Whipple
POD#0
Post op orders -> check labs (CBC, BMP, Mg, Phos, iCal, INR)
if Cr ok and LFTs not elevated then start tylenol (975mg q8H down NJ), gabapentin (100-300 TID),
celebrex (200 BID)
q4 SSI high dose
incentive spirometer
protonix 40mg q12hr
LR @150cc/hr
Ancef q8h and diflucan 400mg x48hr post op
dPCA
lovenox PM dose 40mg
POD#1
limited CLD (250cc per shift, no carbonated beverages, no straws), should be bari-clears so they are in medicine cups
clamp trial (usually 6-8 hours). If passes, then remove NG while patient takes sips to not dislodge NJ
start Tube feeds at 10cc/hr via NJ
POD#2
Unlimited CLD
TF @ 20cc/hr
POD#3
FLD
TF @ 30cc/hr
JP drain studies (amylase, lipase, TG, ?cultures if needed) -> eval for milky fluid after meals
POD#4
Remove JP if studies and cultures are negative
soft diet
Post op GJ with G tube on Gastric outlet obstruction
POD1
G-tube to gravity, CLD for pleasure, continue TPN
POD2
G tube clamp, vent q4h and document output. Also vent PRN for nausea, vomiting, or epigastric distension. CLD, continue TPN
POD3
if no venting for issues and less than 400cc during venting on prior day: clamp G tube, vent before meals ro as needed for nausea. FLD PO and high protein milkshakes. continue TPN
POD4
If no venting for issues and less than 400cc during venting in prior day, G tube clamped, vent before meals. FLD for 2 weeks (dietician education), calorie counts and wean TPN if taking more than 75% requirements
If they have problems any day, consider staying on the same day protocol or backing up one day. If unable to progress, arrange for cycled home TPN.
Aguila surgical oncology questions:
– What is it
– Tissue diagnosis needed?
– Baseline tumor markers to identify and monitor cancers
– CA 19–9 only when biliary tree decompressed
– Is it resectable?
– Vascular involvement?
– Neoadjuvant chemo/rads needed to downstage tumor before surgery?
– Do they have metastatic disease?
– Imaging workup. CT chest often needed in addition to CTAP
– Will the patient tolerate surgery?
– Baseline functionality/METS–weight loss
– To the need a period of nutritional optimization?
– Do they need pulmonary, cardiac, other medical optimization?