ERAS Lite

File:ERAS-LITE updated Aug 2022.docx

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)