Perioperative Care Pathway designed to achieve early recovery

• Reexamined traditional surgical/anesthesia practices and replaced them with evidence-based best practices

• Comprehensive and Multidisciplinary Approach to Perioperative Care

• Reduce patient’s stress response, optimize physiologic function, and facilitate recovery

Perioperative Techniques proven to Decrease Length of Stay (30%) Decrease Perioperative Complications (50%) Decrease Nausea/Vomiting Decrease Postoperative Pain Decrease Time to Return to Baseline Function Improve Patient Satisfaction

Varandhan, KK et al. The enhanced recover after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin. Nutr 2010.

ERAS Society: History. Retrieved from http://erassociety.org/about/history/

International Journal of Surgical Research2014; 3(1): 1-6 doi:10.5923/j.surgery.20140301.01 Cytokines and Postoperative Hyperglycaemia: From Claude Bernard to Enhanced Recovery after Surgery

Enhanced recovery protocol after radical cystectomy for bladder cancer. Daneshmand S, Ahmadi H, Schuckman AK, Mitra AP, Cai J, Miranda G, Djaladat H. J Urol. 2014 Jul;192(1):50-5. doi: 10.1016/j.juro.2014.01.097. Epub 2014 Feb 8. PMID: 24518775

Preoperative

o Alvimopan (Urology) o Gabapentin 600mg PO (Urology) o Acetaminophen 1000mg PO (Urology) o Heparin 5,000 sq (Urology)- given prior to induction o 12 oz of Gatorade up to 2 hours prior to induction.

(PAT/Urology)

o Avoid Midazolam

o use fentanyl, if needed, for epidural placement

Intraoperative

o Ropiv 0.2% @ 3-5cc/hr via epidural o Vigileo for Goal Directed Fluid Therapy o 5% Albumin for Fluid Bolus o Maintain normothermia

o No NGT (OG Tube, intraop only)

o Maintenance 1-3cc/kg/hr Crystalloid

Postoperative

o Ropiv 0.1% or Ropiv/Sufenta via epidural x 72hrs o Maintenance fluids per Urology

Set up Vigileo

With patient on controlled ventilation, record SVV/ SV(Afib)

Start Plasmalyte at 1-3cc/kg/hr (max 400cc/hr)

Is SVV >13 or

SV increased by >10% with fluid

bolus??

Monitor SVV or SV

Give colloid (5%Albumin) bolus

of 250cc

YES

Is Pt hypotensive?

Consider starting vasopressor

NOO

NOO YES

Advanced Hemodynamic Monitoring: The Flotrac Sensor. Retrieved from https://www.edwards.com/eu/products/mininvasive/Pages/strokevolumevariationwp.aspx

Cystectomy Colorectal Breast Thyroid Thoracic Ortho (pending)

Liver (pending)

Carb Drink + + + + + +

Gabapentin + + + + + +

Tylenol + + + + +

Celebrex + + +

Regional Anesthesia

Epidural Epidural PECs Block

Epidural Peripheral nerve block

Epidural

Goal Directed Fluid Therapy

+ + +