INTRA-OP

INDUCTION/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 at 6 – 10 ml/hr

• TAP block

  • • x4 quad

    • For laparoscopic or robotic

• IV opioid

  • • No administration without Anesthesiologist-CRNA discussion

• Induction of anesthesia:

  • • Propofol

    • Ketamine 0.5 mg/kg IV bolus

    • Magnesium 30 mg/kg IV bolus (slow)

• Multimodal Analgesia:

  • • Ofirmev 1 g IV (15 mg/kg)

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

• PONV prophylaxis

  • • Decadron 10 mg IV

• If no epidural:

  • • Ketamine 0.5 mg/kg IV Q1 hr – max dose 160 mg (max case dose 200 mg)

    • Magnesium continuous infusion 8 mg/kg/hr (d/c at extubation)

• Goal Directed Fluid Therapy (GDFT)

  • • Treat per protocol

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

• Tidal volumes <6 ml/kg, PEEP 5-7

• Forced air warming after draping

AFTER INCISION

• Maintain normothermia (Temp >36 °C)

• Introp opioids

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

• 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

• Confirm ALL fluids both input and output are documented