INTRA-OPERATIVE:

• IVF

  • • on pump (use GDT protocol)

• Non-invasive CO monitor

• Maintain Normothermia

  • • Under body Bair Hugger

INDUCTION

• Esmolol 0.5 mg/kg boluses to blunt any anticipated sympathetic responses to stimuli during case

• Ketamine 0.5 mg/kg IV bolus

• Avoid Opioid Use

PRIOR TO INCISION

• Antibiotic prophylaxis:

  • • Cefazolin 1-3 g IV (Clindamycin 600 mg IV if allergic to cefazolin) given 30-60 min BEFORE incision

• BLOCKS

  • • TAP Blocks: 0.25% Bupiv c̅ 1:400,000 Epi

    • SAP blocks: 0.25% Bupiv c̅ 1:400,000 Epi (NONE FOR DELAYED RECONSTRUCTION)

      • • 20-30 mL unilaterally or bilaterally (consider max daily dose 400 mg/24 hr)

        • Placed under ultrasound guidance in OR after induction

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

• PONV

  • • Decadron 10 mg IV slow push

    • Haldol 2 mg if high risk

• Goal Directed Fluid Therapy (GDFT) per protocol

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

    • SV optimization

AFTER INCISION

• Lidocaine Infusion

  • • 4-6 hours AFTER TAP/PEC blocks

    • Lidocaine infusion of 1 mg/kg/hr and continue for 24 hours after termination of anesthesia (remind ICU RN in Hand off)

• Goal Directed Fluid Therapy

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

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

• Maintain normothermia (Temp >36 °C)

• Introp Medications and when to administer

  • • Introp Opioids

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

    • Heparin 5000 U IV

      • • at approximately 1:00 pm when flaps go ischemic – consult with surgeon on exact timing

    • Esmolol 0.5 mg/kg boluses

      • • to blunt any anticipated sympathetic responses to stimuli during case

    • Ofirmev 1 g IV

      • • at end of case OR 8 hrs from pre-op acetaminophen dose

    • Ketamine 0.5 mg/kg IV bolus

      • • Q 1hr

    • Ketorolac 15 mg IV

      • • AT END OF CASE: confirm surgeon’s preference regarding dose:

• PONV prophylaxis

  • • Propofol gtt 50-100 mcg/kg/hr – start 3 hours prior to end of case

    • 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 at end of case

• Confirm ALL fluids both input and output are documented