Julie Thacker



Troy Beaumont – ERAS protocol: Bariatric Surgery – revised 6/29/18STTAR ClinicBariatric ERAS patients are patients of Drs. Krause, Kole, and Chengelis who are scheduled to have Gastric Bypass, Sleeve, or Lap band proceduresSurgeon provides patient with general surgery educational booklet and encourages patient to attend pre-op STTAR (Surgical Testing Accelerated Recovery & Teaching) clinicCase will be boarded with “ERAS” in case notesPatients are phone screened at a scheduled appointment time by screening nurse. STTAR clinic appointment made during the phone screen appointment. Patients who attend STTAR clinic, ideally 3 weeks prior to surgery, will be instructed to: start/increase physical activity, use incentive spirometer, stress/anxiety reduction, drink pre- op Ensure 2 hours before arrival time. Patients at STTAR clinic will have CBC with diff, BMP, T&S, and HbA1C drawn, CXR & PT/PTT to also be completed in clinic on Dr. Kole patients, verify pre-op EKG completed & obtain if not, pre-op ERAS order set initiated & offered hospital tour Carboxyhemoglobin drawn in STTAR Clinic for those with tobacco use in last 1 year, if abnormal carboxyhemoglobin to be repeated on DOS (for Dr. Kole’s patients).Order HbA1C on all patients who attend STTAR clinic 3 weeks prior to surgery – consult with surgeon, MDA, PCP if >9. Patients instructed to shower with antibacterial soap 3 times prior to surgery on 2 nights before surgery, 1 night before surgery, and morning of surgery. Patient provided with special instructions to thoroughly clean their belly button.Patient provided with instruction regarding CPAP machine and scopolamine patch - instruct patient to keep patch on during admission & may be removed at time of discharge Dr. Kole patients that are not participating in the WCC Bariatric program:? Receive pre-op diet instruction through Dr. Kole’s office (pt directed to Dr. Kole’s office following STTAR Clinic appt) – Dr. Kole patients that are participating in the WCC Bariatric program:? Receive pre-op diet instruction through the WCC dietitiansPre-op Start 1 IV in preop. Fluids based on patient needs.Ofirmev 1 gram IV to be given 30 minutes prior to end of case (ordered with pre-op phase of care meds)Neurontin 300 mg po - hold if patient >70 years old, with pre-existing confusion/sedation, or with renal failureLovenox 30mg or 40mg subcutaneously depending on weight - BMI of 50 or greater to have 40mg LovenoxPepcid 20 mg IVApply scopolamine patch (will remain in place post-op until time of discharge)Administer pre-op antibioticsAvoid/limit pre-surgical narcotics & benzodiazepinesNo epiduralsDraw blood sugar on patients who have a HgA1C >6Intra-opLidocaine bolus 1.5mg/kg with induction followed by infusion at 2 mg/min <70 kg or 3 mg/min 70 kg and above until emergenceUse sevoflurane for the duration of the caseKetamine 0.25mg/kg IVP at or just after induction. Maximum dose 50 mg. Goal directed Fluid therapyNG tubes should be avoided (use of OG for decompression ok) Visigi bougie for lap sleevesSurgeon use local anesthetic at surgical site if appropriateMonitor blood sugar if HgA1C >6.0 in pre-op or FBS >200Toradol 15 mg IVP to be given at end of case – per surgeon preference Zofran 4mg at end of caseDecadron (Dexamethasone) 8 mg IV at inductionPACUIce chips only in PACUMaintain scopolamine patchPost-opIdentify Physician to Nurse order to indicate this is an ERAS patientMedicationsScopolamine patch (placed in pre-op) to continue and be removed at time of dischargeCelebrex 200mg po daily until dischargeAcetaminophen elixir 1000mg po 6 hours after intra-op dose (1 dose only)Neurontin 300mg po q8 hours x72 hours - hold if patient > 70 years old, with pre-existing confusion/sedation, or with renal failurePCA for POD #0 – per surgeon preference – discontinue PCA once oral pain medications orderedPepcid 20 mg IV bidHycet 15 ml po q4 hours prn (max dose: 6 tablespoonfuls daily) vs. Norco 10/325 mg po q4 hours prn beginning on POD #1 -per surgeon preference DietPOD #0 – NPO except ice chips and popsiclesPOD #1 - drink protein shake (Boost) in morning and then advance diet as directed per surgeon preferencePatient to chew sugar free gum 20 min 3 times daily in chair if not contraindicated (implants, sedated) Avoid use of strawsActivityPatient gets out of bed on evening of surgery POD #0 (if tolerated on nursing assessment)Patient to take multiple brief walks & be up in bedside chair 6-8 hours daily as tolerated beginning POD #1Patient to complete limb/breathing exercises 10 times/hour when awakeIf CPAP dependent, resume nightly with same home settings.LabsCheck blood sugar if HgA1C >6 POD1 and 2Discharge/HomePatient discharged home using ERAS discharge instructions Patient receives discharge phone call from floor nurse ................
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