DAYTON CHILDREN S HOSPITAL CLINICAL PRACTICE GUIDELINES

Transcription

1 DATO CHILDRE S HOSPITAL CLIICAL PRACTICE GUIDELIES DISCLAIMER: This Clinical Practice Guideline (CPG) generally describes a recommended course of treatment for patients with the identified health needs. This CPG is not presented and should not be used as a substitute for the advice of a licensed independent practitioner, as individual patients may require different treatments from those specified, and guidelines cannot address the unique needs of each patient. Dayton Children s shall not be liable for direct, indirect, special, incidental or consequential damages related to the use of this CPG. Dayton Children s Hospital One Children s Plaza Dayton, Ohio

2 Pain Pathway Flowchart For Spinal Fusion Patient (Idiopathic and M patients) Idiopathic- Congenital, Kyphosis euromuscular,-syndromic, Other Created 1/23/2014 Revised 2/27/2014 3/13/2014; 3/27; 5/21, 6/30; 7/24 Intrathecal Medication Pathway Idiopathic pt. receives Celebrex (200mg) preop Gabapentin 15mg/kg (900mg max) Consider preop meds for M patients as well Epidural Medication Pathway Preop intrathecal injection of Duramorph given by anesthesia/ortho Case proceeds. arcotic infusion per IV (analgesia & anesthesia) IV acetaminophen 15mg/kg not to exceed 1GM given per anesthesia Hardware placement Pt. goes to PACU. PCA started 0.1mg Dilaudid q 10 mins demand dose, 0.1mg/hr basal for 24 hours (2.4 mg lockout for 4 hours) All pts. go to OR for induction and IV placement Is patient intubated? To PICU if intubated; Intensivists manage pain Case proceeds. arcotic infusion per IV (analgesia & anesthesia) IV acetaminophen 15mg/kg not to exceed 1GM given per anesthesia Hardware placement & epidural cath placed prior to skin closure Patient goes to PACU Epidural infusion started; supplemental PCA started if narcotics not in epidural Pt. transferred to PICU Pt. transferred to PICU Continue PCA (administration by R, patient or family as appropriate) 1)-Toradol.5mg/kg for 72 hrs. 2)-IV Acetaminophen 15mg/kg q6hrs. for 72 hrs. (max 1 GM) convert to PO as tolerated; 3)-Once tolerating PO begin oxycodone 5mg tab every 8 hrs. scheduled and Oxycodone 5mg q4h prn for breakthrough pain 1)-Toradol.5mg/kg for 72 hrs. 2)-IV Acetaminophen 15mg/kg q6hrs. for 72 hrs. (max 1 GM) convert to PO as tolerated; 3)-Once tolerating PO begin oxycodone 5mg tab every 8 hrs. scheduled and Oxycodone 5mg q4h prn for breakthrough pain Idiopathic patient transferred to 3E after 24 hours; M pt may remain in PICU or IMCU With PCA plus prn po meds; child life consult Idiopathic patient transferred to 3E after 24 hours; M pt may remain in PICU or IMCU With PCA and/or epidural plus prn po meds; child life consult Wean PCA starting POD #1; when pain controlled on PO meds; D/C home w/ physiciandetermined analgesia A Page 2 of 18

3 A Epidural removed prior to pt OOB (approx. 48 hrs after surgery); once epidural removed anesthesia signs off IV doses PR with PO meds Does it need to be a PCA? Does patient need to continue IV meds? Continue PCA infusion D/C IV Pain meds/pca when pt. tolerating PO meds. D/C home with physiciandetermined analgesia Page 3 of 18

