ICU

**Patient is a direct admit to ICU due to Q1hr monitoring of breast flap; 1:1 Patient/RN ratio. At ANY time if there is any question about breast flap, call Dr. Wormer ASAP. The sooner a possible complication is detected, the better possibility of resolution w/o permanent damages.


  • Identify patient as ERAS

  • Hand Off

      • Confirm with CRNA ALL medications given intra-op for safety precautions and to ensure no double dosing occurs

      • Confirm time of last Acetaminophen dose in OR

      • CRNA to communicate intraop optimized SV, CI to bedside RN

  • Monitor breast flap

      • Q 1 hr with Vioptix and Doppler

      • Call Dr. Wormer if loss of doppler tracing and/or sustained ↓10% in StO2 via Vioptix

  • Diet

      • Clear diet POD 0

      • Advance to regular diet POD 1

      • Document all PO liquid and solid intake in Dimensions on "input/output" flowsheet- Please document Type of Diet

  • Ambulation

      • DOCUMENT in Dimensions as "Ambulation in Hall" NOT "Up Ad Lib

      • POD 0: x1 in hallway w/assistance night of surgery

      • POD 1-2: ambulate TID

      • Out of bed to chair for all meals

      • If patient is unable to ambulate due to fatigue, nausea, or refuses, please make note on Activity flowsheet. If patient does refuse, remind them they were educated on this prior to surgery, benefits of ambulation and risk of not ambulating

  • Lidocaine Infusion

      • Continue lidocaine infusion for 24 hours after termination of anesthesia

  • Multimodal:

      • Acetaminophen 1000 mg Q8 (if dosing meets 3g/24hr limit, contact pharmacy to reschedule; do not skip dose)

      • Gabapentin 300 mg Q8

      • Ketorolac 15 mg IV Q6

      • Oxycodone 5-10 mg PO Q3 PRN pain ≀7

      • Hydromorphone 0.5 mg IV PRN for breakthrough pain or pain >7

      • Flexeril 5 mg PO Q8 PRN muscle spasm

      • Β·***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***

***If any of the multimodal medications are not ordered or not ordered correctly, contact surgeon ASAP for correction***

  • VTE/DVT prophylaxis

      • Enoxaparin – Begin POD 1 @ 0600

      • SCDs- continued

  • PONV

      • Ondansetron 4 mg IV/PO Q 6hrs PRN

      • Haldol 0.5-1 mg IV PRN

      • Continue scopolamine patch up to 72 hrs postoperatively

  • Foley

      • D/C @ 0700 POD 1

  • Maintenance fluids

      • until POD 1 at 7 am

  • Continue abx regimen for 24 hours

  • Patient Guide to ERAS Booklet

      • Encourage use while in ICU and when transferred to Nursing Unit

      • Stress importance of documenting in Diaries

      • Check diaries frequently for ambulation, diet, etc- Document info recorded in Dimensions

  • It is possible the patient may be discharged from ICU without transferring to Nursing Unit depending on patient's progression since surgery

    • Defined discharge criteria (if being d/c from ICU)

      • Discussed preoperatively and from POD 0

      • Reinforce expectations with patient and family

      • Anticipate discharge needs

          • Follow-up appointments