Medications simplified and standardized to improve safety and effectiveness in the management of pain, itching, nausea/vomiting. Management: o The Anesthesiologist will continue to manage pain in the PACU. o Surgeon manages pain in the post-operative unit for all patients., Nausea/Vomiting, Respiratory Depression: Hypotension: ESO Orders for the management of hypotension now available in the Anesthesia PACU Phase Orders Hypertension: o OB/GYN notification of obstetric-related hypertension now available o Hypertensive management of the non-ob patient identified Phase/Order Management: To accommodate these safety measures, management of phases will now be different. Significant Changes are highlighted below: WHS POSTOPERATIVE ANESTHESIA ORDERS PACU PHASE IV Solutions Lactated Ringers at 125ml/hr for GYN patients Oxytocin 20 units in 1000ml LR at 175ml/hr for OB patients Management Mild Scale 1-3 Contraindications NSAIDs Acetaminophen 1000 mg PO or IVPB once (IV only if not tolerating PO) Ketorolac (Toradol) 30 mg once Moderate Scale 4-6 Oxycodone 5 mg, 1 tab, PO, once HYDROmorphone (Dilaudid) 0.3 mg, IV push, PRN Q10MIN, if not tolerating PO Morphine 2 mg, IV push, PRN Q10MIN Sever Scale 7-10 HYDROmorphone (Dilaudid) 0.5 mg, IV push, PRN Q10MIN Morphine 4 mg, IV push, Q10MIN FentaNYL 50 mcg, IV push, Q10MIN Promethazine (Phenergan) 6.25 mg, IV push, Q 30MIN Ondansetron (Zofran) 4 mg, IV push, once Scopolamine patch 1 patch, TD, once Shivering Meperidine (Demerol) 12.5 mg, syringe, IV push, Q15MIN, PRN shivering, May repeat x 1 Nalbuphine (Nubain) 5 mg, IV push, Q 20 MIN, PRN itching, May repeat x 1 dose DiphenhydrAMINE (Benadryl) 12.5 mg, IV push, Q15MIN, PRN itching, May repeat x 1 dose Naloxone (Narcan) 0.1 mg, IV push, once Respiratory Hypertension (for non-ob patient) Naloxone (Narcan) 0.1 mg, IV push, Q2MIN, PRN reverse narcotic effect Bronchodilator Protocol, once, STAT select if RT to come to bedside STAT Albuterol (Proventil) 0.083% inh soln 2.5 mg, inh soln, NEB, Q5MIN, PRN wheezing Ipratropium (Atrovent) 0.02% inh soln 0.5 mg, inh soln, inhalation, Q5MIN, PRN wheezing Labetalol (Trandate) 5 mg, IV push, Q5MIN, PRN blood pressure maintenance. Non-OB patients only For repeated SBP > 180 or DBP > 105. Hold for HR < 60. Total max 20 mg HydrALAZINE (Apresoline) 5 mg, IV push, Q15MIN, PRN blood pressure maintenance. Non-OB patients only For repeated SBP greater than 180. Hold for HR > 100. Max total dose 20 mg
Hypertension OB Patient Hypotension Agitation Labs Notifying the Provider Notify Surgeon for OB patients with either SBP 140 or DBP 90 on 2 occasions at least 4 hours apart, or an isolated SBP 160 or an isolated DBP 100 Lactated Ringers, 250 ml, IV Bolus, PRN Hypotension, For SBP less than 90 and symptomatic. 1ST Line. May Repeat x 1 Ephedrine 5 mg, IVP, once, PRN Hypotension, For SBP less than 90 and symptomatic. 2ND Line. For post spinal and epidural patients only. If ineffective, repeat dose of 10 mg IVP x 1 Ephedrine 10 mg, IVP, once, PRN Hypotension, For SBP less than 90 and symptomatic. For post spinal and epidural patients only if no clinical improvement after 5 mg dose Midazolam (Versed) 0.5 mg, vial, IV push, Q5MIN, max 2mg Blood Sugar Monitoring POC once, in PACU if diabetic CBC with Platelets Blood, Stat collect Basic Metabolic Panel Blood, Stat collect Hemoglobin and Hematocrit Blood, Stat collect Blood Gas Notification STAT Notify Anesthesia: SBP < 90 general anesthesia, <80 spinal anesthesia, SBP > 160 or DBP >100, HR < 50 or >120 or more than 50% baseline, RR < 10 or > 30, SpO2 < 95%, If vital signs discharge criteria not met at 3 hours in PACU, Persistent Nausea and Vomiting Notify Surgeon: SBP > 160 or DBP >100, Temp > 38 o C (100.4 F), Urine output < 30 in 1 hour, If discharge criteria not met at time of discharge but anesthesia has agreed to patient transfer Respiratory Extubate when patient is awake and breathing spontaneously, sustains head lift > 5 secs, maintains O2 sat > 95% and follows commands. Keep patient intubated until otherwise ordered To maintain oxygen saturation goal > 95%, use nasal prongs at 2-5 liter/min or simple mask at 8-10 liter/min. Capnography/End Tidal CO2 continuous while in PACU WHS POSTOPERATIVE ANESTHESIA ORDERS POST DURAMORPH PHASE (For Duramorph patients only, initiated by the post-op RN once patient arrives to Post-Op Unit) Vital Signs Respiratory Orders for monitoring vital signs, pulse Ox, Oxygen supplementation, & Patient Care (including when to call for Rapid Response Team) Promethazine (Phenergan) 6.25 mg, IV push, Q 4 H PRN Ondansetron (Zofran) 4 mg, IV push, Q 4 H, PRN Notify Provider For persistent N/V call Anesthesiologist ***NOTE***Patient may have a Scopolamine (TransDermScop) patch behind the ear, placed in PACU Diphenhydramine (Benadryl) 25 mg PO (or IV if not tolerating PO), Q 6 H PRN Nalbuphine (Nubain) 2.5 mg, IV Push x 1; If ineffective, notify Anesthesiologist Naloxone (Narcan) 0.1 mg, IV push, Q2MIN, PRN reverse narcotic effect, also PRN respiratory rate < 10/min, unable to respond and/or inadequate ventilator effort call Anesthesiologist and Surgeon immediately and Rapid Response Team if Anesthesia unable to come to bedside.