4 Spinal Deformity Pre-Hospital Flowchart Idiopathic- Congenital, Kyphosis euromuscular-syndromic, Other Decision to do surgery Schedule F/U appt. and give website information. Created August 1, 2013 Revised October 2, 2013 Revised January 9, 2013 January 14, 2014, 2/13/2014, 2/18/14; 5/21; 6/30; 7/24 Instruct family to begin taking a MVI OTC Further consults as needed Pt. seen by consulting MD; report sent to surgeon Ortho surg scheduler to track consults from initiation to completion Consults reviewed by anesthesia & surgeon Is there a secondary diagnosis? Second Visit with Ortho Surgeon: *Informational and Q & A with family *Spinal surgery scheduling form; spinal surgery scheduling worksheet completed *Ortho surgery scheduler calls pt./family to tell them about packet of info. and mail information to patient/family; fill out nutrition assessment worksheet * Give pt scoliosis binder * Set up Preop and Post op appts.. 1.Ortho office staff complete preop orders (faxed to Pre- Surg. Clinic) 2. Surgery scheduling form completed/faxed to Pre- Surgery Clinic 3. utritional assessment done by surgery scheduler; faxed to central scheduling & PICU RD. Does the patient need a brace? Family instructed to contact Hanger Clinic (ORPRO ) Will case be delaye DCH surgery calls family to schedule anesthesia consult; education with the nurse Anesthesia must communicate with surgeon directly Ortho surgery scheduler reschedules surgery after clearance obtained from appropriate consultant A Page 4 of 18

5 A 1-2 weeks prior to surgery, DCH surgery dept. calls to schedule a preop visit 48 hours before surgery 48 hour surgery preop appt at DCH: *Education done by surgery R *Anesthesia consult - Orders entered *Preop testing *Discuss surgery time-given instruction sheet * H&P done by PP - Orders entered Page 5 of 18

6 A 3-4 weeks prior to surgery patient has preop appt with Ortho: *Final details of surgery *Q & A with family *Discusses risk and complications days prior to surgery preop appt at DCH: *Education *Anesthesia consult (anesthesia will discuss plan to admit M patients prior to day of surgery) *Preop testing *Discuss surgery time-given instruction sheet * preop Chlorahexidene shower-24 hrs. prior OR scheduler notifies the neuromonitoring rep. 48 hours prior. Page 6 of 18

7 Intra-Op Flowchart for Spinal Deformity Patient Idiopathic- Congenital, Kyphosis euromuscular- Syndromic, Other Revised 9/19/2013 4/22/2014; 5/21; 6/30; 7/24 Patient arrives in perioperative area R: *reviews admitting form *releases orders *calls bloodbank *obtains meds. P updates H&P Surgeon sees pt., signs consent Anesthesia sees pt.; signs consent Circulator checks for Evokes/equipment available. SSI HAC is followed Traffic in OR to be limited/signs in OR Anesthesiologist * Reviews orders * Answers further questions Does the pt. need a Central Line? Anesthesia plans central line; CLABSI-HAC is followed To OR: *Anesthesia monitors placed *Induction & intubation Bundle procedure CAUTI Additional IV started; euro-monitor leads placed *art line started *foley inserted * central line placed if needed Antibiotics started Within 1 hour before incision A --Tobramycin, Ancef (routine) prophylaxis --Tobramycin, Vancomycin (if personal hx of MRSA) --Cefazolin (Ancef) mg IV (33mg/kg) max dose 2000mg; repeat intra-operatively in 3.5-4hrs. --Tobramycin mg IV (2.5mg/kg) repeat intra-operatively in 6 hrs. --Vancomycin mg IV (15mg/kg) max dose 2000mg; repeat intraoperatively in 6hrs. Page 7 of 18

8 A Prep: surgeon specific: betadine, chloroprep and betadine gel (SSI bundle) Positioned prone; Arms in proper position; Pad Bony Prominences; duoderm to iliac crest/other bony prominences as needed Pressure Ulcer Prevention HAC Prep & Drape Arm position critical; o more than 90 degrees of abduction with padding support under shoulders. Contracted child: extra arm boards & special care due to placing in hip sling (for hips) Surgical Time Out Surgery started Deformity straightened Family updated regularly Vanco powder 1 GM in bnne graft Epidural Cath placed Epidural needed? Is post-op brace necessary? Make mold Post op analgesia orders written. To PICU- usually intubated; hand-off communication report with entire team (intensivists, anesthesia, PICU and OR nurses, RT) Is patient going to PACU or PICU? To PACU Obtain order Is post-op X-ray ordered? Are postop labs indicated? o labs obtained B Page 8 of 18

