DRUG AND TREATMENT Diet Diet NPO After Midnight NPO except for meds with sip of water NPO NPO except for meds with sip of water Diet Message Clear liquids until 0800 if surgery after 1400 (except for CV Surgery patients which are ALL NPO after midnight Nursing Orders Pre-Operative Anesthesia Reference Text See Reference Text Patient Education Instruct patient not to eat or drink anything after midnight the day of surgery OR if surgery is scheduled after 1400 may have clear liquids until 0800 (except for CV Surgical patients which are ALL NPO after midnight) Comments: Patient is to continue all usual daily AM medications and take with sip of water the morning of surgery EXCEPT the following:-send insulin to holding with patient -HOLD oral hypoglycemics, NSAIDS, diabetic medications, diuretics (except when a diuretic drug is a component of an antihypertensive combination), ACE inhibitors, and vitamins, including herbal supplements (herbal supplements should be held for one week)-hold anticoagulants and Aspirin unless specifically told by surgeon or cardiologist. Patients should continue to take their Aspirin, if the patient has a stent in place. Permission from the patient's cardiologist is necessary to stop Aspirin and/or other antiplatelet drugs Comments: Instruct patient to remove contact lenses, glasses, hearing aids and body piercings prior to entering OR. May wear all dental appliances without adhesive.instruct patient to NOT wear body lotion, perfume, powder, deodorant or makeup day of surgery. Notify Anesthesia if Pacemaker or AICD battery check is GREATER than 6 months Page 1 of 7
DRUG AND TREATMENT Comments: 1. Copy of the device card of the CIED (pacemaker/aicd) and document device model and number. This provides the manufacturer information. If the patient doesn't have the card, a chest xray can show the same information.2. Recent (within past year) 12-lead EKG.3. Contact the patient's physician/clinic who manages the CIED to obtain a plan of action for the perioperative management of the patient's CIED; complete the Perioperative Management Form for Cardiac Rhythm Management Devices form. For most patients, the patient's CIED clinic should be able to review their records to provide a plan of action for the perioperative management of the patient's CIED. This information should include when device was placed and why (Bradycardia or Tachyarrhythmia), if an AICD has ever fired or shocked patient and when the battery was last checked. A small percentage of patients may require a consultation from CIED specialists if the information is not available.4. Many patients will need the CIED reevaluated within one month after the procedure.5. Elective procedures might have to be rescheduled if the CIED registration card, EKG, or requested information from the patient's CIED clinic is not available on the date of the procedure.6. The perioperative management of CIEDs must be individualized to the patient, the type of CIED and the procedure being performed. A single recommendation for all CIED patients is not appropriate.7. Pacemakers need to have been interrogated within the past 12 months to proceed with elective surgery. Copies of the report must be available.8. Defibrillators, including battery check, need to have been interrogated be within the past 6 months to proceed with elective surgery. Copies of the report must be available.9. Copies of any cardiac studies done within the past 2 years including echocardiogram, stress tests, catheterizations, etc.10. Some pacemakers/aicds will need to be interrogated postoperatively which will be specified by the Anesthesia Provider. Start IV/INT Insert 18 gauge. May infiltrate insertion site w/lidocaine 1% prior if patient not allergic ***(NOTE)***Order Blood Glucose (POC) if patient is on oral hypoglycemic agents, insulin, has diabetes, has gastroparesis, is pregnant, or is morbidly obese Blood Glucose Monitor POC ONCALL, for OR Blood Glucose Monitor POC Q2H, Check glucose every 2 hours if patient given insulin and call if LESS than 100 mg/dl or GREATER than 200 mg/dl Notify Anesthesiologist if glucose is LESS than 100 mg/dl or GREATER than 200 mg/dl. If glucose 100-200 mg/dl, give 1/3 of usual insulin dose and start D5LR at 125 ml/hr Notify Anesthesiologist if glucose is GREATER than 200 mg/dl Notify Anesthesiologist if patient has history of difficult intubation Page 2 of 7