WHS POSTPARTUM CESAREAN SECTION: POSTOPERATIVE ORDERS C/S PHASE Management: SURGEON MANAGES PAIN IN THE POST-OPERATIVE UNIT FOR ALL PATIENTS., Nausea/Vomiting, Respiratory Depression: Phase/Order Management: To accommodate these safety measures, management of phases will now be different Significant Changes are highlighted below: Vital Signs Vital Signs Per Unit Guidelines; If T 38-38.4 C recheck in 2 hours Notify Provider Vital Signs T > 38 C (100.4 F) on 2 occasions at least 4 hrs. apart or T greater than or equal to 38.5 C; SBP 140 or DBP > 90 on 2 occasions at least 4 hours apart or any isolated SBP > 160 or DBP 110; HR <50 or >120; RR < 10 or > 30, UO < 120 ml in 4 hrs Non-Pharmacologic Management Heat Therapy, PRN Order, Order K-pad prn for abdomen and/or lower back discomfort Mild Scale 1-3, Acetaminophen Option 1: Acetaminophen 1000 mg PO Q 6 H, while awake, begin 6 hours from prior APAP dose if given Option 2: Acetaminophen 1000 mg IV x 1, begin 6 hours from prior APAP dose if given (for patients NOT TOLERATING PO). Once tolerating PO, switch to PO) Acetaminophen 1000 mg PO Q 6 H, while awake, begin 6 hours from prior APAP dose if given Mild Scale 1-3, NSAID Option 1: ketorolac (Toradol) 30 mg, IV push, Q6H, for 3 doses, begin 6 hours from prior ketorolac if given (Once complete or if tolerating PO, switch to PO ibuprofen 600 mg Q6H) ibuprofen 600 mg, PO, Q6H, while awake, to begin after IV ketorolac complete Option 2: ibuprofen 600 mg, PO, Q6H, while awake, to begin after IV ketorolac given Or: Contraindications NSAIDs Moderate Scale 4-6 Oxycodone 5 mg, 1 tab, PO, Q 3 H, PRN, MR x 1 hr, if ineffective, may escalate to severe PO pain order at next PRN frequency HYDROmorphone (Dilaudid) 0.2 mg, IV push, Q2H, PRN, if not tolerating PO Morphine 2 mg, IV push, Q3H, PRN Sever Scale 7-10 Oxycodone 10 mg, 1 tab, PO, Q 3 H, PRN, MR x 1 hr, if ineffective, may escalate to severe PO pain order at next PRN frequency HYDROmorphone (Dilaudid) 0.5 mg, IV push, PRN Q10MIN Morphine 4 mg, IV push, Q3H, PRN ***NOTE*** Patient may request a lower level of pain medication than pain level indicated Opioid Reversal naloxone (Narcan) 0.1 mg, IV push, Q2MIN, PRN reverse narcotic effect, Also PRN respiratory rate less than 10/minute, unable to respond and/or inadequate ventilatory effort, then call Anesthesiologist and Obstetrician immediately and Rapid Response Team if anesthesia unable to come to bedside. supplied as vial. Antibiotics For all antibiotics, use WHS Infectious Disease Orders WHS POSTPARTUM CESAREAN SECTION: SURGEON COMFORT C/S PHASE Activated after Anesthesia Post Duramorph Phase has completed (24 hours) in patients who received spinal Duramorph, or activated immediately upon arrival to post-op unit if patient did not receive spinal Duramorph. Ondansetron SoluTab (Zofran ODT) 4 mg, PO, Q 4 H, PRN Ondansetron (Zofran) 4 mg, IV push, Q 4 H, PRN, if not tolerating PO and has IV in place Promethazine (Phenergan) 6.25 mg IV Q 4 H PRN, if not tolerating PO and has IV in place Nursing Task: Remove Scopolamine Patch 24 hours from placement, if placed Diphenhydramine (Benadryl) 25 mg PO (or IV if not tolerating PO), Q 6 H PRN Zolpidem (Ambien) PRN is no longer available/has been removed from the powerplan
