Baptist Health Lexington. ERAS Protocols

Transcription

1 Baptist Health Lexington ERAS Protocols

2 Enhanced Recovery After Surgery

3 BHLex Colorectal ERAS Protocol Preoperative Patient/Family Education: PAT and office, ERAS brochure & educational flyer/checklist Prehabilitation Carbohydrate loading and elimination of NPO - Bowel prep per physician - clear liquids day before surgery - 20 oz Gatorade or G2 (if diabetic), completed 3 hours before surgery start time Multimodal Analgesia Antibiotics - Acetaminophen 1000mg oral dose x 1 - Pregabalin 75 mg oral dose x 1 - Meloxicam 15 mg oral dose x 1 - Scopolamine Patch 1.5 mg- DO NOT apply if patient has history of glaucoma or >65 years old

4 BHLex Colorectal ERAS Protocol Intraoperative General Anesthesia Propofol Infusion 25mcgkg/min Bilateral TAP Blocks after induction Avoid/Minimize Opioids and Benzodiazepines Dexamethasone 4-8mg Zofran 4mg Ketamine 0.25mg/kg (for patients with chronic opioid use only) Minimize Excess Fluid Administration

5 BHLex Colorectal ERAS Protocol Postoperative Nutrition - Clear liquids 2 hours after surgery, advance as tolerated Analgesia - Acetaminophen 1000 mg PO Q6H x 2 days - Mobic 15 mg daily x 48 hrs - Opioids PRN Mobilization - Out of bed on arrival to floor (patients are instructed to walk from stretcher to bed) - Out of bed evening of surgery- ambulate or up in the chair - Post op Day 1 till discharge- out of bed and walking 5 times/day

6 BHLex Colorectal ERAS Protocol Other key components: - Continued teaching- empowering our patients - decrease drains: foleys, NG s, JP s,etc - Incentive Spirometry - Chew gum 30 minutes TID NOT given to ileostomy patients

7 BHLex Orthopedics- Hip/Knee ERAS Protocol Preoperative Patient/Family Education: PAT and office- ERAS brochure, joint replacement booklet, flyer/checklist, attendance at joint class Prehabilitation Carbohydrate loading and elimination of NPO - may eat until midnight prior to surgery - 20 oz Gatorade or G2 (if diabetic), completed 3 hours before surgery start time Multimodal Analgesia - Acetaminophen 1000mg oral dose x 1 - Pregabalin 75 mg oral dose x 1 - Meloxicam 15 mg oral dose x 1 - Scopolamine Patch 1.5 mg- DO NOT apply if patient has history of glaucoma or age > 65 years old Antibiotics

8 BHLex Orthopedics- Hip/Knee ERAS Protocol Intraoperative Spinal Anesthetic-Marcaine 10-12mg, No Opioids Light Propofol Sedation Failed Memory Screening: No Sedation Music Therapy Avoid/Minimize Opioids and Benzodiazepines Dexamethasone 4-8mg Zofran 4mg TKA: Posterior Capsule Injection by surgeon or IPACK block by Acute Pain Service Tranexamic Acid 10mg/kg X 2 doses Minimize Excess Fluid Administration

9 BHLex Orthopedics-Knee ERAS Protocol Adductor Canal Catheter Placement Needle must be below the sartorius fascia Advance needle into the adductor canal (9 O clock to the artery) Marcaine 0.25% 20ml Place catheter over the artery but below fascia of sartorius muscle Visualize spread of local via catheter directly over and lateral to artery 9

10 BHLex Orthopedics-Knee ERAS Protocol Adductor Canal Catheter Infusion Parameters Ropivacaine 0.2% Initial infusion started at 12ml/hr For VAS>5 increase pump to 16ml/hr for 2 hours slow bolus Return to original rate after 2 hour slow bolus If patient experiences excessive quad weakness or inability to do a straight leg raise, place knee immobilizer, turn pump down to 8ml/hr, and call Acute Pain Service 10

11 BHLex Orthopedics-Knee ERAS Protocol Postoperative Nutrition - Clear liquids and advance diet as tolerated the day of surgery Analgesia - Acetaminophen 650mg PO Q6hours Mobilization - Meloxicam 15mg PO Daily - Adductor Canal Catheter (placed in PACU) Infusion at ml/hr with bolus available - Oxycodone 5-10mg PO Q4H PRN - Hydromorphone mg IV Q2H PRN - Daily Rounding by the Acute Pain Service - Acute Pain Service available by phone for questions by the orthopedic floor nurses, physical therapy and surgeon - Ambulate with Physical Therapy on day of surgery - Out of bed the evening of surgery and walking unless otherwise instructed - Out of bed and walking 3-5 times daily unless otherwise instructed - sitting up in chair for all meals

12 BHLex Orthopedics-Knee ERAS Protocol Beyond Discharge Protocol Patient sent home/rehab with disposable infusion pump and adductor canal catheter Provide educational demonstration and printed educational materials related to care of Adductor Canal Catheter at home Allow patients to contact on call provider 24/7 (On-Call Central) Call patients daily at home while Adductor Canal Catheter is in place Adductor Canal Catheter removed by patient at home when infusion is complete 12

