1 of 5. Integrated Order Set Inpatient, Adult. Gynecological Surgery Enhanced Recovery Orders apply to patients 18 years and older.

Transcription

1 Orders apply to patients 18 years and older. All preprinted doses are based on normal renal and hepatic function and must be assessed for adjustment against the individual patient s renal and hepatic function and for interactions with other medications. ADMISSION/TRANSFER: Only Admit to: Full Admission. Observation. Only Level of Care: General Care. Progressive Care Unit (PCU)/Intermediate. ICU. INTRAVENOUS FLUIDS: Do not order fluid bolus(es) in increments larger than 250 ml. Discontinue operating room fluids upon arrival to floor. 0.45% NaCL with 20 meq KCL/L at 40 ml/hour until 0800 day after surgery then discontinue infusion. Peripheral IV saline lock upon arrival to floor. Peripheral lock IV when patient has 600 ml PO intake or at 0800 on day after surgery whichever comes first. MEDICATIONS: Analgesics: Oxycodone 5 10 mg orally every 4 hours as needed for pain. Give 5 mg for pain scores 4 through 6, use 10 mg for pain greater than or equal to 7. For patients that received intrathecal analgesia start 24 hours after intrathecal dose given. Acetaminophen (Tylenol) 1,000 mg orally 4 times a day (not to exceed 4 grams in 24 hours). Use for patients with no or mild hepatic disease. Acetaminophen (Tylenol) 1,000 mg orally twice daily (not to exceed 4 grams in 24 hours). Use for patients with moderate hepatic disease. Maximum Acetaminophen (Tylenol) should not exceed 4000 mg per 24 hours from all sources. 1 of 5

2 NSAIDs: Patient able to take NSAIDs. For patients greater than 80 kg and less than 65 years of age: Ibuprofen (Motrin) 800 mg orally every 6 hours. Start 6 hours after last Ketorolac dose administered. For patients kg and less than 65 years of age or greater than 80 kg and 65 years of age or older: Ibuprofen (Motrin) 600 mg orally every 6 hours. Start 6 hours after last Ketorolac dose administered. Must For patients kg and 65 years of age or older: Ibuprofen (Motrin) 400 mg orally every 6 hours. Start 6 hours after last Ketorolac dose administered. For patients less than 50 kg: Ibuprofen (Motrin) 200 mg orally every 6 hours. Start 6 hours after last Ketorolac dose administered. Patients unable to take NSAIDs: Tramadol (Ultram) 100 mg orally 4 times per day. Start at 0600 day after surgery. Use for patients less than 65 years of age and no history of renal impairment or hepatic disease. Tramadol (Ultram) 100 mg orally 2 times per day. Start at 0600 day after surgery. Use for patients 65 years of age or older or creatinine clearance (CrCL) less than 30 ml/minute or history of hepatic disease. Breakthrough Pain: If pain greater than 7 more than 1 hour after receiving Oxycodone: Hydromorphone (Dilaudid) 0.4 mg intravenously once if patient did not receive intrathecal medications and pain greater than 7 more than 1 hour after receiving Oxycodone. May repeat once after 20 minutes if first dose ineffective. Notify service if two doses of Hydromorphone given during hospitalization and patient continues to have breakthrough pain. 2 of 5