WHS POSTOPERATIVE GYN: POSTOPERATIVE ORDERS GYN PHASE Management: o SURGEON MANAGES PAIN IN THE POST-OPERATIVE UNIT FOR ALL PATIENTS., Nausea/Vomiting, Respiratory Depression: Phase/Order Management: To accommodate safety measures, management of phases will now be different. Note: Urine Voiding Urinary Catheter Insertion Intermittent/Straight, PRN. For post void residual > 200 ml. Insert continuous foley catheter if straight catheter needed greater than 2 times Bladder Scan for post void residual, PRN, every 6 hours for urinary retention and/or PRN distension See order changes identified in the WHS Postpartum Cesarean: Postoperative Orders C/S Phase. Management VTE Prophylaxis Intermittent Pneumatic Compression Knee High - On Remove 1 hour every 8 hours. Continue Intermittent Pneumatic Compression Device until ambulating independently. Antibiotics Antibiotics Removed. For all antibiotics, use WHS Infectious Disease Orders WHS POSTOPERATIVE GYN: SURGEON COMFORT ORDERS GYN PHASE See changes outlined in WHS Postpartum C/S: Surgeon Comfort Orders C/S Phase See changes outlined in WHS Postpartum C/S: Surgeon Comfort Orders C/S Phase Zolpidem (Ambien) Removed For additional orders refer to Powerplan: ing Medications Common
Women s Oncology Postoperative WHS PHASE Management: SURGEON MANAGES PAIN IN THE POST-OPERATIVE UNIT FOR ALL PATIENTS., Nausea/Vomiting, Respiratory Depression: Phase/Order Management: To accommodate safety measures, management of phases will now be different. Note: Urine Voiding See changes outlined in WHS Postoperative GYN See order changes identified in the WHS Postpartum Cesarean: Postoperative Orders C/S Phase, and the following: Management Mild Scale 1-3, Acetaminophen Option 3: Acetaminophen 1000 mg IV x 3, begin 6 hours from prior APAP dose if given, for patients not tolerating PO meds Acetaminophen 1000 mg PO Q 6 H, while awake, begin 6 hours from prior APAP dose Opioid Reversal VTE Prophylaxis Antibiotics Patient Controlled Analgesia (PCA): Note: PRN IV and PO opioids and concomitant PCA opioids are generally to be avoided. Please choose either (1) PRN IV and PO opioids or (2) PCA opioid. For orders, refer to Powerplan: PCA Hydromorphone Intravenous For orders, refer to Powerplan: PCA Morphine Intravenous See WHS Postoperative GYN above Intermittent Pneumatic Compression Knee High - On - Remove 1 hour every 8 hours. Continue Intermittent Pneumatic Compression Device until ambulating independently. Option 1 (bowel not involved): cefazolin (Ancef) 2 g, IV, Q8H, x 2, Give 1 st dose 8 hours from last dose. To D/C 24 hr from surgery end time Option 2 (when expanded anaerobic coverage needed), select both: cefazolin (Ancef) 2 g, IV, Q8H, x 2, Give 1 st dose 8 hours from last dose. To D/C 24 hr from surgery end time metronidazole (Flagyl) 500 mg IVPB, Give 1 st dose 8 hours from last dose. To D/C 24 hr from surgery end time Type 1 Allergy to Penicillin or severe allergy to Cephalosporins: (assumes patient received 5 mg/kg gentamicin pre-op, if gentamicin < 5 mg/kg administered pre-op, add gentamicin post-op) Option 1: clindamycin 900 mg, IVPB, Q8H, x 2. Give 1 st dose 8 hr from last dose. To D/C 24 hrs from surgery end time. Option 2 (when expanded anaerobic coverage needed), select both: clindamycin 900 mg, IVPB, Q8H, x 2. Give 1 st dose 8 hr from last dose. To D/C 24 hrs from surgery end time. metronidazole (Flagyl) 500 mg IVPB, Give 1 st dose 8 hours from last dose. To D/C 24 hr from surgery end time Postoperative Vancomycin: If estimated CrCl =< 40 ml/min, no vancomycin postoperative dose needed. Vancomycin 15 mg/kg, IVPB, once, Indication: Peri-operative/procedural prophylaxis, Reason: Prophylaxis If estimated CrCl > 40 ml/min, Give 12 hours after the previous dose. Do not give any doses beyond 24 hrs from surgery end time. Women s Oncology Postoperative: SURGEON COMFORT ORDERS GYN Ondansetron SoluTab (Zofran ODT) 4 mg, PO, Q 4 H, PRN Ondansetron (Zofran) 4 mg, IV push, Q 4 H, PRN, if not tolerating PO and has IV in place Promethazine (Phenergan) 6.25 mg IV Q 4 H PRN, if not tolerating PO and has IV in place metoclopramide (Reglan) 10 mg, IV push, Q 6 H, PRN Nursing Task: Remove Scopolamine Patch 24 hours from placement, if placed See changes outlined in WHS Postpartum C/S: Surgeon Comfort Orders C/S Phase Zolpidem (Ambien) Removed For additional orders refer to Powerplan: ing Medications Common