Bill Test

Pre-Operative Clinic

Information Given to Family at Pre-Admission Testing Appointment

  • Discuss plan and associated risks including:
    • Endotracheal tube (ETT),
    • Total intravenous anesthesia (TIVA),
    • IVs, invasive monitoring, possible need for central access,
    • Pain management, IT morphine injection,
    • Risk of vision loss,
    • Potential need for blood transfusion,
    • Post-op facial swelling andpressure points.
  • Time of arrival for surgery and where to check in.
  • NPO instructions.
  • Instruct patient to drink 10-12 oz of clear carbohydrate drink 2 hours prior to arrival.
  • Bathing protocol- Per Physician Preference.
  • Verify Procrit (epoetin alfa) regimen if ordered by the surgical service.

Pre-operative Labs

  • Type & Screen, CBC, chem-8, coagulation studies (INR, PT, PTT).
  • Pregnancy Test.
  • COVID-19 Test.

Order Appropriate Medications

  • Premeds for anxiety as indicated.
  • Gabapentin for day of surgery:
    • 600 mg for patients weighing > 50 kg, or
    • 10 mg/kg for patients < 50 kg.
  • Anti-emetic: if high-risk, consider Emend and placing a Scopolamine patch (1mg) behind the ear in preop area. It should remain on the patient for 72 hours.

Surgical Day

Holding Area

  1. Obtain weight and height and record in the EMR
  2. Draw ordered lab work. Send for diagnostic testing if indicated
  3. Arrange for EKG if ordered
  4. Sign and witness surgical and anesthesia consent
  5. Apply and activate Bair Hugger warming gown

Intra-Operative Management

Equipment Checklist

  1. Appropriate airway device
  2. Invasive monitoring
  3. Spinal kit with preservative-free morphine
  4. Hemodilution bags x2
  5. Albumin 5% 250 ml x2
  6. Bair Huggers x2
  7. Hotline connected to a blood transfusion set

Anesthesia Pathways

  • Pathway 1: Intrathecal Morphine (max 5-10mcg/kg - 0.5 mg) + Remifentanil (0.05-0.4mcg/kg/min)
    (If spinal placement is challenging, have surgeon place spinal or IV methadone)

  • Pathway 2: IV Methadone 0.2mg/kg + Remifentanil (0.05-0.4mcg/kg/min)

All Cases Get:

  • Lidocaine: 2 mg/kg iv bolus, infusion at 1 mg/kg/hr
  • Phenylephrine drip on standby
  • Propofol infusion: BIS goal of 50-60

Anti-Fibrinolytic

  • Amicar-Load: 100 mg/kg over 30 minutes (max 5 g). Maintenance infusion at 30 mg/kg/hour, continue until skin closure
  • TXA-Load: 50 mg/kg over 30 minutes (max 5 g). Maintenance infusion at 5 mg/kg/hour, continue until skin closure

Antibiotics

  • Cefazolin 25mg/kg (max 2 g) – Re-dose q4h
  • If allergies: Clindamycin 10mg/kg (max 900mg). Re-dose q6h or Vancomycin 10mg/kg (max 1g) Re-dose q6h

Other Medications

  • Neuromonitoring: MEP/SSEPs/EMGs typically monitored. Place bilateral soft bite blocks!
  • Dexamethasone: 4mg
  • Ondansetron: 4mg
  • Diazepam IV 0.05 mg/kg or Methocarbamol (Robaxin): 15mg/kg IV after emergence to treat muscle spasms
  • Minimal to no paralysis on intubation. No nitrous. Max 0.5 MAC inhalation agent – Sevoflurane for rapid emergence

Post-Op Orders Before Leaving OR

  • Demand only PCA
  • If no IT morphine given: Methadone 0.1mg/kg IV/PO x 2 q6h, timed 6 hours after initial dosing
  • Contact the acute pain team add the patient to pain list