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Troy Beaumont – ERAS protocol: Total Knee Arthroplasty (revised 2/21/2018)STTAR ClinicSurgeon provides patient with educational booklet and encourages patient to attend pre-op STTAR (Surgical Testing Accelerated Recovery & Teaching) clinicCase will be boarded with “ERAS” in case notesPatients phone screened at a scheduled appointment time by screening nurse. STTAR clinic appointment made at that time. Patients who attend STTAR clinic (ideal time is 3 weeks prior to surgery) will be instructed to start/increase physical activity, use incentive spirometer at least 30x daily, focus on stress/anxiety reduction, shower with CHG 3 times before surgery (2 nights pre-op, 1 night pre-op, and morning of surgery), drink Ensure 2 hours before arrival time, and that anticipated discharge with be on POD #1. Patients at STTAR clinic will have H&P with RAPT assessment completed, labs drawn, pre-op ERAS order set initiated, & offered hospital tour.Pre-op labs sent: CBC w/ diff, CMP, PT/INR, PTT, T&S, HbA1C, & S. Aureus Screen. UA w/ C&S will be obtained on symptomatic pts (dysuria, hematuria, urinary frequency or urgency) or with h/o recurrent UTIs or renal calculi.- Patients with + S. Aureus screen (MSSA & MRSA) will be instructed to fill Bactroban Rx provided by surgeon and complete 10 pre-op doses as directed.- If Hgb < 10, Hgb A1C > 7, and/or albumin < 3.5 STTAR clinic notify surgeon and refer to PCP for pre-operative management/optimization. If UA and/or urine C&S is abnormal, notify surgeon & surgeon to determine if treatment needed pre-operatively. If S. aureus screen is positive STARR clinic to direct patient to fill Bactroban Rx provided by surgeon’s office and use bid for full 5 days pre-operatively. If positive for MRSA, pre-operative antibiotics to be ordered = Vancomycin + cefazolin. Complete MARCQI surveysFollow up with PCP and/or specialist for pre-op clearancePre-opStart 1 18 gauge IV in pre-op. Pre-op antibiotics as ordered Neurontin 100 mg po given – hold if patient over 70 years old, with pre-existing confusion/sedation, or with renal dysfunctionTranexamic acid 1 gram IVPB (pre-op & intra-op doses both ordered in pre-op phase of care)Acetaminophen 1000 mg po Famotidine 20 mg IVAnesthesiologist completes PONV Risk Assessment Minimize pre-surgical narcotics & benzodiazepines, especially in elderly patientsDraw blood sugar on patients with HgA1C >6Intra-opSingle shot block anesthetic preferredFor bilateral total knees, use local only epiduralKetamine 0.25mg/kg IVP at induction. Maximum dose 50mgSurgeon may use local anesthetic at surgical site if appropriateRepeat blood sugar every 90 minutes if HgA1C >6.0 in pre-op, FBS >200 or insulin administeredIntra-op cocktail administered by surgeon: Toradol, morphine, epinephrine, ropivacaine & clonidine Decadron 8 mg IV at induction Zofran 4 mg IV at end of caseAdminister additional antiemetics per PONV Risk Assessment Tranexamic acid 1 gram IVPB at end of caseAquacel post-operative dressing placed per surgeon preferencePost-opIdentify Physician to Nurse order to indicate this is an ERAS patientPlace ice over surgical site in PACUNon diagnosed diabetic patients with a HbA1C >6 will have an internal medicine consultMedicationsToradol 15mg IV q 6hrs x 48 hours Ultram 50mg po q6 until discharge - initiate POD # 0 on floorAcetaminophen 1000mg po q6 hours until discharge - 1st dose to be given 6 hours after pre-op doseRobaxin 750 mg po q8 hours until dischargeNeurontin 100 mg po q8 hours for 72 hours - hold if patient over 70 years old, with pre-existing confusion/sedation, or with renal dysfunctionPrilosec 20 mg po daily Zofran 4mg IV or Reglan 10mg IV PRNRoxicodone 5mg po for moderate breakthrough pain Roxicodone 10mg po for severe breakthrough pain0.5mg Dilaudid IV PRN q3 for severe breakthrough pain (only after oral meds have been tried first)Post-op antibiotics given per protocolDietPatient to advance to regular diet on DOS as appropriate at nurse discretionActivityPatient gets out of bed on day of surgery Physician to nurse order to continue applying ice 20 minutes on and 20 minutes off throughout the dayKnee immobilizer in place for 48 hours post-op when out of bed Remove Foley 24 hours after spinalPhysician to nurse order to SL IV on POD #0 if tolerating clear liquidsIncentive spirometry 10 x/hour when awakePhysical Therapy and Occupational Therapy consultsAmbulate in hallway per PT VTE prophylaxis per surgeonLabsCheck blood sugar if HgA1C >6 POD #1 and #2Follow sliding scale per Internal Medicine if known diabeticDischarge/HomePatient discharged home using ERAS discharge instructions Patient receives discharge phone call from floor nurseMobic 15 mg po daily for 14 days (hold if patient has renal insufficiency)Robaxin 750 mg po q8 hours prn x 2 weeks Prilosec 20 mg po daily x 4 weeks PT planning prior to discharge ................
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