r*po1004*r PO1004 Page 1 of 3 DATE HOUR PRE OP STANDING ORDERS To be ordered if results are not on the chart or have not already been ordered. Do not duplicate orders from other sources. 1. No narcotics or sedatives prior to anesthesia interview. 2. CBC without diff Previous study acceptable if less than1 month and no interval change. Age greater than 60 Diabetes Significant pre operative bleeding warfarin (COUMADIN) or heparin prescription or order Chemotherapy or radiation treatment within 6 months Unresolved cardiac, pulmonary, renal disease or malignancy Procedures associated with significant blood loss (see list) 3. H&H Previous study acceptable if less than 1 month and no interval change. Age less than 6 months 4. T&S Must be drawn within 72 H of need. Procedures associated with significant blood loss (see list) 5. Basic Metabolic Profile Previous study if less than 1 month and no interval change. Complete Metabolic Profile for all laparocsopic cholecystectomy Hypertension Diabetes Steriod Rx Unresolved cardiac, pulmonary, renal disease or malignancy Potassium level For repeat of high or low Potassium level on previous study. 6. Liver Function Tests Previous study acceptable if < 1 month and no interval change Hepatitis or other hepatic disease 7. PT, PTT, INR warfarin (COUMADIN), heparin, or low molecular weight heparin (i.e. enoxaparin (LOVENOX)) prescription or order Hepatitis or other hepatic disease Bleeding tendency 8. Pregnancy Test Females less than 1 year post menopause unless surgical (tubal ligation not a contraindication) 9. AM Glucose, if above 150, consult anesthesia. 10. PreOp Antibiotic Administer surgeon ordered antibiotic within 1 60 minutes prior to incision. (1 120 minutes for vancomycin or quinolones). As directed, in accordance, with the guidelines developed to comply with SCIP protocols. If the surgeon orders antibiotics per hospital protocol, refer to Table 2 for selection. 11. Beta Blockers Continue beta blocker peri operatively. If the patient did not receive their regular dose the night before or morning of surgery notify anesthesia and administer unless there are contraindications. Beta Blocker to be given in PreOp Contraindications History of adverse reaction/allergy to beta blocker 2nd or 3rd degree AV heart block Acute bronchospasm (caution with asthma or COPD) Congestive heart failure exacerbation Heart Rate less than 50 bpm Systolic blood pressure less than 100 mmhg Acute hemodynamic instability (See Table 1 for a list of beta blockers) 12. IV Orders Start IV with large gauge IV catheter. If patient already has an IV, assess site for patency and adequacy. Start Ringers Lactate 1000 ml at 30 ml per H for Routine / Regular Surgery. Start Normal Saline 500 ml at 30 ml per H for Renal Failure Patients (Scr > 2.5) or specific Physician order. Start Ringers Lactate 500 ml at 30 ml per H for pediatric patients. PH ANES 0711PH DATE PRINTED PHY00337
r*po1004*r PO1004 DATE HOUR PRE OP STANDING ORDERS Page 2 of 3 13. Medications lidocaine (XYLOCAINE) 1% 0.2 ml to 1 ml intradermal PRN for IV insertion scopolamine (TRANSDERM SCOP) 1.5 mg patch applied behind the ear in preop midazolam (VERSED) 2 mg IV x 1 may repeat once metoclopramide (REGLAN) 10 mg IV x 1 famotidine (PEPCID) 20 mg IV x 1 ondansetron (ZOFRAN) 4 mg IV x 1 hydromorphone (DILAUDID) 0.2 mg IV Q 5 to 10 minutes PRN pain or headache. Maximum dose 1mg. morphine 1 mg to 2 mg Q 5 to 10 minutes PRN pain or headache. Maximum dose 10 mg. 14. EKG Previous study acceptable if less than 3 months and no interval. Obesity Male greater than 50 Female age greater than 55 Chest pain, SOB, diminished exercise tolerance Diabetes, hypertension, peripheral vascular disease (especially