Post-Operative Care Algorithm for Pancreatic Resection

Supplemental Material

Post-operative care algorithm for pancreatic resection

Unasyn (or equivalent) is administered for the first 24 hours postoperatively and is then discontinued.
All patients who undergo Whipple or Total pancreatectomy are cared for the in the surgical intensive care unit (ICU) or the post-anesthesia care unit (with ICU-level care) on the operative day. Patients are then down-graded to a “stepdown” unit on postoperative day 1 unless continued ICU-level care is clinically indicated. Patients who undergo other partial pancreatectomy are transferred to a standard-acuity hospital bed from the post-anesthesia care unit.
Epidural or spinal catheter placement is not standardized. Patients are administered a PCA post-operatively and Ketorolac 15mg IV q8 hours is added on postoperative day #1 and continued for 5 days, unless a contraindication (bleeding or chronic renal insufficiency) is present. Discontinuation of PCA and transition to oral medications occurs when the patient can tolerate oral intake.
Patients routinely receive Furosemide IV (average dose 20mg) on postoperative day 2.
Patients are started on an insulin drip postoperatively if a single blood glucose is above 180mg/dL. Insulin drip is continued (with a goal blood glucose of 120-180mg/dL) while the patient is nil per os until the patient is tolerating oral intake. Oral hypoglycemic are not used while the patient is in the hospital. All patients who require insulin while the patient is tolerating meals are referred to the surgical endocrinology service, which provides diabetes education, instruction on the administration of medications, and outpatient follow-up for patients and care-givers.
All patients after Whipple or total pancreatectomy exit the operating room with gastric decompression, either by gastrostomy tube or nasogastric tube. Nasogastric tubes are removed and gastrostomy tubes are clamped on postoperative day 2. If after 6 hours of clamping of the gastrostomy tube, gastric residual volume is less than 250cc, the gastrostomy tube is clamped for an additional 18 hours. If residuals remain low, oral intake is begun. If clamp trials are aborted due to high residuals or symptoms (pain, bloating, nausea), or if a nasogastric tube needs to be reinserted due to pain, bloating, nausea, or vomiting, the stomach remains decompressed for 24 hours while metoclopramide 10mg IV q8 hours is started. Clamp trials resume after 24 hours of metoclopramide administration.
Foley catheter remains in place until postoperative day 2.
Abdominal wound dressings are removed on postoperative day 2.
Drain placement is not standardized, however, drain management is standardized: drains remain in until the patient tolerates oral intake. If output is less than 200cc per day, the drain is removed. Drain fluid is not routinely sent for chemistry analysis (Amylase, Lipase, Bilirubin), however, high drain output, change in drain consistency, or appearance of frank bile or purulent fluid in the drain are causes for fluid analysis.