1. May Have Clear Liquids Such As Gatorade up to 2 Hours Prior to Arrival

SPINE PROTOCOL

PREOPERATIVE

1.  May have clear liquids such as Gatorade up to 2 hours prior to arrival.

2.  Acetaminophen 1 gm po upon arrival

3.  Lyrica 50 mg po OR Gabapentin 300 mg po upon arrival. If patient is taking Lyrica at home, order Lyrica, otherwise order Gabapentin. Only order 150 mg of Gabapentin if patient is over 70 or has renal insufficiency.

4.  Post –op Ketamine infusion needs to be ordered by 0900 for first case and 1300 for second case in order to ensure delivery to PACU. Place the order as a “SIGN” not a “SIGN AND HOLD”.

5.  To Order KETAMINE PROTOCOL. Type KETAMINE into the “ORDER SET”. Items are prechecked. You just need to check the Acetaminophen order and either the Gabapentin or Lyrica for post-op.

Let PACU know that this is a Ketamine patient.

6.  Precedex infusion needs to be ordered to be sent to preop. Call pharmacy at 7930 when you order it and order it as a STAT. Preop releases the precedex order as soon as the patient arrives in preop.

INTRAOPERATIVE

1.  Magnesium4 GMS over 1 hour – premade and available in PYXIS in core.

2.  Benadryl 12.5 mg IV and decadron 4 -6 mg IV for PONV prior to incision

3.  Infusions: all at ideal body weight.

Propofol 50 mcg/kg/min

Ketamine 0.167 mg/min (10 mg/hr)

Precedex 0.2-0.5 mg/min

Lidocaine 1mg/kg/hr.

.Loading doses:

Ketamine 0.5 mg/kg

Lidocaine 1 mg/kg (give with Propofol for induction)

4.HINTS: Start the Propofol/Precedex/Lidocaine/Magnesium infusions

after induction. I usually bolus the Ketamine just before going

prone and start the Ketamine after the turn is completed – less

chance of hypotension. Usually only give Fentanyl 50mcg on

induction to lessen the hypotension also. May use Sevo up to

0.5 MAC

Remember if you are only doing interbody fusions, watch the

Amount of muscle relaxant you give up front as they need twitches

Soon after incision. Usually only give Rocuronium 30 mg. Check with surgeon.

5. The drip rates are “suggestions” They can be increased or decreased as

you see fit. Try not to increase the Propofol more than 100

mcg/kg/min as it will affect the SSEP’s

6.Depending on their preoperative pain requirements, I decrease the Lido

to 0.5 mg/kg/hr about 2 hours into the case.

7.When one side of screws are in, shut off the Precedex.

8. When second side of screws are in, shut off the Lidocaine

9. Stop the Propofol when start to close

10. At this point, you can start titrating in Dilaudid if necessary and if it is

longer than six hours since their preoperative Acetaminophen, you may

give them 1 GM IV.

11.I keep the Ketamine on as long as possible as they will be continuing it

in PACU.

PACU

1.  Order 0.9% Normal Saline @ 50cc/hr as carrier for Ketamine.

2.  Program Ketamine pump to 1 cc/hr (10mg/hr) and do the dual

Sign off with the PACU nurse.

3. Write postop orders for pain medications as needed.