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132
A. S. Wright and R. P. Petersen
Standardized discharge criteria are important and help make sure that all mem­bers of the team, the patient, and the patient’s support structure are all in alignment. There is no need to await bowel movement prior to discharge. Patient-friendly care maps can be posted on the wall or on a whiteboard in each room to help with com­munication of these goals, which typically are: (1) tolerating diet and taking suf­cient oral intake, (2) on a sustainable oral pain regimen, and (3) able to assume self-care or has adequate help to ensure safety.
Patient Education
Patient and caregiver education is essential in any ERAS program, and this starts at the rst pre-operative clinic visit. Good patient education results in shorter hospital stays, less need for analgesia, increased patient satisfaction, and increased patient compliance [60, 61]. Clear written guidelines should include specic goals for each day, the expected length of stay, and discharge criteria. These patient-friendly care maps should be designed for patients with potentially limited health literacy, include visuals and images, and ideally be available in multiple languages. They should also follow the patient into the hospital, and in our practice are posted in each patient’s room in order to help with coordination and communication. Our hernia care map is seen in Appendix 2.
Design andImplementation ofanERAS pathway
Every hospital has its own institutional culture, and therefore each ERAS pathway will be to some degree unique in response to clinical practices, administrative sup­port, and patient population [62]. A suggested plan and timeline for implementation can be found on the SAGES SMART website at https://www.sages.org/enhanced-
recovery/sages-smart-implementation-timeline/ [63]. The development process
should start with identication and recruitment of champions from a multidisci­plinary team, including from surgery, nursing, anesthesia, pharmacy, physical and occupational therapy, nutrition, and information technology. The importance of administration buy-in cannot be overstated, and it can be particularly helpful to build a business-case to support the investment in time and money that implementa­tion requires [64]. Current practices need to be reviewed, along with an assessment of evidence-based guidelines. After a draft protocol has been developed, it needs to be presented to relevant stakeholders and edited based on feedback. Once nalized it needs to be translated into actionable items, including standardized forms, tem­plates, patient education materials, and order sets. Auditable metrics such as cost, length of stay, and readmission rates need to be identied and tracked well before the go-live date, in order to be able to measure any positive or negative impact of the
10 Enhanced Recovery inAbdominal Hernia Repair
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133
ERAS pathway [65]. It is important to set timelines for review and revision after go-live, and it is frequent for pathways to need to be modied based on patient out­comes, new practice patterns, or new developments.
Appendix 1: UW Medicine Hernia ERAS Protocol
Complex Hernia Clinical Pathway
Activities Before Surgery
Week-4 to -6 Day-5 to -6 Day-1
Clinic Visit • Implement strong for surgery
Diet •
Medications Other • Patient to follow
pre-hospital clinical interventions
• RN teach class: Patient CareMap and reference Med Consult note
– Tell patient to bring most current
medication list to hospital for review and bring home medication bottles for review (cannot take in hospital)
Clinic provide patient with 2×8oz
• of apple juice and directs patient to drink 1×8oz before midnight night prior to surgery and 1×8oz after parking at hospital day of surgery
•
PCC schedules follow-up visit for 2 weeks post-op (encourage patient to schedule 1-week post-op with PCP immediately following call)
• Consent signed
• MRSA/MSSA screen
• Impact drink 6 days prior (optional)
• If MRSA/ MSSA positive, Intranasal Mupirocin for 5 days prior
Drink 1×8oz of apple juice before midnight
• No food after midnight, clear liquids as instructed
pre-surgery shower and shaving instructions
• Patient to bring 1×8oz bottles of apple juice to hospital
134
A. S. Wright and R. P. Petersen
Complex Hernia Clinical Pathway
Day 0: Pre-, Intra-, and Post-Operative Milestones
Pre-OP Intra-OP
Pain • 1000mg Acetaminophen po (then
Diet • Carbo loading: apple juice 2–3h
Fluids • If IV in place, LR at 50mL/h • Induction period—7mL/kg of LR
Mobility Medications • Abx per standard pre-op orders
Vitals/ Monitoring
