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University of Virginia Health System Clinical Pathway: Whipple Enhanced Recovery After () LOS: 4-5 days Date of Origin/Revision: June 29, 2016/September 6, 2017/January 31, 2018 : SAS : : : D1 D2 D 3/ Assessment Consults & Referrals - Identify pt as Whipple create episode in EPIC -Vital signs, baseline height/wt OSA, VTE, and diabetes -Assess for chronic narcotic use, tobacco and alcohol use -Verify home -Ambulatory RD consult if screen positive for -Cardiology if necessary - Link visit to episode -Stratify cardiac risk OSA aspiration tobacco use, diabetes -Identify patient with positive antibody screen -Review home -Cardiology if necessary -Phone screening and readiness assessment by nurses - Link SAS visit to episode -Vital signs -Med -Notify cardiology for pacemaker patients -Vital signs and monitoring per standards -VS (with MAP) Q2h x2 and then then Q4h -Document ETCO2 Q4 with VS -UOP Q4h -Continuous pulse oximetry with capnography x24hrs -Consult NP for lidocaine infusion -Inpatient Nutrition/RD -Consult -Notify LIP if O2 <92% or ETCO2 >60 or <10, MAP <60, T>38.5, UOP <120 cc over 4 s, or change in neuro status -VS Q4 -Daily s -Strict I/O -Assess for interdisciplinary consult needs: RT, SW, Nutrition, Chaplain, PT/OT -VS Q4 -Daily s -Strict I/O -Drain care/removal as -Finalize plan for community or home health needs with Case Manager

: SAS : : : D1 D2 D 3/ Tests & Orders Add l Actions Activities -Use Whipple General under the ordersets tab -EKG (M>50, F>60) -Labs: CBC, CA199, CEA, CMP, Pt/PTT, T&H (0 units) -HgB A1c if -XR Chest PA or AP and Lateral -Post case with Spinal indication in case request -Give CHG information for and Complete: -EKG (M>50, F>60) -Labs: CBC, CA199, CEA, CMP, Pt/PTT, T&H (0 units) -HgB A1c if -XR Chest PA or AP and Lateral CHG and CHG -Type and hold (0 units) if not done -Stat PT if patient is on Coumadin -Finger stick if -Confirm CHG shower the - Use designated orderset Focused with specific section for Whipple - Labs: CBC -Stand patient for in -Use Surg Whipple Post Op for postop orders -Labs: BG AC/HS -Abdominal binder -Walk on night of within 6hrs of arrival to unit -Head of bed at 30 degrees at all times Labs: CBC, -BG AC/HS -DC foley unless poor UOP least 6 s -Labs: BG AC/HS -DC foley if remaining least 6 s -No additional labs unless indicated -Use Whipple and Non- orderset for discharge orders least 6 s

: SAS : : : D1 D2 D 3/ Fluid management Medications -Place intraop phase of care orders for VTE and ABX: -Cefazolin 2g and 500mg -Heparin - 5000U SQ immediately after spinal -Instruct pt on oral fluids prior to clear fluids/gatorade up until 2hrs scheduled -Preop instructions for and anticoagulation patients oral fluids prior to clear fluids/gatorade up until 2hrs scheduled -Follow orders re: and anticoagulation -Carbohydrate drink 2 s (Gatorade 20 ounces (50 grams of carbohydrate)) -Insert PIV and saline lock -Hypertension meds with sip of water -SAS nurse to release preop to intraop phase of care meds for OR VTE and ABX -Fluid Goal-directed intravenous fluid guided by Pleth Variability Index -Ancef injection 2g 0-60 minutes incision; 500mg upon entry into the room -DVT prophylaxis with 5000U heparin immediately after spinal -Induction: Propofol, ketamine 0.5 mg/kg, magnesium 30 mg/ kg bolus -LR at 125 cc/hr -LR at 125 cc/hr -LR at 125 cc/hr -LR at 100 cc/hr -DC LR once patient is taking fluids -Postop Antibiotics: Cefazolin 1g IV Q8 x 2 doses and 500mg IV Q8 BID -Begin bowel Dulcolax 10mg rectal suppository PRN, Senna 2 tabs nightly, Milk of Magnesia 10mL Nightly PRN -VTE prophylaxis based on risk stratification -Restart additional home BID -Restart anticoagulation if appropriate or BID or BID

