WRITE WITH BLACK BALL POINT INK ONLY USING FIRM PRESSURE.
DOCTOR WRITING ORDER IS TO RECORD DATE AND TIME WITH EACH SET OF ORDERS WRITTEN. AUTHENTICATE WITH FULL SIGNATURE AND BEEPER NUMBER.
MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
CARDIOTHORACIC SURGERY HOSPITAL ORDERS
(Supraventricular Tachycardia Management) - Page 1
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Attending Physician _________________________________________________________
Weight ____________________kg
Allergies __________________________________________________________________
LOCATION: Monitored Bed
Primary Diagnosis __________________________________________________________
Condition: G stable G guarded G severe G critical
VITALS:
1. Monitor blood pressure and heart rate continuously during bolus of medications.
2. Then monitor BP and HR during IV infusion, at least every 15 minutes x 4, then every 3 minutes x 2,
then every 1-2h as clinically indicated.
3. Call House Officer: _____ less than HR (bpm) greater than 200
_____ less than SBP (mmHg) greater than _____
_____ less than DBP (mmHg) greater than _____
or for any HF not controlled at 15 mg/hr of Diltiazem
ACTIVITY: _________________________________________________________________
NUTRITION: _______________________________________________________________
NURSING ORDERS:
Continuous cardiac monitoring via telemetry or portable unit required.
Diagnostic orders:
Initial Assessment, please obtain the following tests:
1. Stat Chest X-ray (Portable) Reason_______________________________________
2. EKG - 12 lead G Atrial Fibrillation G Atrial Flutter G SVT (list)
Reason ___________________________________________________________
3. Na*, K, Cl, CO2, MG Ca++
4. ABG
5. CBC
6. When starting Amiodarone, obtain:
G TSH
G SGOT
G SGPT
Rev. 7/11
cgr 9/16/05
_________________________________________________
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MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
CARDIOTHORACIC SURGERY HOSPITAL ORDERS
(Supraventricular Tachycardia Management) - Page 2
Medication orders: Rate Control: Ensure hemodynamic stability prior to administering.
Note: Monitor blood pressure and heart rate continuously, during bolus of medications. Then monitor BP
and HR during IV infusion, every 15 minutes x 4, then every 30 minutes x 2, then every 1-2h while on
infusions and as clinicated indicated.
Rate Control - administer medication indicated.
1. Diltiazem (administer dosage selected):
G Administer Diltiazem bolus 0.25 mg/kg x ______ kg = ______ mg Diltiazem IV
Push over 2 minutes or
G Diltiazem 20 mg IV Push over 2 minutes. (For patients with weight greater than 45 kg) or
G Diltiazem 10 mg IV Push over 2 minutes. (For patients with weight less than or equal to 45 kg)
Immediately after loading dose of Diltiazem, begin Diltiazem infusion via pump at 5 mg/hr (5 ml/hr)/
(for pharmacy: 1 mg/ml qs 125 ml HS) (See rate adjustment chart below)
2. If ejection fraction greater than 50% consider Metoprolol in place of Diltiazem.
G Metoprolol (Lopressor®) 5 mg IV Push over 2 minutes. If patient remains in atrial
fibrillation, administer Lopressor 5 mg IV Push over 2 minutes every 5 minutes for
2 more doses. Maximum dose of Lopressor IV to be delivered is 3 doses. (15mg)
G Follow with maintenance dose of:
Metoprolol (Lopressor® G 25 mg PO or G 50 mg PO) every 6h x 48 hrs, then
Metoprolol (Lopressor®) 100 mg PO BID.
Diltiazem Maintenance Dose: (If Diltiazem ordered above)
TARGET HEART RATE (HR) __________________
Maintain: HR between 71 to 114 bpm OR ______ SBP greater than 90 mmHg OR ______________
DILTIAZEM INFUSION RATE ADJUSTMENTS
Adjust Diltiazem continuous infusion based on HR and blood pressure. Adjust Diltiazem dose up or down
by 2.5 mg/hr every 30 minutes x 6, then every 1h prn to achieve and maintain TARGET HR or until
maximum infusion rate of 15 mg/hr has been reached.
