ERAS Breast Cancer

(15 Jan 2021)

NAVAL MEDICAL CENTER PORTSMOUTH

Department of General Surgery

620 John Paul Jones Circle

Portsmouth, Virginia 23708

Enhanced Recovery After Surgery (ERAS)

BREAST CANCER SURGERY PROTOCOL

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