: SAS : : : D1 D2 D 3/ Management -Place SAS orders: -Celecoxib 200 mg (not given to Coronary artery disease) -Gabapentin 600 mg - 975mg -Chronic pain patients should continue home pain until -Chronic pain patients should continue home pain until -Multimodal analgesia: 1.Celecoxib 200 mg (not given to CAD/CKD) 2.Gabapentin 600 mg 3. 975mg -250mcg Intrathecal morphine prior to induction (no epidural) -No intraoperative opioids without attending approval -IV analgesia: lidocaine 40 ucg/kg/min, ketamine 10 ucg/kg/min -Infiltrate wound with 30cc Marcaine lidocaine infusion at 0.5-1mg/min -Ketamine 20mg/40mg IV bolus with midazolam 0.5mg/1.0mg IV PRN for pain as first line treatment (VAS 4-6/VAS 7-10) -Lidocaine infusion at 0.5-1mg/min - 650mg rectal Q6 s -Ketorolac 30mg IV ONCE followed by Ketorolac 15mg IV Q6 PRN analgesia to include: Dilaudid 0.2/0.4mg IV Q2 PRN (VAS 4-6/VAS 7-10) while pt unable to take lidocaine gtt (for open cases) scheduled nonnarcotic meds: - 650mg rectal Q6 s -Ketorolac 15mg IV Q6 -Discontinue Lidocaine gtt (for open cases) -Transition to scheduled nonnarcotic meds: - 975mg TID -Celebrex 100mg BID with meals -Oxycodone 5mg/10mg Q4 PRN (VAS 4-6/VAS 7-10) Use : 975mg Q8 for one week -Ibuprofen 600mg Q8 for one week -Oxycodone 5mg x30 Q4 PRN -Pepcid 20mg forever -Colace 100mg BID PRN Nutrition (if loss > 10% body or albumin <3.5) -No food after midnight -Clears until 2 s p/t -Clears until 2 s prior to -Carbohydrate drink for (20oz Gatorade) **No additional opioids, no PCA, no epidurals (without attending s approval) -N -N -Sips and chips -Clear liquids as tolerated -Transitional diet as tolerated (no bread) Education -Provide notebook expectations around and recovery diet/n for patients -Smoking cessation information expectations -Remind to bring notebook and (if used) CPAP machine to hospital -Ask patient if they have their notebook and review pathway -Postoperative activity and incentive spirometry and nutrition goals and progress and nutrition goals and progress and nutrition goals and progress

: SAS : : : D1 D2 D 3/ Planning Outcomes -Assess for discharge needs, social work needs and advanced directives -Schedule patient s postop visit for 2-4 weeks after Preop assessment initiated Understanding of procedure -Assess d/c needs including insurance needs Preopassessment complete demonstrates readiness for management is effective effective management is effective Hemodynamic Fluid (< 1 kg wt gain) effective OOB -Case Manager assesses for discharge needs Fluid Adequate pain control OOB > 6 s -DC planning finalized Tolerates clear liquid diet Fluid Ambulates Passing gas - meets criteria for discharge Tolerating diet Hydrating Ambulating Bowel functioning ALTERNATIVE PATHWAY OR PLAN OF CARE INITIATED FOR THIS PATIENT ON: DATE INITIALS Guidelines are general and cannot take into account all of the circumstances of a particular patient. Judgment regarding the propriety of using any specific procedure or guideline with a particular patient remains with that patient's physician, nurse, or other health care professional, taking into account the individual circumstances presented by the patient.

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