carotid) Radiation treatment to chest 15. Chest X Ray Previous study acceptable if less than 6 months and no interval change. Chest pain, SOB, newly diminished exercise tolerance Bronchospasm, productive cough, fever or chills Expected prolonged intubation and ventilation 16. Apply forced air warming blanket to all open abdominal procedures and laparoscopic colorectal procedures. Offer to other types of cases and apply PRN. RN Signature Date Time ANESTHESIOLOGIST S SIGNATURE Date Time atenolol (TENORMIN) PO or IV esmolol (BREVIBLOC) metoprolol (LOPRESSOR) PO or IV metoprolol (TOPROL XL) Table 1 BETA BLOCKERS bisoprolol (ZEBETA) labetalol (TRANDATE) PO or IV nadolol (CORGARD) B A C K carvedilol (COREG) propranolol (INDERAL) nebivolol (BYSTOLIC) sotalol (BETAPACE) Table 2 ANTIBIOTIC PROTOCOL PROPHYLAXIS RECOMMENDATIONS BY SURGICAL PROCEDURE Patients < 18 years of age are excluded from recommendations 1. Head and Neck, involving incisions through oral or pharyngeal mucosa 2. Craniotomy 3. Spine 4. Cardio thoracic (see Table 3) 5. Intra abdominal except colorectal (see below) 6. Vascular 7. Orthopedic 8. Hernia with mesh 1. Appendectomy 2. Colorectal 3. Hysterectomy vaginal, abdominal, or radical 4. Vaginal Sling Procedure 5. Genitourinary 1. Penile prosthesis cefazolin (ANCEF) 1 g IVP **If allergic vancomycin 1 g IV in 250 ml NS over 2 hours or clindamycin (CLEOCIN) 600 mg IV over 60 min cefoxitin (MEFOXIN) 1 g IVP **If allergic metronidazole (FLAGYL) 500 mg IVPB over 30 min PLUS gentamicin 100 mg IVPB over 30 min gentamicin 100 mg IVPB over 30 minutes PLUS cefazolin (ANCEF) 1 g IVP **If allergic gentamicin 100 mg IVPB over 30 min PLUS vancomycin 1 g IV in 250 ml NS over 2 hours **ALLERGIC to cefazolin (ANCEF) or a life threatening reaction to ANY cephalosporin or penicillin PH ANES 0711PH DATE PRINTED PHY00337 ANES0003 PREOP002
DATE r*po1004*r PO1004 HOUR Prophylactic Antibiotic Dosing Protocol for Cardiac Surgery Table 3 Page 3 of 3 Antibiotic Selection 1. First Choice cefazolin (ANCEF) see dosing below 2. Second Choice vancomycin (VANCOCIN) see dosing below. a. Recommended for patients genuinely allergic to cefazolin (ANCEF) presumed or known Staphylococcal colonization high institutional presence of MRSA preop hospitalization more than 3 days transferred from another inpatient facillity or SNF already on antibiotics other than vancomycin prosthetic valve or vascular graft insertion b. If vancomycin is selected additional gram negative coverage with gentamicin is strongly recommended. Initial Dosing of Antibiotics 1. cefazolin (ANCEF) dosing for any serum creatinine or GFR give cefazolin within 60 minutes of first incision (preferably within 30 to 60 minutes of incision) actual weight is less than 80 kg give cefazolin 2 g IV x 1 dose preop weight greater than or equal to 80 kg 80 kg to 89 kg give cefazolin 2.5 g IV 90 kg to 109 kg give cefazolin 3 g IV 110 kg to 124 kg give cefazolin 3.5 g IV greater than 125 kg give cefazolin 4 g IV 2. vancomycin (VANCOCIN) dosing for any serum creatinine or GFR start infusion within 2 hours of first surgical incision with completion recommended before incision. actual weight less than 80 kg give vancomycin 1000 mg IV over 2 hours x 1 dose preop actual weight greater than or equal to 80 kg 80 kg to 99 kg give vancomycin 1250 mg IV over 2 hours greater than 100 kg give vancomycin 1500 mg IV over 2 hours 3. gentamicin dosing for any serum creatinine or GFR start infusion within 60 minutes of first surgical incision (preferably within 30 to 60 minutes of incision) For any weight give gentamicin 4 mg per kg IV over 60 minutes, up to a maximum dose of 500 mg Redosing of Antibiotic during Surgery 1. cefazolin (ANCEF) Redose