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Revision as of 06:27, 1 September 2022

Weeks prior to surgery      Appointment to discuss operation if applicable  

o     Book case as “ERAS-LITE” on S3

     Pre-operative nurse appointment

     Appointment with anesthesia if otherwise indicated

     Lab-work and imaging

     Smoking cessation

     Nutrition appointment

     Preoperative marking with wound care if applicable

     Walking/Exercise program

Days prior to surgery      Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)

     Blood thinner:  Surgeons’s discretion

     ACE and ARBs to be held the day of surgery

     Diuretics to be held the day of surgery (unless CHF)

     Beta-blockers should be taken day of surgery

     For patients without type 2 dependent diabetes: ENSURE pre-surgery drink: 2 bottles the night before surgery and 1 bottle at 0400 the day of surgery

     For patients with type 2 diabetes not requiring insulin: Ensure pre-surgery drink: 2 bottles the night before surgery and 1 bottle at 0400 the day of surgery.  Check blood sugar on day of surgery and use sliding scale insulin as needed to adjust glycemic levels preoperatively

     For patients with type 2 diabetes requiring insulin: No ensure presurgery drinks.  Drink 16-20 ounces of water or other sugar free/calorie free liquid the night before surgery and 8-10 ounces of water or other sugar free/calorie free liquid 4 hours before scheduled surgery start.

Day of Surgery

     Chlorhexidine shower the morning of surgery

     Bring home medications list and CPAP

     Bring Sugarless Chewing Gum

Pre-operatively      Premedications

o     PO Celecoxib 200mg x 1

o     PO Pregabalin 75 mg x1

o     PO Tylenol 975mg x 1

o     IV Versed 2mg x1 Prior to OR

     History of PONV

o     Consider PO Emend 40mg

o     Consider Scopalamine Patch

     Antibiotics: Per surgeon

     IV in non-operative limb

o     LR at KVO

     Hair removal done in pre-op holding area

     Regional Anesthesia as indicated

o     Hold Heparin/Lovenox SQ until after neuraxial/regional

Intra-operatively      Positioning Devices as Indicated

     Normothermia/Bair Hugger

     Targeted fluid therapy

     Induction

o     Ketamine 0.2-0.3 mg/kg

o     Lidocaine 1-1.5 mg/kg

o     Propofol as indicated

o     Sympathtic blunting agent;

▪     Esmolol 0.3-0.5 mg/kg

▪     Fentanyl 0.5-2 mcg/kg

o     NMBA as indicated

o     Dexamethasone 0.1mg/kg

▪     Max dose 8 mg

     Maintenance

o     Volatile Anesthetics as indicated

o     Pain Adjuncts as indicated

▪     Propofol gtt

▪     Lidocaine gtt

▪     Magnesium bolus/gtt

▪     Dexmedetomidine bolus/gtt

o     Opioids as indicated

     Ondansetron 4mg IV

     Surgeon administered long acting local anesthetic wound infiltration

Post-operatively/PACU      PACU Medications

o     Ketamine 20mg IV q15min PRN First line for pain if not tolerating PO

o     Tramadol 50-100mg PO x1 PRN First line for pain if tolerating PO

o     Ondansetron 4mg IV x1 PRN

o     Midazolam 2mg IV x1 PRN Anxiety

o     Hydromorphone 0.2-0.4 mg IV PRN Second line for pain

     LR at 75 mL/hr

     Clear liquids when awake if no aspiration risk

     PACU X-Ray as indicated

POD#0 (Inpatient)      Pain Meds:

o     PO Acetaminophen 975mg q8h timed from preop dose

o     PO Celecoxib 200mg 12 hours following preop dose

o     PO Tramadol 50-100 mg PO q6h prn pain

o     PO Oxycodone 5-10mg q4h PRN Breakthrough Pain (first line)

o     IV Hydromorphone 0.4mg x1 PRN Breakthrough Pain (second line)

     Bowel Regimen

o     Colace 100mg BID PRN

     Antiemetic

o     Ondansetron 4mg q4h PRN

     Advance diet as tolerated

     Ambulating 2-3 times/day outside of room

     PT/OT consult if Required

     Wound Care consult if required

     Consider foley removal

Ward POD#1 (Inpatient)      POD 1 labs: CBC and BMP/Mag/Phos

     Start VTE prophylaxis after first CBC

o   Lovenox 40 mg SQ daily

o   Heparin 5000 U TID if bleeding concerns or renal insufficiency

o   Heparin 5000 U BID if older than 75 year of age

     Pain Meds

o   If needed, add PO Pregabalin 150mg qDay

o   If needed, add oral Valium 5 mg q8h prn muscle spasm

     Consider removal of foley if in situ

     Continue to advance diet

     Discontinue IVF once tolerating > 500 mL orally

     Ambulate TID

     ICS 10x/hr

     Discharge Planner to See

Ward POD #2 & Onward (Inpatient      Out of bed 8 hours

     Consider discharge once meets criteria

     Discharge Medications as below:

POD#0 (Outpatient)      Discharge Meds

o     Acetaminophen 975mg q8h

▪     63 Tabs (7 days)

o     Naproxen 500mg q12h

▪     14 Tabs (7 days)

o     Oxycodone 5mg q4h PRN

▪     5-15 Tabs (1-2 days)

o     Colace 100mg BID PRN

▪     14 tabs (7 days)

o     Zofran 4mg q4h PRN

▪     30 tabs (5 days)