PRIOR TO INDUCTION

• Epidural if specified by surgeon

  • • Thoracic epidural placed preop at level T9

    • Standard ERAS infusion of 0.0625% bupivacaine

    • Infusion at 8-10 ml/hr

INDUCTION

• No Opioids

• Ketamine 0.25 mg/kg/IV

• Esmolol 0.5 mg/kg/IV bolus for tachycardia/hypertension

PRIOR TO INCISION

• Antibiotic prophylaxis

• If epidural, Epidural bolus and infusion

  • • After test dose, bolus epidural with 4-6 ml 0.25% bupivacaine for intraop analgesia

    • Begin epidural infusion from pharmacy as soon as possible

• TIME OUT for TAP block procedure

• 4 Quadrant TAP Blocks

  • • 0.25% Bupiv 1:400,000 w/Epi

    • 15 mL each quadrant

    • Placed under ultrasound guidance in OR after induction

    • Parallel process: allow circulating RN to perform foley placement during TAP block

• PONV prophylaxis

  • • Decadron 10 mg IV slow push

• Goal Directed Fluid Therapy (GDFT)

  • • Per protocol if case posted for > 2 hours in duration

    • Document SV, SVV, CI PRIOR to incision and then per protocol

• DO NOT USE CHEETAH (GDT) IF CASE IS POSTED FOR ≤ 2 HOUR IN DURATION

  • • Minimally Invasive: If no GDT, LR infusion (ON PUMP) at 3 mL/kg/hr, max rate of 240 mL/hr

    • Open Case: If no GDT, LR infusion (ON PUMP) at 5 mL/kg/hr, max rate of 300 mL/hr

    • Bolus as needed, being mindful of zero balance goal

• Forced air warming after draping

Other Multi-modal considerations

• Ketamine 0.25 mg/kg IV (max case dose 2 mg/kg)

• Precedex 0.2-0.5 mcg/kg bolus or infusion

• Discuss with Anesthesiologist use of: precedex, labetalol, metoprolol

AFTER INCISION

• Goal Directed Fluid Therapy

  • • Use non-invasive monitor and GDFT algorithms throughout case

    • Not needed if case is posted for <2 hours

    • Do not use quantitative urine output or NIBP as guide for fluid management

    • If patient is anuric, check foley catheter and consider fluid bolus or increasing BP

• Maintain normothermia (Temp >36 °C)

• Introp Opioids

  • • Avoid/limit introp opioids (consideration for TAP blocks)

• Esmolol 0.5 mg/kg IV bolus for tachycardia/hypertension

• Fentanyl

  • • Max of 100 mcg Fentanyl (discussion with anesthesiologist if further dosing needed)

• Ketorolac 15 mg IV– AT END OF CASE-DISCUSS WITH SURGEON

• PONV prophylaxis

  • • Ondansetron 4mg IV at emergence

• Blood glucose monitoring

  • • For all diabetic patients, continue PAA glycemic control order set

      • Check FSBG Q1hr

    • For all non-diabetic patients, check FSBG within 60 min after induction

      • Goal blood glucose between 100-180 mg/dl

      • Check FSBG Q2hr

      • If FSBG >180, initiate PAA glycemic control order set

• Minimize tubes, drains, lines

  • • Consider D/C foley unless low pelvic cases or epidural in place

• Ensure ALL fluid given intra-op are documented

PACU HANDOFF

• Identify patient as ERAS

• Ensure to relay ALL medications given to PACU RN as to safeguard against double dosing