9 B Complete ordered x-ray stat Obtain labs specific to patient Is patient s neuro exam appropriate? otify surgeon & anesthesiology immediately Recovery continued until transfer criteria met per anesthesia Patient to PICU after transfer sign-out by anesthesiologist Anesthesia to intensivist report & PACU to PICU bedside hand-off report Page 9 of 18

10 Spinal Deformity Post Op Flowchart (for Extubated Idiopathic Patient in the PICU) Idiopathic-Congenital, kyphosis Created 10/17/2013; 5/21; 6/30; 7/24 HOB flat for 6 hours, then log roll q2 hrs. Restrictions per surgeon (Dr. Lehner) HOB at 30 degrees; Activity ad lib. If not moving on own, turn q2 hrs. Restrictions per surgeon (Dr. Wiemann/Albert) euro checks q1hr and vital signs til AM; if stable then q2hrs.; PU Prevention HAC Diet Clear Liquids with supplements and advance as tolerated; monitor for nausea, give antiemetics as ordered Respiratory: Incentive Spirometer q1hr. while awake SCD s for DVT prophylaxis, follow DVT HAC Monitor arterial line and foley cath, CAUTI HAC Antibiotics while drain or epidural in, or 3 doses post-op (whichever is longer), monitor dressing w/ each pt. turn, notify ortho if needed Do they have a drain? B Tobramycin, Ancef (routine) prophylaxis --Tobramycin, Vancomycin (if personal hx of MRSA) --Cefazolin (Ancef) mg IV (33mg/kg) max dose 2000mg; repeat intra-operatively in 3.5-4hrs. --Tobramycin mg IV (2.5mg/kg) repeat intraoperatively in 6 hrs. A Page 10 of 18

11 Spinal Deformity Post Op Flowchart (for Extubated Idiopathic Patient in the PICU) Idiopathic-Congenital, kyphosis Created 10/17/2013; 5/21; 6/30; 7/24 A Monitor output with assessments & empty QS or prn otify surgeon for 400cc or more per shift If stable, pull A-line and transfer to unit (3E) POD #1 B Page 11 of 18

12 Spinal Deformity Post Op Flowchart (for euromuscular Patient in the PICU) euromuscular- Syndromic, Other Revised 5/13/14; 6/12; 6/30 Hand-off communication report given to ICU team. Initial assessment done; Consult to dietician HOB 30 degrees as tol (consider reverse Trendelenburg), Assess contractures if present and pad boney prominences. Log roll q 2h as tol, Pressure Ulcer Prevention HAC euro checks if possible and vital signs q1hr; if stable in AM then q2hrs. Obtain post-op labs Is Pt Intubated? euro checks if possible Vital signs q1hr Obtain post-op labs. VAP HAC Respiratory: CPAP / nebs / o2 per protocol, pulm toilet if necess., IS Extubate per Intensivist Will intubation be prolonged POD #1: Diet tube feed vs. PO. Clear Liquids w/supplements; advance as tolerated. Respiratory: Vent management per intensivist/rt. CXR and CBG qam while intubated Extubation when appropriate per Intensivists CLABSi HAC Does the pt. have a central line Obtain enteral access if pt does not already have and advance diet as tol A Page 12 of 18

13 A SCD s for DVT prophylaxis, DVT HAC Monitor arterial line and foley cath, CAUTI HAC Antibiotics while drain or epidural in, or 3 doses post-op Monitor dressing with pt. turn, notify ortho if needed. Barrier prevention to protect from stool and urine. Does pt have a drain Monitor output with assessments & empty QS or prn otify surgeon for 400cc or more per shift OOB to chair after brace arrives (if required) & epidural out (if present) If stable, pull A-line and transfer to 3E or IMCU Page 13 of 18