Equipment • Portable sequential compression
Support Services
Other • Patients should be admitted in
po or IV q6h until discharge)
• Gabapentin 300mg po (continued once tolerating pills again)
• Thoracic Epidural—aimed at upper level of incision (tested with 3mL
1.5% Lidocaine w/Epi 1:200K)
prior to surgery; patient directed to drink 1×8oz immediately after parking at the hospital
– If MRSA positive; administer
Vancomycin and abx per standard pre-op orders
• For Bowel Resection ONLY (5% of cases); minimum of 30min prior: Alvimopan 12mg po q12h until rst B.M. or discharge
– Unless chronic opioid user (on
narcotics within 1 week of surgery)
• Heparin 5000 units subcu
• Blood glucose check. If >100, recheck 30–60min after incision. If >140 start insulin GTT
devices on in pre-op
inpatient status
• Have sleeve patients void prior to moving back to OR
• Pain: 1/16% Bupivacaine plus Fentanyl 2μg/mL infused at 10mL/h started ASAP after anesthesia induction. Avoid systemic opiates (especially Morphine and Dilaudid)
over 30min
• During surgery—5mL/kg/h of LR.Target a urine output of
0.3–0.5mL/kg/h
• Blood loss—replace with colloid (5% Albumin) mL for mL
• Abx per standard intra-op orders
• Continue glucose management
• Place Foley
• No nasogastric tubes (remove at end of case if placed for gastric decompression)
• Abdominal binder for comfort per surgeon discretion
10 Enhanced Recovery inAbdominal Hernia Repair
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Complex Hernia Clinical Pathway
Day 0: Pre-, Intra-, and Post-Operative Milestones
PAC U
Pain • Changed to PCEA with 6mL/h infusion
Diet Fluids • LR at 1mL/kh/h
Mobility Medications Vitals/Monitoring • Continue glucose management Equipment Support Services Other
•
Breakthrough pain: Epidural Fentanyl (25–50μg) (followed by 3cm NS) and infusion increased, by 2mL/h—followed by increased Bupivacaine concentration (1/10% then 1/8%) if BP okay
– If BP low or marginal or pressors ongoing talk with surgeons about
ketorolac (vs. bleeding vs. nephrotoxic risks vs. anastomotic risk). If BP unable to be controlled with low dose pressors or uid bolus
3
(500cm
) “split” epidural (take fentanyl out of epidural infusion and
add IV opiate PCA) in preparation for, or as start of, stopping epidural
• Target urine output of 0.3–0.5mL/kg/h
135
3
Complex Hernia Clinical Pathway
Inpatient Milestones: Target Post-op LOS=3–4 Days
Day 0 Day 1
Pain • PCEA and acetaminophen PO continued. After
Diet • Ice chips and sips of clears • Advance diet as tolerated. General diet, if
Fluids •
Mobility • Edge of bed after last set
of post-op VS (usually 6h) with orthostatic VS
Medications •
Heparin 5000 units subcu q8h
Vitals/ Monitoring
Continue glucose
• management
clear liquid lunch, start ibuprofen 600mg po q6h (consider ketorolac 15mg q6h if opiate side effects and NPO)
patient has no nausea, no distention, no belching/hiccups
LR at 1mL/kg/h. Cease IV uids asap. Saline lock IV uids when oral intake greater than 500 or adequate urine output. Aim for early oral uid intake
• OOB for all meals. Walk 3–4 times in the hall—Goal 9 laps. OOB 6h/day
• Start 17g Mirolax 1× daily
• Labs Days 1–4, as clinically indicated
136
Inpatient Milestones: Target Post-op LOS=3–4 Days
Day 0 Day 1
Equipment • Incentive spirometer 10×/h
while awake until discharge
• Sequential compression devices on, unless ambulating until discharge
Support Services
Day 2 Day 3–4
Pain • Epidural stopped and
oxycodone started after breakfast tolerated (epidural pulled 4h later)
Diet • Advance diet as tolerated.
General diet, if patient has no nausea, no distention, no belching/hiccups
Fluids Mobility • OOB for all meals. Walk
3–4 times in the hall— Goal 18 laps. OOB 6h/ day until discharge
Medications • DC Alvimopan (if bowel movement)
Vitals/ Monitoring
Equipment • JP drain teaching Support
Services
• DC Foley (just pull)
• PT visit on day 1, latest
• Gabapentin discontinued on day 3
• Do not prescribe Gabapentin at discharge
• Acetaminophen and ibuprofen continued at discharge
– Unless chronic opioid user (on narcotics
within 1 week of surgery)
• Advance diet as tolerated. General diet, if patient has no nausea, no distention, no belching/hiccups
• OOB for all meals. Walk 3–4 times in the hall—Goal 18 laps. OOB 6h/day until discharge
• Med rec on day before discharge
A. S. Wright and R. P. Petersen
10 Enhanced Recovery inAbdominal Hernia Repair
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Appendix 2: Patient-Friendly Hernia Care Map
137
138
A. S. Wright and R. P. Petersen
10 Enhanced Recovery inAbdominal Hernia Repair
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139
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