Enhanced Recovery After Surgery »  Health Professionals »  Protocols »  Colorectal Enhanced Recovery Pathway
Enhanced Recovery After Surgery »  Health Professionals »  Protocols »  Colorectal Enhanced Recovery Pathway
Colorectal Enhanced Recovery Pathway
           
           
PERIOD MEDICATIONS ANESTHESIA SURGERY NURSING PATIENT
PREADMISSION PREPARE Phone Consult or Appointment Enter pre-op orders   Enroll in MyChart
Deliver instructions via MyChart or mail. Patient Education in Clinic    Prehabiliation:  Follow Exercise program in patient instructions
  Stoma marking if applicable    Visit ERAS website for information
DOS. PRE-OP     Pre-Op Warming. PIV. Crystalloid @ 30 ml/hr No bowel prep for ileocolic, right, transverse, colectomy Please complete Pre-Op RN checklist 45 minutes prior to OR start time, then Green Light. Nothing by mouth for eight hours before surgery except for a Boost Breeze completed 2 hours before coming to hospital.
MEDS ANALGESICS Gabapentin 600mg once Nothing by mouth for eight hours before surgery except for a Boost Breeze completed 2 hours before coming to hospital.
Acetaminophen 1000mg once Apply Warming Blanket to patient. Teach IS. Risks of surgery and anesthesia will be discussed.  You will sign a consent for the procedure, and discuss the possibility of receiving blood products.  
Diclofenac            (if eGFR>60) 100mg once IV Placed.  Crystalloid started at 30ml/hr.
PONV Scopolamine   1.5mg TD once Gabapentin 600, APAP 1000, Diclofenac given once with water (<100ml).  Antiemetics may also be ordered.
Age < 60 years   Consent checked, Site Marking, and 24-hr H&P completed 40 minutes before OR start time. If there is any chance you might be pregnant, please discuss with surgery and anesthesia
REGIONAL 30 minutes before start time, complete anesthesia assessment, go to Block Room, and place Thoracic Epidural placed at T8-10
  SCIP-VTE Heparin 5000units SQ X 1 after epidural placement If on steroids, ask for Hydrocortisone 100mg IV x 1    
INTRA-OP     Orogastric tube to low intermittent suction.    
    Fluids:  NTE 2L unless EBL>300ml,    
SCIP-10 Patient temperature must not drop below 36.0 C.        
SCIP-Inf-1,2 Antibiotic: Ertapenem 1 gram IV x 1      
MEDS   Opioid of Choice: Hydomorphone or Morphine.  Titrate to RR 12bpm at time of extubation.      
If Opioid-Tolerant, continue their opioid regimen intra-op.  Start ketamine load and infusion. 0.2 mg/kg x 1.  Then 2 mcg/kg/min.       
PONV Dexamethasone 4mg IV x 1 after induction      
Metoclopramide 10mg IV X 1. Unless contraindicated.      
Ondansetron  4mg IV x 1      
REGIONAL OR Thoracic Epidural 0.0625% Ropi + Fentanyl 2 mcg/ml @ 8 ml/hr      
Bilateral TAP Block. 20ml of Ropi 0.2%. Done prior to prep & drape.      
PACU MEDICATION Order opioid of Choice: 
Hydomorphone or Morphine. May start PCA.
Order Postop Colorectal Surgery Addendum # 154 Hydomorphone or Morphine IV PRN
Titrate to RR 10bpm
 
Order Antiemetics Choose Famotidine (if GERD or steroids ) Thoracic Epidural 0.0625% Ropi + Fentanyl 2 mcg/ml @ 8 ml/hr  
REGIONAL Thoracic Epidural 0.0625% Ropi + Fentanyl 2 mcg/ml @ 8 ml/hr Choose Toradol if appopriate   
FLOOR/ICU POD 0 MEDICATIONS Gabapentin 600mg PO QHS   Vital Signs q 4H, I&O shift, weight daily, surgical incision care abdomen,  Out of bed 6 hours after surgery
Acetaminophen 1000mg IV q6H   Out of bed 6 hours after surgery with assistance of Nursing Incentive Spirometry x10 q 1H
Toradol                 (if eGFR>60) 15mg IV q6H   Encourage Incentive Spirometry x10 q 1H Limited Clears 
If Opioid-Tolerant, continue ketamine infusion 2 mcg/kg/min and maintain daily opioid req.     Foley Catheter to gravity.   Gum Chewing OK
PCA HM 0.2/10/0   DVT Proph: Heparin 5kU SQ TID  
REGIONAL Thoracic Epidural 0.0625% Ropi + Fentanyl 2 mcg/ml @ 8 ml/hr       
FLOOR/ICU POD 1 MEDICATIONS Gabapentin 600mg PO QHS Evaluate IV Fluids and avoid hypervolumia  Vital Signs q 4H, I&O shift, weight daily, surgical incision care abdomen,  Walking 5 times a day.  At least first time with nurse.  
Acetaminophen 1000mg IV/PO q6H Labs: CBC, Cr, BUN Ambulation: OOB to chair (3hrs) BID
Ambulation 5 x per day
Incentive Spirometry x10 q 1H
Toradol OR
Diclofenac (eGFR)
15mg IV q6H
50mg PO TID
Advance diet to unlimited clears if tolerated and reg food later if doing well Encourage Incentive Spirometry x10 q 1H Unlimited clears or Reg diet 
If Opioid-Tolerant, continue ketamine infusion 2 mcg/kg/min and maintain daily opioid req.   Address Foley removal either today o POD 4 (if pelvic dissection) Remove Foley Catheter in AM Gum Chewing OK
PCA HM 0.2/10/0 Address steroid taper if appropriate  DVT Proph: Heparin 5kU SQ TID  
REGIONAL Thoracic Epidural 0.0625% Ropi + Fentanyl 2 mcg/ml @ 8 ml/hr   Unlimited clears or soft Diet. Gum chewing ok.    
FLOOR/ICU POD 2 MEDICATIONS Gabapentin 600mg PO QHS Evaluate IV Fluids and avoid hypervolumia  Vital Signs q 4H, I&O shift, weight daily, surgical incision care abdomen,  Walking 5 times a day. 
Acetaminophen 1000mg IV/PO q6H Labs: CBC, Cr, BUN Ambulation: OOB to chair (3hrs) BID
Ambulation 5 x per day
Incentive Spirometry x15 q 1H
Toradol OR
Diclofenac (eGFR)
15mg IV q6H
50mg PO TID
Regular diet /Low residue for new ileostomies or new working ileoanals  Encourage Incentive Spirometry x10 q 1H Regular diet / Low residue diet 
If Opioid-Tolerant, continue ketamine infusion 2 mcg/kg/min Nutrition Consultation for new ileostomies or new working ileoanal anastomosis     
If Opioid-Tolerant, continue their daily opioid requirement. Hold 6AM Heparin dose DVT Proph: Heparin 5kU SQ TID  
REGIONAL STOP epidural infusion at 6AM.  Catheter to be removed at 8AM.   Address steroid taper if appropriate  Regular diet / Low residue diet   
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