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
Obtain weight and height and record in the EMR
Draw ordered lab work. Send for diagnostic testing if indicated
Arrange for EKG if ordered
Sign and witness surgical and anesthesia consent
Apply and activate Bair Hugger warming gown
Intra-Operative Management
Equipment Checklist
Appropriate airway device
Invasive monitoring
Spinal kit with preservative-free morphine
Hemodilution bags x2
Albumin 5% 250 ml x2
Bair Huggers x2
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