DRUG AND TREATMENT ***(NOTE)*** Select the "Transfuse Blood Previously on Hold" order below, to transfuse blood on hold Transfuse Blood Previously on Hold Medications lidocaine (Lidocaine 1% MDV inj) 1 ml INFILTRATE inj ONCE Comments: At IV insertion site if patient is not allergic ***(NOTE)***Hold Reglan for Parkinson's disease, agitation, hallucination, depression movement disorder, seizure disorder, GI obstruction or bowel perforation metoclopramide (Reglan) 10 mg tab PO ONCALL (DEF)* GREATER than30), renal failure and/or GERD. HOLD if allergic or if LESS than 12 years of age. HOLD for Parkinson's disease, agitation, hallucination, depression movement disorder, seizure disorder, GI obstruction or bowel perforation 10 mg inj IV PUSH ONCALL Comments: Give slowly over 10 minutes to reduce incidence and severity of akathisia. Give for diabetics, obesity (BMI GREATER than30), renal failure and/or GERD. HOLD if allergic or if LESS than 12 years of age. HOLD for Parkinson's disease, agitation, hallucination, depression movement disorder, seizure disorder, GI obstruction or bowel perforation ranitidine (Zantac) 150 mg tab PO ONCALL (DEF)* 50 mg inj IV PUSH ONCALL 150 mg tab PO BEDTIME, Duration: 1 dose 300 mg tab PO BEDTIME, Duration: 1 dose famotidine (Pepcid) 20 mg tab PO ONCALL (DEF)* Comments: Give On call to OR, prior surgery with sips of water 20 mg inj IV PUSH ONCALL Comments: Give On call to OR, prior surgery if unable to take PO medication Page 3 of 7
DRUG AND TREATMENT glycopyrrolate (Robinul) 1 mg tab PO ONCALL (DEF)* Comments: HOLD in patients with glaucoma, tachycardia (HR GREATER than 100), obstructive uropathy, paralytic ileus, GI obstruction, myasthenia gravis, ulcerative colitis, toxic mega colon, or unstable cardiovascular status in acute hemorrhage.give if BMI GREATER than 40 and contact Anesthesia if the patient has a history of difficult intubation. 0.1 mg inj IV PUSH ONCALL Comments: HOLD in patients with glaucoma, tachycardia (HR GREATER than 100), obstructive uropathy, paralytic ileus, GI obstruction, myasthenia gravis, ulcerative colitis, toxic mega colon, or unstable cardiovascular status in acute hemorrhage.give if BMI GREATER than 40 and contact Anesthesia if the patient has a history of difficult intubation. citric acid-sodium citrate (Bicitra) 30 ml PO soln ONCALL Comments: In OR Holding midazolam (Versed) 2 mg inj IV PUSH PRE-OP (DEF)* Comments: In OR holding after Anesthesiologist & Surgeon has obtained/confirmed informed consent and Circulator has completed interview 1 mg inj IV PUSH PRE-OP Comments: In OR holding after Anesthesiologist & Surgeon has obtained/confirmed informed consent and Circulator has completed interview diazepam (Valium) 5 mg tab PO PRE-OP Comments: In OR holding after Anesthesiologist & Surgeon has obtained/confirmed informed consent and Circulator has completed interview SUB ANES Scopolamine (SUB)* Non Categorized Contraindications: Closed angle glaucoma, Acute Hemorrhage, Tachycardia secondary to cardiac insufficiency or hyperthyroidism, pregnancy, lactating (breast feeding) females, possible intestinal obstruction, prostatic hyperplasia, chronic renal, hepatic, pulmonary or cardiac disease. Use with caution for elderly patients.(note)* Patients considered high risk must have at least 3 of the following risk factors: non-smoking status, female gender, previous history of PONV and history of motion sickness(note)* Nursing Orders Patient Education Instruct patient on side effects seen with Scopolamine: dry mouth, blurry vision and confusion in the elderly. Medications scopolamine 1.5 mg patch TRANSDRM ONCE, Clinical Instructions: apply disc behind the ear 2 hours prior to surgery for patients at high risk for Post Operative Nausea and Vomiting. Page 4 of 7
