INTRA-OPERATIVE:
- SCS and TED hose placed on patient prior to induction
INDUCTION
No opioid administration
Esmolol 0.5 mg/kg IV bolus for tachycardia/hypertension
PRIOR TO INCISION
Arterial line placement
Antibiotic prophylaxis
- For patients NOT receiving an On-Q pain pump
serratus anterior plane block placement by Anesthesiologist (0.25% bupivacaine w/ epi)
IF case is > 4 hrs and NO preop Tylenol given: Ofirmev 1 g IV (15 mg/kg)
Propofol 25-50 mcg/kg/min infusion
Decadron 10 mg IV โ PONV prophylaxis
Magnesium 30 mg/kg IV bolus (over 10 min)
Esmolol 0.5 mg/kg IV for attenuation of post-intubation hypertension/tachycardia
- Goal Directed Fluid Therapy (GDFT) per protocol
5% Albumin based strategy to avoid excess crystalloid
LR infusion: 2 ml/kg/hr
Document SV, SVV, CI PRIOR to incision and then per protocol
Forced air warming after draping
- ABG
Baseline then as needed
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)
- Avoid introp opioids
Magnesium continuous infusion 8 mg/kg/hr (max dose: 2 gm and d/c at extubation)
Esmolol 0.5 mg/kg IV bolus for tachycardia/hypertension
CONSIDER: Precedex 0.2-0.5 mc/kg/hr infusion
- AT END OF CASE
if patient has sulfa allergy and did not celecoxib, give Ketorolac 15 mg IV โ consult with surgeon for any bleeding issues
- AT EMERGENCE
Ondansetron 4mg IVโ PONV prophylaxis
- Paravertebral On-Q pump placement by Dr. Kraut
- 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
- Confirm ALL fluids both input and output are documented