INTRA-OP

  • SCDs and TED hose placed on patient prior to induction

FOR NEUROMONITORING CASES:

      • TIVA

      • BIS Monitoring

INDUCTION

  • Goal: No opioid administration

  • Esmolol 0.5 mg/kg IV for post-intubation hypertension/tachycardia

  • Ketamine 0.25 mg/kg IBW IV bolus at induction

  • Lidocaine 100 mg IV bolus at induction

  • Lidocaine infusion (begin after bolus): 2 mg/kg/hr IBW ON PUMP – discontinue at end of case. (Contraindications: profound liver disease, recent MI < 6 mths, seizure disorder, 2nd or 3rd degree heart block, WPW)

PRIOR TO INCISION

  • Antibiotic prophylaxis:

      • COH protocol

  • Dexamethasone 10 mg IV

  • Phenylephrine PRN hypotension: DRIPS MUST BE ON PUMP

  • TXA 1 gram (Note: COH exclusion criteria)

  • Maintain normothermia

  • Goal Directed Fluid Therapy using NICOM

      • Document SV, CI, SVV prior to positioning

      • Follow SV optimization protocol throughout case

      • Document SV, CI Q 1hr and if SV ↓ by 10%, indicating a 250 mL fluid bolus

      • LR fluid bolus x2, then use 5% albumin

AFTER INCISION

  • Goal Directed Fluid Therapy

      • Use NICOM and GDFT algorithm throughout case – SV optimization

  • Maintain normothermia – utilize WARM fluids

  • Blood glucose monitoring:

      • For all diabetic patients, continue PAA glycemic control order set

          • Check FSBS Q 1hr

      • For all non-diabetic patients, check FSBG within 60 min after induction

          • Goal blood glucose: 100-180 mg/dl

          • Check FSBG Q 2hr

          • If FSBG >180, initiate PAA glycemic control order set

  • Goal: NO intraoperative opioid

  • Esmolol 0.5mg/kg IV for tachycardia/hypertension

  • Ketamine 0.25 mg/kg Q1 hr for a total max dose of 2mg/kg

  • Precedex 0.25 mcg/kg IV Bolus PRN: Max dose 2mcg/kg OR Precedex 0.25 mcg/kg/hr infusion ON PUMP

  • Check Hgb if EBL >1000 mL or labile hemodynamics

END OF CASE

  • Ofirmev 1 g IV (**IF NOT GIVEN IN PREOP**) towards end of case

  • If patient has a Sulfa allergy and did not get preop Celebrex, then Ketorolac 15 mg IV

  • At emergence: Ondansetron 4 mg IV

  • Confirm ALL fluids both input and output are documented