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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
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 sufcient 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 specic 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 andImplementation ofanERAS 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 identication 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 identied 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 inAbdominal Hernia Repair
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 modied 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
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 2×8oz
of apple juice and directs patient to
drink 1×8oz before midnight night
prior to surgery and 1×8oz 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
Diet • Drink 1×8oz of
Medications
Other • Patient to follow
• Impact drink 6
days prior
(optional)
• If MRSA/
MSSA positive,
Intranasal
Mupirocin for 5
days prior
apple juice before
midnight
• No food after
midnight, clear
liquids as
instructed
pre-surgery
shower and
shaving
instructions
• Patient to bring
1×8oz 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 • 1000mg Acetaminophen po (then
Diet • Carbo loading: apple juice 2–3h
Fluids • If IV in place, LR at 50mL/h • Induction period—7mL/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 300mg po (continued
once tolerating pills again)
• Thoracic Epidural—aimed at upper
level of incision (tested with 3mL
1.5% Lidocaine w/Epi 1:200K)
prior to surgery; patient directed to
drink 1×8oz 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 30min prior:
Alvimopan 12mg 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 30–60min 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 2μg/mL infused at 10mL/h
started ASAP after anesthesia
induction. Avoid systemic opiates
(especially Morphine and Dilaudid)
over 30min
• During surgery—5mL/kg/h of
LR.Target a urine output of
0.3–0.5mL/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 inAbdominal Hernia Repair
Complex Hernia Clinical Pathway
Day 0: Pre-, Intra-, and Post-Operative Milestones
PAC U
Pain • Changed to PCEA with 6mL/h infusion
Diet
Fluids • LR at 1mL/kh/h
Mobility
Medications
Vitals/Monitoring • Continue glucose management
Equipment
Support Services
Other
• Breakthrough pain: Epidural Fentanyl (25–50μg) (followed by 3cm
NS) and infusion increased, by 2mL/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
(500cm
) “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 0.3–0.5mL/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 • LR at 1mL/kg/h. Cease IV uids asap. Saline
Mobility • Edge of bed after last set
of post-op VS (usually
6h) with orthostatic VS
Medications • Heparin 5000 units subcu
q8h
Vitals/
Monitoring
• Continue glucose
management
clear liquid lunch, start ibuprofen 600mg po
q6h (consider ketorolac 15mg q6h if opiate
side effects and NPO)
patient has no nausea, no distention, no
belching/hiccups
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 6h/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 4h 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 6h/
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 6h/day until
discharge
• Med rec on day before discharge
A. S. Wright and R. P. Petersen
10 Enhanced Recovery inAbdominal Hernia Repair
Appendix 2: Patient-Friendly Hernia Care Map
137
138
A. S. Wright and R. P. Petersen
10 Enhanced Recovery inAbdominal Hernia Repair
139
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