INTRA-OP

INDUCTION/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-standard infusion of 0.0625% bupivacaine at 6-10 mL/hr

• Medications

  • • Ketamine 40 mg IV at induction (No Fentanyl)

    • Magnesium 2gm (over 10 min)

    • Ofirmev 1 g IV (15 mg/kg)

• IV analgesia:

  • • Ketamine 0.5mg/kg IV Q1 hr – max of 160 mg total

• PONV prophylaxis

  • • Decadron 10 mg IV

• Goal Directed Fluid Therapy (GDFT)

  • • Treat per protocol

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

• Tidal volumes <6 ml/kg, PEEP 5-7

• Forced air warming after draping

Intraop: Maintenance

• 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

• Maintain normothermia (Temp >36 °C)

• Introp opioids

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

• 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

Closing/Emergence

• Minimize tubes, drains, lines

• PONV prophylaxis

  • • Ondansetron 4mg IV at emergence

• Keep NG in place

• Keep Cheetah pads on patient (to be used in the ICU)

• Confirm ALL fluids both input and output are documented