INTRA-OPERATIVE:

INDUCTION

  • Limit or eliminate opioid administration

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

  • TAP Blocks

      • TIME OUT for TAP block procedure

      • 4 Quadrant TAP Blocks: 0.25% Bupiv cฬ… 1:400,000 Epi

          • 15 mL each quadrant

          • Placed under ultrasound guidance in OR after induction

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

  • PONV prophylaxis

      • Decadron 10 mg IV slow push

  • 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 ยฐC)

  • Introp Opioids

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

      • Max of 100 mcg Fentanyl (discussion with anesthesiologist if further dosing needed)

  • B&O suppository prior to emergence

  • Ketorolac 15 mg IV at end of case

  • PONV prophylaxis

      • Ondansetron 4mg IV at emergence

  • Blood glucose monitoring

      • For all diabetic patients, continue PAA glycemic control orderset

          • 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 unless low pelvic cases or epidural in place

  • Multimodal considerations:

      • Ketamine 0.5 mg/kg IV bolus (max case dose 160 mg)

      • Precedex 0.2 -0.5 mcg/kg IV

  • Confirm ALL fluids both input and output are documented