INTRA-OP
INDUCTION/PRIOR TO INCISION
- CVC Placement
For CVP monitoring for lobe resection only (NOT for wedge or left lateral segment 4B & 5)
Goal CVP <7
- Antibiotic prophylaxis
- Epidural for open left lobe resection
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 β 10 ml/hr
- TAP block
x4 quad
For right lobe resection or robotic
- CVP
If opening CVP >7, start low dose Nitroglycerine infusion, titrate to obtain goal of CVP<7
- Phenylephrine infusion for hypotension
- IV opioid
No administration without Anesthesiologist-CRNA discussion
- Induction of anesthesia:
Propofol
Ketamine 40mg IV (No Fentanyl)
Magnesium 30 mg/kg IV bolus (over 10 min)
- Multimodal Analgesia:
Ofirmev 1 g IV (15 mg/kg)-Clear with surgeon prior to administering Ofirmev (NO Ofirmev for right lobe)
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 β 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 if NO CVP
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 Β°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
- Remove OG
- Confirm ALL fluids both input and output are documented