Order Entry — Orders > Order Sets > Neuro-ICU

TESTPATIENT, DEMO · MRN 999999 · 52F · Day 7 post-SAH (coiled) · CrCl 112 · Wt 68 kg

DCI Rescue — Induced Hypertension + Milrinone (super order set)

Neurocritical Care Unit · v1.0 DRAFT · Order Set ID: NICU-DCI-RESCUE
Use: Patient with aneurysmal SAH and secured aneurysm developing new neurologic deficit, GCS drop ≥2, or worsening TCD velocities consistent with DCI (typically days 4–14 post-bleed). This order set launches induced hypertension as first-line therapy; check the milrinone sub-section to layer on second-line therapy when IH alone is inadequate.
1. Safety verification ALL REQUIRED
  • 1. Is the ruptured aneurysm secured (coiled or clipped)? Induced hypertension is contraindicated if the aneurysm is unsecured — rebleed risk.
    • ⚠ Best Practice Advisory — Signing blocked
    Aneurysm must be secured before starting induced hypertension. Confirm aneurysm status with neurosurgery attending and update this response, or exit this order set.
  • 2. Does the patient have severe aortic stenosis, mitral stenosis, or hypertrophic obstructive cardiomyopathy (HOCM)? These are absolute contraindications to milrinone's afterload reduction. Induced hypertension alone may still be acceptable — cardiology consult recommended.
    • ⚠ Best Practice Advisory — Blocks milrinone section
    Severe obstructive valvular disease or HOCM is an absolute contraindication to IV milrinone. The milrinone section below will be disabled. Consider cardiology consult and IR referral for IA rescue as alternative. If "Unknown," obtain echocardiogram before signing.
Design note: Only these two are hard stops per NSGY/Neuro-ICU input. Other considerations (CrCl, CAD, EF, pulmonary edema) are left to attending judgment and surfaced as clinical reminders in the order details, not gates.
2. Hemodynamic goals (induced hypertension) REQUIRED
SBP floor — the goal for induced hypertension

Nurse will titrate pressors to maintain SBP at or ABOVE this floor. This value populates the admin instructions on both the norepinephrine and (if used) milrinone orders.

MAP floor — secondary hemodynamic goal
Logic: MAP is a floor, mirroring SBP. Nurse maintains both SBP ≥ floor AND MAP ≥ floor. Higher MAP floors generally pair with higher SBP floors — a patient on the Aggressive SBP 200 tier usually needs MAP 110–120 to clinically correlate.
3. Vasopressors and fluids REQUIRED
norepinephrine infusion — FIRST-LINE pressor
Starting rate: 0.05 mcg/kg/min
Titration range: 0.02–1.5 mcg/kg/min
Goal: SBP ≥ — AND MAP ≥ 100 mmHg
Titrate: every 3–5 minutes by 0.02–0.05 mcg/kg/min until goal achieved
phenylephrine infusion — SECOND-LINE (if norepi tachycardia limits titration)
Starting rate: 0.5 mcg/kg/min
Titration range: 0.25–5 mcg/kg/min
Use: Add when norepinephrine titration limited by HR >130 or pure α is preferred (tachyarrhythmia concern)
vasopressin infusion — THIRD-LINE adjunct
Rate: 0.03 units/min (non-titrated)
Use: Add when norepinephrine ≥0.5 mcg/kg/min AND SBP still below floor. Fixed dose, not titrated.
0.9% NaCl maintenance IV fluids
Rate: 75 mL/hr continuous
Goal: Maintain euvolemia. Do NOT provide hypervolemia (2023 AHA/ASA and NCS guidelines recommend against).
▶ Admin Instructions preview — norepinephrine

Goal: Maintain SBP ≥ — mmHg AND MAP ≥ 100 mmHg

Titrate: 0.02–0.05 mcg/kg/min every 3–5 min to achieve goal. Max 1.5 mcg/kg/min.

If unable to achieve goal at norepinephrine 1.5 mcg/kg/min: add phenylephrine; if still inadequate, add vasopressin 0.03 units/min; if still inadequate after triple pressor support, notify attending — consider IR consult for IA rescue.

