Sremick: should have been practice group article

2023-08-04T13:32:26Z

should have been practice group article

← Older revision		Revision as of 06:32, 4 August 2023
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	~~'''(15 Jan 2021)'''~~

	~~'''NAVAL MEDICAL CENTER PORTSMOUTH'''~~

	~~'''''Department of General Surgery'''''~~

	~~620 John Paul Jones Circle~~

	~~Portsmouth, Virginia 23708~~

	~~'''E'''nhanced '''R'''ecovery '''A'''fter '''S'''urgery ('''ERAS''')~~

	~~BREAST CANCER SURGERY PROTOCOL~~
	~~{\| class="wikitable"~~
	~~\|'''Weeks prior to surgery'''~~
	~~\| Appointment to discuss operation if applicable~~

	~~o Book case as “ERAS-BRCA” on S3 to ensure post-op bed~~

	~~Pre-operative nurse appointment~~

	~~Appointment with anesthesia~~

	~~Lab-work and imaging~~

	~~Smoking cessation~~

	~~Preoperative marking with wound care if applicable~~

	~~Walking/Exercise program~~

	~~Discuss Regional Anesthesia (PVB vs PECS)~~
	\|-
	~~\|'''Days prior to surgery'''~~
	~~\| Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)~~

	~~ACE and ARBs to be held the day of surgery~~

	~~Beta-blockers should be taken day of surgery~~
	\|-
	~~\|'''Day of Surgery'''~~
	~~\| Chlorhexidine shower the morning of surgery~~

	~~Bring home medications list and CPAP~~

	~~Clear glucose containing drink (Gatorade or Ensure Pre-op) up to 2 hours prior to start of surgery.~~

	~~Gabapentin 600mg PO on arrival to DOS~~

	~~Celecoxib 400mg PO on arrival to DOS~~

	~~Acetaminophen 975mg PO on arrival to DOS~~

	~~Aprepitant 40mg PO if high PONV risk~~

	~~Prophylactic antibiotics per surgical team~~

	~~DVT prophylaxis heparin 5,000U SC q8h after block completed. May start lovenox 12h after placement of block due to hematoma risk per ASRA guidelines.~~
	\|-
	~~\|'''Regional Anesthesia'''~~
	~~\| Primary: Paravertebral Block performed with plain bupivacaine in pre-op holding area~~

	Secondary: If contraindication to PVB including patient refusal for awake block, consider PECS 1 & 2 blocks with 10mL & 20mL plain bupivacaine/liposomal bupivacaine mixture respectively per side performed prior to induction
	\|-
	~~\|'''Intra-operatively'''~~

	~~\| Plan GETA via propofol TIVA~~

	~~Induction with lidocaine, propofol, rocuronium, & esmolol prn~~

	~~Maintenance with propofol TIVA~~

	~~Esmolol gtt at 10-30mcg/kg/min~~

	~~Breakthrough pain control~~

	~~o 1st line Esmolol gtt increase to max 50mcg/kg/min~~

	~~o 2nd line Ketamine bolus (0.2 to 0.5 mg/kg)~~

	~~PONV Prophy~~

	~~o Dexamethasone 8mg at beginning of case~~

	~~o Ondansetron 4mg prior to skin closure~~

	~~PECS plane infiltration with liposomal bupivacaine in normal saline by surgeons~~

	~~If no regional technique performed, plan for Ketamine gtt 5-10mcg/kg/min with lidocaine 40mcg/kg/min~~
	\|-
	~~\|'''Post-operatively/PACU'''~~
	~~\| Scheduled~~

	~~o Gabapentin 300mg PO qHS x10 days~~

	~~o Acetaminophen 1000mg PO q8h times from pre-op dose x6 total doses then BID for 2 weeks, then PRN~~

	~~o Celecoxib 200mg PO qDay for 1 month~~

	~~Breakthrough~~

	~~o 1<sup>st</sup> line Acetaminophen 1000mg PO q8h prn if not receiving as scheduled~~

	~~o 2<sup>nd</sup> line Tramadol 50mg PO q4h prn~~

	~~o 3<sup>rd</sup> line Oxycodone 5mg PO q4h prn~~
	\|}

Sremick: created

2023-08-04T13:31:21Z

created

New page

'''(15 Jan 2021)'''

'''NAVAL MEDICAL CENTER PORTSMOUTH'''

'''''Department of General Surgery'''''

620 John Paul Jones Circle

Portsmouth, Virginia 23708

'''E'''nhanced '''R'''ecovery '''A'''fter '''S'''urgery ('''ERAS''')

BREAST CANCER SURGERY PROTOCOL
{| class="wikitable"
|'''Weeks prior to surgery'''
| Appointment to discuss operation if applicable

o Book case as “ERAS-BRCA” on S3 to ensure post-op bed

Pre-operative nurse appointment

Appointment with anesthesia

Lab-work and imaging

Smoking cessation

Preoperative marking with wound care if applicable

Walking/Exercise program

Discuss Regional Anesthesia (PVB vs PECS)
|-
|'''Days prior to surgery'''
| Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)

ACE and ARBs to be held the day of surgery

Beta-blockers should be taken day of surgery
|-
|'''Day of Surgery'''
| Chlorhexidine shower the morning of surgery

Bring home medications list and CPAP

Clear glucose containing drink (Gatorade or Ensure Pre-op) up to 2 hours prior to start of surgery.

Gabapentin 600mg PO on arrival to DOS

Celecoxib 400mg PO on arrival to DOS

Acetaminophen 975mg PO on arrival to DOS

Aprepitant 40mg PO if high PONV risk

Prophylactic antibiotics per surgical team

DVT prophylaxis heparin 5,000U SC q8h after block completed. May start lovenox 12h after placement of block due to hematoma risk per ASRA guidelines.
|-
|'''Regional Anesthesia'''
| Primary: Paravertebral Block performed with plain bupivacaine in pre-op holding area

Secondary: If contraindication to PVB including patient refusal for awake block, consider PECS 1 & 2 blocks with 10mL & 20mL plain bupivacaine/liposomal bupivacaine mixture respectively per side performed prior to induction
|-
|'''Intra-operatively'''

| Plan GETA via propofol TIVA

Induction with lidocaine, propofol, rocuronium, & esmolol prn

Maintenance with propofol TIVA

Esmolol gtt at 10-30mcg/kg/min

Breakthrough pain control

o 1st line Esmolol gtt increase to max 50mcg/kg/min

o 2nd line Ketamine bolus (0.2 to 0.5 mg/kg)

PONV Prophy

o Dexamethasone 8mg at beginning of case

o Ondansetron 4mg prior to skin closure

PECS plane infiltration with liposomal bupivacaine in normal saline by surgeons

If no regional technique performed, plan for Ketamine gtt 5-10mcg/kg/min with lidocaine 40mcg/kg/min
|-
|'''Post-operatively/PACU'''
| Scheduled

o Gabapentin 300mg PO qHS x10 days

o Acetaminophen 1000mg PO q8h times from pre-op dose x6 total doses then BID for 2 weeks, then PRN

o Celecoxib 200mg PO qDay for 1 month

Breakthrough

o 1st line Acetaminophen 1000mg PO q8h prn if not receiving as scheduled

o 2nd line Tramadol 50mg PO q4h prn

o 3rd line Oxycodone 5mg PO q4h prn
|}

ERAS Breast Cancer - Revision history

Sremick: should have been practice group article

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