INTRA-OPERATIVE:

INDUCTION

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

PRIOR TO INCISION

• Antibiotic prophylaxis

• BLOCKS

  • • Serratus Anterior Plane Blocks: 0.25% Bupiv c̅ Epi

    • PEC I block if expanders are used or implant under the muscle

      • • 30 mL unilaterally or bilaterally

        • Placed under ultrasound guidance in OR after induction

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

• Propofol 25-50 mcg/kg/min infusion

• Decadron 10 mg IV

• Haldol 2 mg IV

• Goal Directed Fluid Therapy (GDFT) per protocol

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

• Forced air warming after draping

AFTER INCISION

• 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

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

• Maintain normothermia (Temp >36 °C)

• No intraop opioids – discuss with Anesthesiologists if opioid needs consideration

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

• 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 at end of case

• Confirm ALL fluids both input and output are documented