14 Spinal Deformity Post Op Process Idiopathic Patient (patient who is ambulatory, verbal and on regular diet) Idiopathic- Congenital, Kyphosis 3E B Created 10/24/2013 Revised: 10/25 & 11/7; 5/21; 6/30 Initial Assessment done: VS, airway; O2 per protocol; Pressure Ulcer HAC, neurovasc. Checks, foley, CAUTI HAC initial bowel protocol, nutritional screen; reg. diet w/ supplements as needed (Co-managed by Hospitalists) Which Surgeon? Dr. Wiemann/Albert: OOB on day 1 with nursing Activity ad lib, log roll Q2 hrs. if not ambulatory. -assess dressing QS & prn - dressing remains in place for LOS; change dressing only as needed -drain in place until less than 60cc/shift or post op Day #3 Dr. Lehner: HOB at 30 degrees; log roll Q2 hrs. til brace arrives -assess dressing QS & prn; change as needed PT consult PT evaluates & treats patient A Page 14 of 18

15 A Is patient mobilizing (effectively) Continue with PT Cont. with assistive ambulating w/ nursing Does the patient need assistive devices? Order assistive devices for home; continue with PT To medical imaging for post-op scoliosis film-standing AP/ lateral film Is pt. tolerating oral intake & passing flatus? Initiate aggressive bowel protocol Discharge criteria met; D/C to home Page 15 of 18

16 Spinal Deformity Post Op Process euromuscular Patient euromuscular- Syndromic, Other IMCU/3E B Created 11/7/13 Revised: 5/21; 6/12; 6/30 IMCU Pulmonary consult; RT to assess for respiratory needs i.e. cough assist, IS, percussion; CPAP/nebs/O2 per RT/LIP; pulm. toilet prn Initial Assessment done: VS, airway; O2 per protocol; Pressure Ulcer Prevention HAC, neurovasc. checks, foley CAUTI HAC, initial bowel protocol Hospitalists co-management consult Which Surgeon? Bed position/padding to accommodate for contractures; Dr. Wiemann: Activity ad lib, log roll Q2 hrs. if not ambulatory. OOB with assist. -assess dressing QS & prn - dressing remains in place for LOS; change dressing only as needed -drain in place until less than 60cc/shift or post op Day #3 Drs. Lehner/Albert: HOB at 30 degrees; log roll Q2 hrs. til brace arrives -assess dressing QS & prn; change as needed PT evaluates/treats patient A Page 16 of 18

17 A Does the patient need assistive devices/d ME Order assistive devices for home; continue with PT To medical imaging for post-op scoliosis film via bed/wc if indicated Is pt. tolerating enteral intake & passing flatus? Initiate aggressive bowel protocol Discharge criteria met; D/C to home w/ appropriate education Page 17 of 18

18 References Awad, S., Stephenson, M. C., Placidi, E., Marciani, L., Constatin-Tedosiu, D., Gowland..., P. A., et al. (2010). The effects of fasting and re-feeding with a metabolic preconditioning drink on substrate reserves and mononuclear cell mitochondrial function. Clinical utrition, 29, Low-Risk Spinal Fusion Clinical Care Guideline: Age (2012). The Children s Hospital Denver, Colorado Rusy, L. M., Hainsworth, K. R., elson, T. J., Czarnecki, M. L., Tassone, C., Thometz..., J. G., et al. (2010). Gabapentin Use in Pediatric Spinal Fusion Patients. Anesthesia & Analgesia, 110, Thoracolumbar Spine Surgery: A guide to Preop and Postop Patient Care. Agency for Healthcare Research and Quality (2012). Waters, M. and Coad, J. (2009). Preparation of children for spinal surgery: An exploratory study, Pediatric ursing, 18(10). Wu, M., Wong, C., iu, C., Tsai, T., Chen, L., & Chen, W. (2011). A comparison of three types of postoperative pain control after posterior lumbar spinal surgery. Spine, 36, Vitale, M. et al (2013) Building Consensus: Development of a Best Practice Guideline for Building Consensus: Development of a Best Practice Guideline (BPG) for Surgical Site Infection (SSI) Prevention in High-Risk Pediatric Spine Surgery, J Pediatric Orthop, 33 (5), Page 18 of 18