within 3 to 4 hours of initial PreOp dose actual weight less than 80 kg give cefazolin 1 g actual weight greater than or equal to 80 kg 80 kg to 89 kg give cefazolin 1.5 g IV push greater than 90 kg give cefazolin 2 g IV push 2. vancomycin (VANCOCIN) Redose within 6 to 8 hours of initial PreOp dose actual weight less than 60 kg give vancomycin 500 mg IF over 1 hour actual weight 60 kg to 79 kg give vancomycin 750 mg IV over 2 hours actual weight greater than 80 kg give vancomycin 1000 mg IV over 2 hours 3. gentamicin No Redosing Recommended Developed March 2003 Revised July 2011 PH ANES 0711PH DATE PRINTED PHY00337pg3
Page 1 of 6 IV Date PreOp PreOp Antibiotic given per Anesthesia Yes See Anesthesia Record Ringers Lactate 1000 ml at 30 ml / H for Routine / Regular Drip 0.9% Sodium Chloride 500 ml at 30 ml / H for Renal Failure Patients/Mini Drip Ringers Lactate 500 ml at 30 ml / H for Children/Mini Drip lidocaine (XYLOCAINE) 1% 0.2 ml to 1 ml intradermal PRN for IV insertion scoplamine (TRANSDERM SCOP) 1.5 mg patch applied behind the ear in preop midazolam (VERSED) 2 mg IV x 1 may repeat once metoclopramide (REGLAN) 10 mg IV x 1 ondansetron (ZOFRAN) 4 mg IV x 1 famotidine (PEPCID) 20 mg IV x 1 hydromorphone (DILAUDID) 0.2 mg IV Q 5 to 10 minutes PRN pain or headache Maximum dose 1 mg morphine 1 mg to 2 mg Q 5 to 10 minutes PRN pain or headache Maximum dose 10 mg Dev7/08 Rev 7/11 (Page 1 of 2) Location/Size F R O N T 0701 1500 1501 2300 2301 0700 PHY00337PG4
Page 2 of 6 PreOp (Page 2 of 2) vancomycin 1 g IV over 2 hours x 1 in preop gentamicin 80 mg (premixed) IV over 60 minutes x 1 in preop ciprofloxacin (CIPRO) 400 mg IV over 2 hours x 1 in preop oxycodone extended release (OXYCONTIN) mg PO x 1 in preop warfarin (COUMADIN) mg PO x 1 in preop celecoxib (CELEBREX) 200 mg PO x 1 in preop 0701 1500 1501 2300 2301 0700 B A C K PHY00337PG5
Page 3 of 6 gelatin sponge (GELFOAM) fibrillar microfibrillar collagen (AVITENE) topical thrombin units IntraOp (Page 1 of 2) bacitracin 50,000 units units in ml NaCl betadine Ointment kanamycin (KANTREX) 1 g in 3 ml g in ml NaCl neomycin and polymyxin B (NEOSPORIN G.U) Irrigant ml in ml NaCl heparin units in ml NaCl in ml Plasmalyte in ml LR papavarin 30 mg per ml mg in ml plasmalyte in ml LR betadine solution betadine soap F R O N T 0701 1500 1501 2300 2301 0700 PHY00337PG6
Page 4 of 6 IntraOp (Page 2 of 2) lidocaine (XYLOCAINE) 2% topical jelly ml used lidocaine (XYLOCAINE) % with epinephrine without epi with ml Sodium Bicarb. Total Volume Injected bupivacaine (MARCAINE) % with epinephrine without epi with ml Sodium Bicarb. Total Volume Injected 0701 1500 1501 2300 2301 0700 B A C K PHY00337PG7
Page 5 of 6 PostOp morphine 2 mg to 5 mg IV PRN every 5 minutes up to a maximum of 20 mg if respiratory rate is greater than 8 hydromorphone (DILAUDID) 0.1 mg to 0.5 mg IV every 5 minutes PRN to a maximum of 2 mg if respiratory rate is greater than 8 ondansetron (ZOFRAN) 4 mg IV PRN nausea x 1 promethazine (PHENERGAN) 6.25 mg to 12.5 mg IV PRN nausea x 1 dexamethasone (DECADRON) 8 mg IV PRN nausea x 1 lidocaine 1% (plain) 0.2mL to 2mL intradermal PRN for IV insertion scopolamine (TRANSDERMSCOP) 1.5 mg patch applied in PreOp Instruct patient and/or nursing staff to remove the patch within 24 to 72 hours depending on patients nausea level. VTE prophylaxis enoxaparin (LOVENOX) 40 mg SUBQ daily enoxaparin (LOVENOX) 30 mg SUBQ Q 12 H heparin 5000 units SUBQ Q 8 H warfarin (COUMADIN) mg PO daily none (Page 1 of 2) F R O N T 0701 1500 1501 2300 2301 0700 PHY00337PG8
Page 6 of 6 PostOp (Page 2 of 2) cefoxitin (MEFOXIN) 1 g IV over 30 minutes cefazolin (ANCEF) 1 g IV over 30 minutes 0701 1500 1501 2300 2301 0700 B A C K PHY00337PG9