Page 239 - 2026 SMOG

EXAMPLE: STANDING ORDER SHEET FOR
CRITICAL CARE PATIENT TRANSFERS
Respiratory
[ ] Keep O Sat > _______ %
2
Oxygen: [ ] Nasal Cannula at _______ LPM [ ] Non-rebreather at _______ LPM
Ventilator Setting
Mode: [ ] SIMV [ ] AC [ ] CPAP [ ] BiPAP
Rate: _______ breaths per minute I:E ratio: _______
Tidal Volume: _______ mL FiO : _______ % PEEP: _______ cm H O PIP: _______
2 2
Vasoactive Medications
[ ] Dopamine _____ mg/ _____ mL at _____ mcg/kg/min IV; titrate to MAP > _____ mmHg
[ ] Norepinephrine 4mg/ _____ mL at _____ mcg/min IV; titrate to MAP > _____ mmHg
[ ] Phenylephrine 10mg/ _____ mL at _____ mcg/min IV; titrate to MAP > _____ mmHg
[ ] Epinephrine _____ mg (1:10,000)/ _____ mL at _____ mcg/min IV;
titrate to MAP > _____ mmHg [ ] Other
Sedation and Analgesics
[ ] Ketamine _____ mg/kg q _____ minutes IVP prn sedation to Riker Sedation-Agitation Scale
of 1–2
[ ] Midazolam _____ mg q _____ minutes IVP prn sedation to Riker Sedation-Agitation Scale
of 1–2
[ ] Haloperidol _____ mg q _____ minutes IVP prn sedation to Riker Sedation-Agitation Scale
of 1–2
[ ] Lorazepam _____mg q _____ minutes IVP prn sedation to Riker Sedation-Agitation Scale
of 1–2
[ ] Fentanyl _____ mcg q _____ minutes IVP prn pain
[ ] Morphine _____ mg q _____ minutes IVP prn pain
[ ] Other: _________________________________________________
Paralytics
[ ] Rocuronium _____ mg IVP
[ ] Vecuronium _____ mg IVP
Intracranial Hypertension
[ ] 3% Hypertonic Saline 250cc bolus for any signs of herniation
[ ] Mannitol Infusion Rate: __________
Labs
[ ] ABG 15minutes prior to departing sending facility
[ ] Other: _________________________________________________
Additional critical information:
Physician Signature:

2026 Standard Medical Operating Guidelines (SMOG) • 231