DRUG AND TREATMENT IV Solutions Lactaid Ringers Injection (Lactated Ringers) IV bag 125 ml/hour Comments: Use Sodium Chloride 0.9% (Normal Saline) at 25 ml/hr if patient is on dialysis or undergoing craniotomy Sodium Chloride 0.9% IV bag 25 ml/hour Comments: If patient is on dialysis or is undergoing craniotomy Dextrose 5% in Lactated Ringers Injection (D5LR) IV bag 125 ml/hour Laboratory ***(NOTE)*** Order CBC if history of Anemia, Hemorrhage, Radiation/Chemotherapy, Systemic Lupus, Transplant Rejection, Leukemia, Sickle Cell Disease, Renal Disease or active infection process. Hemoglobin and Hematocrit Complete Blood Count *** (NOTE)*** Order PT/PTT if history of Coagulation Disorder, Anticoagulation Therapy, Hemorrhage, Anemia, Ethanol Abuse, or Liver Disease Prothrombin INR Partial Thromboplast Time ***(NOTE)*** Order Chem 7/BMP if patient is currently taking diuretics, steroids, Diabetes, Thyroid or Pancreatic disease medications and patients with history of gastric bypass or transplants. Post dialysis chem 7 on day of surgery for renal failure patients. Potassium Level Basic Metabolic Panel ***(NOTE)*** Order Liver Profile if recent history and/or current Hepatitis and Ethanol Abuse Liver Profile ***(NOTE)*** Obtain Thyroid Studies, if patient has a history of thyroid disease or goiter and has not been checked in the past 6 months (get results), or if patient experiencing symptoms (increased heart rate, sweating, weight gain, hair loss, and cold intolerance) Page 5 of 7
DRUG AND TREATMENT Thyroid Stimulating Hormone T4 Total Triiodothyronine Total ***(NOTE)*** Obtain a Beta HCG (Quantitative Serum) within 7 days of surgery. Urine HCG morning of surgery (EXCLUDING those who have had a hysterectomy) HCG Quantitative ***(NOTE)*** If on the day of surgery the documented first day of the last menstrual period is GREATER than 21 days AND if a HCG Screen Quantitative Serum test was performed GREATER than 72 hours prior, obtain a Urine HCG (EXCLUDING those with a missed/incomplete AB OR who have had a hysterectomy OR undergone menopause). Patient needs to have been free of menses (vaginal bleeding) for 12 months Comments: Obtain Urine HCG if on the day of surgery the documented first day of the last menstrual period is GREATER than 21 days AND if a HCG Screen Quantitative Serum test was performed GREATER than 72 hours prior (EXCLUDING those with a missed/incomplete AB OR who have had a hysterectomy OR undergone menopause). Patient needs to have been free of menses (vaginal bleeding) for 12 months Urine HCG Pre-Op, URINE, ONCE Digoxin Level Comments: For all patients taking digoxin Phenytoin Level Comments: For all patients taking phenytoin ABORH Type ***NOTE)*** If wanting to place specific blood products on Hold, select the Adult Blood Administration subphase and select your products with a Transfusion Priority of Hold Type and Screen BLOOD Page 6 of 7
DRUG AND TREATMENT GEN Blood Administration (SUB)* ***Reminder: Order GEN Blood Administration (SUB) on a separate form*** Radiology ***(NOTE)*** Obtain Chest X-ray if any of the following conditions are met: history of Pulmonary Disease, including Infection (Pneumonia, Bronchitis), CHF, COPD, symptomatic Asthma, OSA, SOB, and BMI GREATER than 40, or if changes in these conditions are noted within 3 months XR Chest *2 view PA and LAT Pre-op, Pending Discharge No XR Chest *1 view AP Portable Pre-op, Pending Discharge No Cardiology ***(NOTE)*** Obtain ECG Standard if any of the following conditions are met: male patients age 40 and over, female patients age 50 and over OR if a copy of a previous ECG is not available within 6 months and if abnormal ECG changes are noted within 3 months; if history of CAD, Cardiac Arrhythmias, CHF, Chest Pain, Sleep Apnea, High Blood Pressure, Diabetes and BMI GREATER than 40 ECG Standard Pre-op, ONCE Comments: Call Anesthesia for abnormal ECG Notify Anesthesia for abnormal ECG Consults ***(NOTE)*** In patients with Sickle Cell disease, if Hematocrit is less than 30% consult anesthesia; patient may need hematology consult for moderated to high risk surgical procedures and pre-op transfusion to a Hematocrit of 30%. Any patient with a history of sickle cell crisis within the last 6 months should be seen by a hematologist prior to elective surgery. Physician Consult Hematology Physician Consult Baptist Heart Specialists Physician Consult Pulmonary, Post Op Sleep Study evaluation and possible Obstructive Sleep Apnea Page 7 of 7