Maximum Diltiazem infusion rate = 15 mg/hr (page physician if HR is not controlled in TARGET HR at
15 mg/hr)
Note: The physician must give a separate new medication order to utilize a higher dose.
Adjust infusion by 2.5 mg/hr UP for HR greater than 115 bpm
Adjust infusion by 2.5 mg/hr DOWN for HR less than 70 bpm.
Stop infusion for HR less than or equal to 50 bpm or SBP less than 90 mmHg and call house officer
immediately.
Rev. 7/11
cgr 9/16/05
________________________________________________
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MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
CARDIOTHORACIC SURGERY HOSPITAL ORDERS
(Supraventricular Tachycardia Management) - Page 3
Medication orders continued:
Chemical Cardioversion
1. If patient remains in Atrial Fibrillation 6 hours after rate control medication has been initiated, give the following:
a. Amiodarone 150 mg IV bolus over 10 minutes followed by Amiodarone infusion at
1 mg/min for 6 hours, then decrease infusion to 0.5 mg/min.
b. Continue current Rate Control medications.
IV to Oral Conversion
1. After patient is in normal sinus rhythm for 24 hours, initiate IV to Oral Conversion of Supraventricular Tachycardia Medication order set.- see page 4
MISC ORDERS:
1. If Atrial Fibrillation persists after 24 hours since the start of rate control medication,
obtain Cardiology Consult to consider patient for cardioversion.
Clinical Indications: G Post-operative G Lung Resection G Esophageal Resection
patient with greater than 24 hours of sustained Atrial Fibrillation on continuous rate control
medication.
2. When cardiology Consult is ordered, obtain:
a. Brain Natriuretic Peptide (BNP) level
b. Echocardiogram Reason _____________________________________________
c. Troponin level
3. If Cardiology Consult ordered, keep patient NPO.
Rev. 7/11
cgr 9/16/05
_________________________________________________
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MR FORM 1C
8/96
PHYSICIAN ORDERS
DIAGNOSIS:
DRUG SENSITIVITY:
Patient Identification
CARDIOTHORACIC SURGERY Supraventricular Tachycardia HOSPITAL ORDERS
(IV to Oral Medication Conversion) - Page 4
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and initial your entry.
MEDICATION orders:
Oral Conversion
After patient is in normal sinus rhythm for 24 hours, initiate oral maintenance as follows:
1. Diltiazem
a. Convert infusion dose to daily PO with the following formula:
Total dose per day = current infusion rate ______ mg/hr x 24 hrs = ______mg
Choose the dose that is equal to or just greater than the calculated total dose.
I. J-tubing Dosing
(a) If patient tolerates j-tube feedings only, crush tablets and administer per j-tube.
(b) Diltiazem (Cardizem®)
G 30 mg per j-tube every 8h for a total dose of 90 mg daily.
G 30 mg per j-tube every 6h for a total dose of 120 mg daily.
G 60 mg per j-tube every 8h for a total dose of 180 mg daily.
G 60 mg per j-tube every 6h for a total dose of 240 mg daily.
G 90 mg per j-tube every 6h for a total dose of 360 mg daily.
II. PO Dosing
(a) Cardizem® SR
G 60 mg PO every 12h.
(b) Cardizem® CD
G 180 mg PO every day.
G 240 mg PO every day.
G 300 mg PO every day.
b. Discontinue Diltiazem infusion 6 hours after starting oral medication.
c. Discharge instructions: continue for 3 months.
2. Metoprolol
a. Dosing
G 25 mg PO or G 50 mg PO every 6h x 48 hours, then 100 mg PO BID.
b. Discharge instructions: continue for 3 months.
3. Amiodarone
a. Dosing
G If patient less than or equal to 95 kg, give 200 mg PO bid; continue infusion at 0.5 mg/min
for an additional 24 hours.
G If patient greater than 95 kg, give 400 mg PO bid; continue infusion at 0.5 mg/min for an
additiona 24 hours.
b. Discontinue Amiodarone infusion 24 hours after initiation of oral dosing.
c. Discharge instructions: continue for 3 weeks then convert to every day dosing for
additional 2 months.
_________/_________/_________
Date
_______________________________
Physician Last Name (Print)
Rev. 7/11
cgr 9/16/05
_____________________
Time
____________________
Pager
__________________________________________
Physician Signature
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