4. Milrinone (second-line adjunct) OPTIONAL
When to add milrinone: Induced hypertension alone is inadequate — persistent neurologic deficit despite SBP at goal AND maximal pressor support, OR worsening TCD velocities despite induced hypertension. Milrinone is a vasodilator/inotrope that improves cerebral microcirculation; it does not replace pressors.
Add milrinone infusion to this order set?
milrinone 20 mg in 0.9% NaCl 100 mL (200 mcg/mL) — continuous IV infusion
Starting dose: 0.5 mcg/kg/min
Max nurse-driven dose: 1.5 mcg/kg/min
Titration: increase by 0.25 mcg/kg/min every 1–2 hours if deficit unchanged/worsening AND no adverse triggers met (see admin instructions)
Line: dedicated central lumen preferred
Loading bolus: OMIT at initiation (may be ordered separately for weaning-phase recurrence only)
▶ Admin Instructions preview — milrinone

Target SBP ceiling: — mmHg (from hemodynamic goals §2; pressor team enforces)  |  MAP floor: 100 mmHg

Baseline HR (locked at order signing): 88 bpm

Titrate milrinone: Start 0.5 mcg/kg/min. Reassess neuro exam every 30 min during active titration. If neurologic deficit unchanged or worsening AND no trigger below is met, increase by 0.25 mcg/kg/min every 1–2 hours.

TriggerAction
Unable to maintain SBP ≥ — mmHg despite norepinephrine at 1.5 mcg/kg/min FAILED milrinone tolerance. Do NOT increase or decrease milrinone — maintain current dose. Escalate pressor support (add phenylephrine / vasopressin). Notify neurointensivist attending.
HR >100 bpm AND increase >20 bpm from baseline (HR > 108) Do NOT up-titrate milrinone. Check K⁺ and Mg²⁺, replace per protocol. If HR remains elevated after electrolytes corrected and sustained >15 min, notify MD.
Dose reaches 1.5 mcg/kg/min Maximum nurse-driven dose. Any further escalation requires new MD order and IR consult for IA rescue consideration.
New atrial fibrillation, ventricular arrhythmia, troponin rise, or platelets <100 × 10⁹/L Hold milrinone. Notify MD immediately.
Deficit worsens despite milrinone at 1.5 mcg/kg/min AND max pressors Notify attending immediately. Consult IR for IA verapamil ± angioplasty.

De-escalation: Begin only after 72 hours symptom-free with stable/improving TCD and attending order. Wean 0.25 mcg/kg/min every 24 hours. See full protocol §13.

bpm
Epic build note: HR trigger = max(baseline HR + 20, 100). SBP floor pulled from §2 selection. The SBP failure trigger fires based on real-time pressor dose from the norepinephrine order — Epic flowsheet integration required.
5. Supporting orders PRE-SELECTED
nimodipine 60 mg PO/NG q4h × 21 days
Continue throughout DCI treatment. Hold for MAP <90 or reduce to 30 mg q2h per attending.
Standing electrolyte replacement (K⁺, Mg²⁺, PO₄)
Maintain K⁺ ≥4.0 mmol/L, Mg²⁺ ≥2.0 mg/dL. Nurse-driven per unit protocol. Polyuria common — empiric replacement reduces arrhythmia risk.
Labs — BMP + Mg q6h × 24h then q12h; CBC daily; troponin baseline and PRN
Transcranial Doppler daily
Trend mean MCA velocity and Lindegaard ratio. Escalating velocities = consider IR consult.
12-lead ECG — baseline, daily, and after milrinone dose escalation >1.0 mcg/kg/min
Consult Interventional Neuroradiology — IA rescue evaluation
Indication (required if checked):
IR consult is prescriber-driven: Check this when evidence supports IA therapy (persistent neurologic deficit, persistently elevated TCD, severe vasospasm on CTA). IR team makes final decision on IA verapamil vs. angioplasty in the suite.
Status: Incomplete — required fields missing