Cardiac CVRU

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CVRU

Identify patient as ERAS
Hand Off
- - Confirm with CRNA ALL medications given intra-op for safety precautions and to ensure no double dosing occurs
SCDs
- - While in bed
Reversal
- - Per reversal order set, if not initiated in OR
ABG
- - Upon arrival to CVRU
Ventilation
- - Ventilation Management/Liberation Protocol
Maintain normothermia
Unless existing confounding factors
- - Anesthesia to communicate to CVRU RN/RT the patient will be a rapid extubation
Dexmedetomidine
- - Continue Dexmedetomidine 0.2-0.7 mcg/kg/hr infusion
  - Reduce infusion by 1⁄2 once patient extubated.
  - D/C within 6 hours after extubation
Consult
- - Nutrition Services
Delirium screening
- - once per shift until discharge from CVRU: CAM for ICU
Labs
- - CBC, BMP, Mg, Ca2+, Coags @ 6 hrs after OR, earlier if needed
Implement standardized transfusion algorithm
- - SEE TRANSFUSION ALGORITHM BELOW
  - Ensure patient temp >36°C
  - Correct pH >7.25
  - Correct ionized calcium to 1.15 mmol/L

Amiodarone Protocol
- - Initiate A-fib Prevention Amiodarone protocol if CI >2 L/min/m2 for 3 consecutive hours:
  - Amiodarone 150 mg IV bolus over 10 min followed by:
  - Amiodarone 1.0 mg/min IV infusion x 6 hrs, then 0.5 mg/min x 18 hrs
  - When infusion complete, D/C IV
  - Then Amiodarone 400 mg PO BID with meals x 5 days
Diet
- - once extubated, start clear liquids
  - Advance to cardiac carb control diet
  - Protein supplementation 3x/day
  - Document all PO liquid and solid intake in Dimensions-please document type of diet being consumed too
Activity
- - OOB to chair- DOCUMENT IN DIMENSIONS
Once extubated
- - Flutter Valve Q1-2 hours 30x while awake
Multimodal Analgesia
- - IF NOT ORDERED AS BELOW, PLEASE CONTACT SURGEON FOR CORRECTION ASAP
  - Acetaminophen 1 g PO Q 8 hrs (if dosing meets 3g/24hr limit, contact pharmacy to reschedule instead of skipping dose)
  - Oxycodone 5 mg PO Q4 hrs PRN pain level 4-6
  - Oxycodone 10 mg Q4 hrs PRN pain level 7-10
  - Tramadol 50-100 mg PO Q8 hrs PRN pain level 1-3
  - ***Ensure appropriate medication given for patient's current pain score (take "Patient's Stated Pain Goal" into account too). ERAS Goal is to limit opioids***
Bowel Regimen
- - Colace 100 mg PO QHS – starting night of surgery

Patient Guide to ERAS Booklet
- - Ask to see their booklet
  - Remind patient importance of documenting in booklet now and once transferred to 5D
  - Check diaries frequently for ambulation, diet, etc- Document info recorded in Dimensions
CONTINUE Amiodarone protocol:
- - Amiodarone 400 mg PO BID with meals x 5 days
IVF
- - D/C if tolerating PO intake
Activity
- - DOCUMENT in Dimensions as "Ambulation in Hall" NOT "Up Ad Lib"
  - Ambulate 3-4x/daily with increasing distance
  - Out of bed to chair if not ambulating or sleeping
Diet
- - Continue cardiac carb control diet
  - Protein supplementation 3x/day
  - Document all PO liquid and solid intake in Dimensions-please document type of diet being consumed too
Multimodal Analgesia
- - IF NOT ORDERED AS BELOW, PLEASE CONTACT SURGEON FOR CORRECTION ASAP
  - Acetaminophen 1 g PO Q8 hrs (if dosing meets 3g/24hr limit, contact pharmacy to reschedule instead of skipping dose)
  - Gabapentin 300 mg PO TID (if > 65 years of age, then BID) starting POD 0
  - Oxycodone 5 mg PO Q4 hrs PRN pain level 4-6
  - Oxycodone 10 mg Q4 hrs PRN pain level 7-10
  - Tramadol 50-100 mg PO Q8 hrs PRN pain level 1-3
  - ***Ensure appropriate medication given for patient's current pain score (take "Patient's Stated Pain Goal" into account too). ERAS Goal is to limit opioids***

- - Lactulose solution 20 gram/30ml PO daily prn
  - Dulcolax suppository 10mg PRN (start POD #1)
  - Colace capsule 100mg PO every HS (start POD #1)
  - Lactulose 20 gram/30ml x 1 on POD #2 (hold if BM in last 24hr)
  - Dulcolax 10mg PO daily (start POD #3) OR suppository 10mg if unable to take PO’s

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