Difference between revisions of "ERAS Breast Cancer"

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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
|}

Latest revision as of 05:32, 4 August 2023