, then temp greater than 101F

d. All Dysrhythmias

e. Systolic BP less than 90 mmHg or heart rate less than 50 or greater than 120 beats per minute

f. PAWP greater than 20

g. Hgb less than 8

h. Urine output less than 30 ml per hour times 2
15. TUBES AND DRAINS:

a. Remove PA line POD #1 if pt hemodynamically stable.

b. Remove arterial line POD #1 if pt stable.

c. Remove foley catheter
16. POST OPERATIVE INCISIONAL CARE:

a. Sternal:
1. Place argales island on post-op until drainage stops. (May stay on wound up to 3 days as long as it is intact and

covers the entire wound.)
2. Place argales film when wound is no longer draining. (May stay on wound up to 3 days as long as it is intact and
covers the entire wound.)

b. Harvest site: Change dressing as needed to keep site clean, dry, and in tact. Keep ACE wrap secure on harvest
site to prevent hematoma.

c. Inform surgeon of drainage
17. Consults:

a. Cardiologist Dr. _______________________________

b. Cardiac Rehab

c. Social Services for discharge planning and Home Health Care.

Physician Signature________________________________________________________ Date/Time_ _________________________________

Addressograph / Patient Label

POST-OPERATIVE CARDIAC SURGERY - DR. CROCKER

Form #18-114.51 (7/09) Page 4 of 4