3 VTE Prophylaxis: In cases with high risk bleeding or in whom Heparin is contraindicated discuss with consultant prior to ordering. High Risk: Patients with prior VTE, familial thrombotic disorder, ovarian/primary peritoneal/tubal cancer, endometrial cancer, or cervical cancer. Heparin 5000 units subcutaneously 3 times a day. Start evening of surgery for patients weighing 50 kg or greater. Must Heparin 5000 units subcutaneously 2 times a day. Start evening of surgery for patients weighing less than 50 kg. Intermediate Risk: Patients without high risk factors undergoing laparotomy with BMI 30 or greater and 61 years of age or greater. Heparin 5000 units subcutaneously 3 times a day. Start evening of surgery for patients weighing 50 kg or greater. Heparin 5000 units subcutaneously 2 times per day. Start evening of surgery for patients weighing less than 50 kg. Low Risk: Minimally invasive benign laparoscopic and robotic surgery, vaginal hysterectomy, urogynecologic reconstructive procedures without laparotomy or radical vulvectomy with or without lymphadenectomy for vulvar cancer. Bowel Care: Polyethylene Glycol (Miralax) 17 grams orally once daily as needed for constipation. Magnesium hydroxide (Milk of Magnesia) 400 mg/5 ml suspension 30 ml orally every 4 hours as needed for constipation. Magnesium oxide 400 mg orally 2 times per day for for 3 days. Start evening of surgery. Hold for diarrhea or stool output greater than 1500 ml/day. Senna [Sennosides 8.6 mg] and Docusate Sodium 50 mg (Senokot S) two tablets PO at bedtime. Start evening of surgery. Note: If patient had surgical opening into the bowel lumen, do not order Senna. Appendectomy is not considered an opening into bowel lumen. Bladder Spasms: Gas Pains: Belladonna alkaloids-opium mg (B&O) suppository rectally every 6 hours as needed for bladder spasms. Do not use if patient had rectovaginal fistula repair, rectotomy, or colon resections. Simethicone (Gas-X, Mylicon) 160 mg orally every 4 hours as needed for gaseous distention. DIET: General. General diet with no raw vegetables. (Use if patient had bowel surgery.) Day of surgery: Provide 1 box of clear liquid oral nutritional supplement. Encourage oral intake of at least 800 ml of fluid, but no more than 2000 ml by midnight. Day after surgery until discharge: Provide 2 boxes of clear liquid oral nutritional supplement. Encourage daily oral intake of ml of fluids. 3 of 5

4 ACTIVITY: RESPIRATORY: Patient up in chair for all meals. Elevate head of bed 30 degrees or less. Day/evening of surgery, out of bed greater than 2 hours, including 1 or more walks and sitting in chair. Day after surgery and until discharge, out of bed greater than 8 hours including 4 or more walks and sitting in chair. Continue oxygen therapy via nasal cannula at a flow rate initiated in PACU. If oxygen saturation less than 90%, increase oxygen flow by 1 Lpm every 5 minutes until oxygen saturation reaches 90% or to a maximum of 4 Lpm. Starting the morning after surgery, wean oxygen to room air by decreasing oxygen flow to 1 Lpm every 15 minutes while maintaining an oxygen saturation level of at least 90%. Notify primary service if unable to wean patient off supplemental oxygen by 24 hours post-surgery. ADDITIONAL ORDERS: In and out catheterize for all urine specimens. Irrigate urinary catheter as needed. Record intake and output. Obtain weight every day. Drain Instructions: Use bulb suction with wound drain. Use low intermittent suction with wound drain. Use low continuous suction with wound drain. Strip wound drains every 8 hours. Urinary Catheter Instructions: Note: The Urinary Retention Protocol (MC ) will be initiated for patients with urinary retention problems after catheter has been removed. Continue urinary catheter. Remove urinary catheter if no vaginal packing in place: Now. Only Day of surgery. At 0800 day after surgery. At 0800 two days after surgery. Continue until (specify date and reason): Notify service regarding removal of vaginal packing before urinary catheter is removed. LABORATORY: CBC with differential in the morning day after surgery. Electrolyte panel in the morning day after surgery. 4 of 5

5 NOTIFY SERVICE: Heart rate greater than 120 or less than 50 beats/minute. Systolic blood pressure greater than 180 or less than 90 mmhg. Temperature greater than or equal to 38.5 degrees Celsius. Urinary output less than 80 ml/4 hour shift for the first 24 hours post-op. For pain rated greater than 4 and greater than comfort goal if patient did not receive intrathecal dose or if it is beyond 24 hours from intrathecal dose. Otherwise, notify Inpatient Pain Service. Patient complains of severe nausea or vomiting not relieved by antiemetic. Patient complains of upper abdominal distention. Notify Inpatient Pain Service for: Pain rated greater than 4 or patient comfort goal within first 24 hours of patient receiving intrathecal analgesia. This is a multi-page order set. Be sure patient information is included on each page and all pages are complete before signing. Prescriber Signature: Prescriber Pager: Prescriber Printed Name: Date: Time: mm/dd/yyyy hhmm (24 hour clock) File in Medical Record This order set has been developed to reflect the practice patterns of the clinicians who wrote it. It sets forth recommendations as to practice, not rigid rules Mayo Foundation for Medical Education and Research. All rights reserved. 5 of 5