13 BHLex Orthopedics-Hip ERAS Protocol Postoperative Nutrition - Clear liquids and advance diet as tolerated the day of surgery Analgesia - Acetaminophen 650mg PO Q6hours Mobilization - Meloxicam 15mg PO Daily - Oxycodone 5-10mg PO Q4H PRN - Hydromorphone mg IV Q2H PRN - Acute Pain Service available by phone for questions by the orthopedic floor nurses, physical therapy and surgeon - Ambulate with Physical Therapy on day of surgery - Out of bed the evening of surgery and walking unless otherwise instructed - Out of bed and walking 3-5 times daily unless otherwise instructed - sitting up in chair for all meals

14 BHLex Orthopedics-Hip/Knee ERAS Protocol Other key components: Continued teaching- empowering our patients Decreased drains: foley catheters/ lines Incentive Spirometry

15 BHLex Orthopedics-Shoulder ERAS Protocol Preoperative Patient/Family Education: PAT and office- ERAS brochure, joint replacement booklet, flyer/checklist Prehabilitation Carbohydrate loading and elimination of NPO - may eat until midnight prior to surgery - 20 oz Gatorade or G2 (if diabetic), completed 3 hours before surgery start time Mulitmodal Analgesia Antibiotics - Acetaminophen 1000mg oral dose x 1 - Pregabalin 75 mg oral dose x 1 - Meloxicam 15 mg oral dose x 1 - Scopolamine Patch 1.5 mg- DO NOT apply if patient has history of glaucoma or age >65 years old

16 BHLex Orthopedics-Shoulder ERAS Protocol Interscalene Catheter Placement Needle placed posterior/lateral to the C5,C6 nerve roots Marcaine 0.25% 15ml Place catheter posterior/lateral to the brachial plexus Visualize spread of local via catheter directly posterior/lateral to the plexus 16

17 BHLex Orthopedics-Shoulder ERAS Protocol Intraoperative Protocol General Anesthetic Propofol Infusion 25mcg/kg/min Avoid/Minimize Opioids and Benzodiazepines Dexamethasone 4-8mg Zofran 4mg Minimize Excess Fluid Administration Interscalene Catheter bolus at end of surgery with 5ml of Marcaine 0.25% 17

18 BHLex Orthopedics-Shoulder ERAS Protocol Interscalene Catheter Infusion Parameters Ropivacaine 0.2% Initial infusion started at 6ml/hr For VAS>5 increase pump to 10ml/hr for 2 hours slow bolus Return to original rate after 2 hour slow bolus If patient experiences shortness of breath and/or difficulty swallowing, turn pump OFF and call Acute Pain Service 18

19 BHLex Orthopedics-Shoulder ERAS Protocol Postoperative Nutrition - Clear liquids and advance as tolerated the day of surgery Analgesia -Daily Rounding by the Acute Pain Service -Acute Pain Service available by phone for questions by the orthopedic floor nurses, physical therapy and surgeon -Interscalene Catheter infusion at 6ml/hr. For VAS > 5 increase infusion to 10ml/hr for 2 hours then return to original rate, may be repeated once every 12 hours. -Acetaminophen 650mg PO Q6hours - Meloxicam 15mg PO Daily -Oxycodone 5-10mg PO Q4H PRN - Hydromorphone mg IV Q2H PRN Mobilization -Ambulate with Physical Therapy on day of surgery - Out of bed and walking 3-5 times daily unless otherwise instructed - sitting up in chair for all meals 19

20 BHLex Breast Cancer-Mastectomy ERAS Protocol Preoperative Patient/Family Education: PAT and office, ERAS brochure & educational flyer/checklist Prehabilitation Multimodal Analgesia - Acetaminophen 1000mg oral dose x 1 - Pregabalin 75 mg oral dose x 1 - Celebrex 200 mg oral - Scopolamine Patch 1.5 mg- DO NOT apply if patient has history of glaucoma or >65 years old Antibiotics

21 BHLex Breast Cancer-Mastectomy ERAS Protocol Intraoperative General Anesthesia TIVA (Propofol) PECS Blocks after induction Avoid/Minimize Opioids Dexamethasone 4-8mg Zofran 4mg Minimize Excess Fluid Administration 21

22 BHLex Breast Cancer-Mastectomy ERAS Protocol Postoperative Nutrition - Clear liquid diet, advance as tolerated the day of surgery Analgesia - Acetaminophen 1000mg PO Q6hours - Celebrex 200mg PO BID - Soma or Flexeril PO Q8H PRN (Pectoral Muscle Spasm) - Tramadol 50mg PO Q6H PRN VAS Oxycodone 5-10mg PO Q4H PRN VAS >7 - Hydromorphone mg IV Q2H PRN VAS >7 Mobilization - Out of bed and walking 3 times/day - Sitting up in chair for all meals 22

23 BHLex Breast Cancer-Mastectomy ERAS Protocol Beyond Discharge Protocol Acetaminophen 1000 mg PO Q6 hours x 48 hours Celebrex 200 mg PO BID x 48 hours Ibuprofen 600 mg PO BID x 48 hours (if insurance will not cover Celebrex) Soma or Flexeril PO Q8H PRN muscle spasm Oxycodone 5-10 mg PO Q4H PRN VAS >7 23

24 Questions? John M. Edwards III, MS, CRNA Central Kentucky Anesthesia Baptist Health Lexington Lindsay Bowles, RN, BSN ERAS Nurse Coordinator Baptist Health Lexington 24