Enhanced Recovery After Surgery (insert new name wherever…)

Non-hepatic Abdominal

Pain Protocol

Goal: Opioid-sparing technique is paramount. The intention is to reduce systemic opioid adverse effects (including respiratory, gastrointestinal, urological and psychiatric complications) by maximizing multimodal management of perioperative pain.

Pre-operative:

  • Multimodal oral meds (ordered by APS)
  • Acetaminophen 1g PO
  • Meloxicam 15mg PO (if over 70, decrease to 7.5mg PO; hold-CrCl <20)
  • Open Procedure w/o Epidural: Pregabalin 150mg PO (hold if over 70)
  • Thoracic Epidural – if indicated, placed by APS
  • Test dose 3mL Lidocaine 1.5% with Epinephrine 1:200k
  • Assess dermatome band with ICE
  • If no band after test dose, repeat dosing until bilateral band
  • 3mL Lidocaine 2% with Epi 1:200k
  • If unilateral or no band, troubleshoot/replace.

Intra-operative:

  • Aggressively MINIMIZE IV Opioids, but give as necessary
  • Induction per Anesthesia care team (midazolam, hypnotic, paralytic)
  • Ketamine 0.2-0.5mg/kg x1 for All Patients

For Patients WITH THORACIC EPIDURAL

  • Epidural analgesia REDUCES MAC, reduce inhalational agent accordingly
  • Establish analgesic level prior toincision.
  • Immediately following induction: 5mL 0.25% bupivacaine or 1% Lidocaine per epidural.
  • Start infusion of 0.25% bupivacaine or 2% Lidocaine at 5mL per hour.
  • When patient’s epidural infusion arrives, connect and start
  • Discontinue other epidural infusion.
  • Hydromorphone PF bolus 0.2-0.5mg per Epidural
  • For perceived acute increase in pain:
  • Bolus 3-5mL 0.25% bupivacaine per epidural (preferred)
  • May also bolus Fentanyl 25mcg per epidural

For Patients WITHOUT THORACIC EPIDURAL

  • All infusions will decrease MAC as case proceeds, reduce gas accordingly
  • Opioid sparing infusions to begin after induction:
  • Ketamine infusion 0.05-0.1mg/kg/hr
  • D/C when closure begins
  • Lidocaine infusion 1-1.5mg/kg/hr
  • D/C at extubation
  • If TAPs block: D/C Lidocaine 1hr prior to end of case.
  • Dexmedetomidine infusion 0.2-0.5mcg/kg/hr
  • D/C at extubation
  • Fentanyl IV 25-50mcg for perception of breakthrough pain
  • Avoid longer-acting opioids
  • TransversusAbdominus Plane or Quadratus Lumborum blocks
  • Done at end of procedure, prior to extubation.
  • Call APS Resident (83324) at fascial closure
  • Dosing and block placement per APS Attending.

Post-operative:

For patients WITH THORACIC EPIDURAL

  • Pain Rounding Service will manage epidurals and ALL pain medications
  • PRS will facilitate transition to oral pain medications, as possible.
  • Multi-modal oral medications tailored to patient factors.
  • Primary team will manage after transition to oral medications.
  • Anticoagulation:
  • Managed by primary team, in conjunction with Pain Rounding Service
  • VTE prophylaxis
  • Heparin 5000 units subcutaneous BID or TID
  • If alternative to heparin, discuss with PRS Attending (34427)
  • VTE Treatment
  • Heparin Infusion to maintain target PTT (target aPTT not greater than 80)
  • Discuss with PRS Attending (34427)
  • Foley Catheter:
  • Managed by primary team
  • Early removal is desired
  • TEA T9-10 or above – May discontinue any time after POD #0
  • TEA T10-11 or below – Maintain until epidural removed
  • Fluid Management:
  • Per Primary Team

For Patients WITHOUT THORACIC EPIDURAL

  • Pain management:
  • PACU meds per intra-operative anesthesia team’s post-op orders
  • Fentanyl IV PRN and/or Hydromorphone IV PRN
  • Ketorolac IV PRN if cleared with surgeon and not previously administered
  • Post-PACU management per primary team.
  • Anticoagulation:
  • Per primary team
  • Foley Catheter
  • Per primary team
  • Fluid management
  • Per primary team