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| '''(15 Jan 2021)'''
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| '''NAVAL MEDICAL CENTER PORTSMOUTH'''
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| '''''Department of General Surgery'''''
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| 620 John Paul Jones Circle
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| Portsmouth, Virginia 23708
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| '''E'''nhanced '''R'''ecovery '''A'''fter '''S'''urgery ('''ERAS''')
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| BREAST CANCER SURGERY PROTOCOL
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| {| class="wikitable"
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| |'''Weeks prior to surgery'''
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| | Appointment to discuss operation if applicable
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| o Book case as “ERAS-BRCA” on S3 to ensure post-op bed
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| Pre-operative nurse appointment
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| Appointment with anesthesia
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| Lab-work and imaging
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| Smoking cessation
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| Preoperative marking with wound care if applicable
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| Walking/Exercise program
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| Discuss Regional Anesthesia (PVB vs PECS)
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| |-
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| |'''Days prior to surgery'''
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| | Stop ASA/NSAIDS five days prior to surgery (may continue aspirin if stent or severe coronary artery disease)
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| ACE and ARBs to be held the day of surgery
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| Beta-blockers should be taken day of surgery
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| |'''Day of Surgery'''
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| | Chlorhexidine shower the morning of surgery
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| Bring home medications list and CPAP
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| Clear glucose containing drink (Gatorade or Ensure Pre-op) up to 2 hours prior to start of surgery.
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| Gabapentin 600mg PO on arrival to DOS
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| Celecoxib 400mg PO on arrival to DOS
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| Acetaminophen 975mg PO on arrival to DOS
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| Aprepitant 40mg PO if high PONV risk
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| Prophylactic antibiotics per surgical team
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| 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.
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| |'''Regional Anesthesia'''
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| | Primary: Paravertebral Block performed with plain bupivacaine in pre-op holding area
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| 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
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| |'''Intra-operatively'''
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| | Plan GETA via propofol TIVA
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| Induction with lidocaine, propofol, rocuronium, & esmolol prn
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| Maintenance with propofol TIVA
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| Esmolol gtt at 10-30mcg/kg/min
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| Breakthrough pain control
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| o 1st line Esmolol gtt increase to max 50mcg/kg/min
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| o 2nd line Ketamine bolus (0.2 to 0.5 mg/kg)
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| PONV Prophy
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| o Dexamethasone 8mg at beginning of case
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| o Ondansetron 4mg prior to skin closure
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| PECS plane infiltration with liposomal bupivacaine in normal saline by surgeons
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| If no regional technique performed, plan for Ketamine gtt 5-10mcg/kg/min with lidocaine 40mcg/kg/min
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| |'''Post-operatively/PACU'''
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| | Scheduled
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| o Gabapentin 300mg PO qHS x10 days
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| o Acetaminophen 1000mg PO q8h times from pre-op dose x6 total doses then BID for 2 weeks, then PRN
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| o Celecoxib 200mg PO qDay for 1 month
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| Breakthrough
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| o 1<sup>st</sup> line Acetaminophen 1000mg PO q8h prn if not receiving as scheduled
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| o 2<sup>nd</sup> line Tramadol 50mg PO q4h prn
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| o 3<sup>rd</sup> line Oxycodone 5mg PO q4h prn
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| |}
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