Enhanced Recovery Thoracic Surgery. Esophagus Pathway
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1 Enhanced Recovery Thoracic Surgery Esophagus Pathway Preoperative Patient Education/Expectations for Hospital and Home Medical Risk Consultation: Cardiac Clearance and PFTs for All Patients Surgery Wellness Referral for >65 years old or concern for diminished functional status Smoking Cessation: Goal 4 weeks prior to Surgery Nutrition: Referral to Dietician Intraoperative Anesthesia: Fasting: Clear liquid diet until 2 hours prior to surgery Surgical Site Infection Prophylaxis: Ancef (discontinue following closure of wound) Normothermia Lung Protective Ventilation and Goal Directed Fluid Management Postoperative Nausea/Vomiting Prevention Central Line: remove at end of case if used Pain Management: PCEA Tylenol ATC (4g/day) NSAIDS ATC: for all patients <75 years old and normal renal function. IV Toradol 15mg q6h until PO intake, then PO Diclofenac 50mg BID Gabapentin 300mg BID: to be started with PO intake Surgery: Minimally invasive techniques (robotic or video-assisted surgery) when possible Intercostal Nerve Block Postoperative Ambulate QID
2 Chest tube amylase and bilirubin NGT to gravity IVF to TKO Daily dulcolax, hold for BM Remove NGT if output <100cc/24h, no gastric conduit distension CXR, and no ileus Chest tube amylase and bilirubin Sips (start with grape juice to see if comes out chest tube) while OOB to Chair POD3 Advance to CLD. Food and Drinks Chest tube amylase and bilirubin (to be continued daily until chest tube removed) Remove Chest Tube if WBC normal/normalizing and output <400cc/24h and clear Wean PCEA POD4 Remove PCEA Advance to FLD RD Consultation POD5 Discharge Home on FLD until clinic Standardized Discharge Instructions (Smartphrase.dcesophagus ) Medications (2-week Supply): Pain- Tylenol ATC, Diclofenac ATC (if indicated), Gabapentin ATC, Opioids prn Bowel Regimen- Colace and Senna
3 Enhanced Recovery Thoracic Surgery Lung Pathway Preoperative Patient Education/Expectations for Hospital and Home Medical Risk Consultation: Cardiac Clearance and PFTs for All Patients Surgery Wellness Referral for >65 years old or concern for diminished functional status Smoking Cessation: Goal 4 weeks prior to Surgery Intraoperative Anesthesia: Fasting: Clear liquid diet until 2 hours prior to surgery Surgical Site Infection Prophylaxis: Ancef (discontinue following closure of wound) Venous Thromboembolism Prophylaxis: Subcutaneous Heparin (given prior to incision) Normothermia Lung Protective Ventilation and Goal Directed Fluid Management Postoperative Nausea/Vomiting Prevention Central Line: remove at end of case if used Pain Management: PCEA: only for open procedures Tylenol ATC (4g/day) NSAIDS ATC: for all patients <75 years old and normal renal function. IV Toradol 15mg q6h until PO intake, then PO Diclofenac 50mg BID Gabapentin 300mg BID Surgery: Minimally invasive techniques (robotic or video-assisted surgery) when possible Intercostal Nerve Block Postoperative Open Lobectomy
4 IV Lasix 20mg x 1 (if previously on diuretic, Wean PCEA in PM PO Lasix 20mg BID (if previously on diuretic,. To be continued until discharge. Remove CT (Output<400cc/24hr and No Air Leak) Remove PCEA POD3 Discharge Home on FLD until clinic Standardized Discharge Instructions (Smartphrase.dclung ) Postoperative Minimally Invasive Lobectomy IV Lasix 20mg x 1 (if previously on diuretic, Remove CT (Output<400cc/24hr and No Air Leak) PO Lasix 20mg BID (if previously on diuretic,. To be continued until discharge. Discharge Home
5 Standardized Discharge Instructions (Smartphrase.dclung ) Postoperative Minimally Invasive Wedge Resection/Lung Biopsy/Pleural Biopsy Foley removed in OR on arrival to ward Remove CT regardless volume of output IV Lasix 20mg x 1 (if previously on diuretic,. If patient stays longer than, start PO Lasix 20mg BID that will be continued until discharge. Discharge Home Standardized Discharge Instructions (Smartphrase.dclung )
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