1. Ambulatory General Surgery CarePath
Laparoscopic
Open
Goals
Reduce PACU length of stay and increase patient satisfaction by reducing post-op pain, PONV, and sedation by minimizing opioids and incorporating a multimodal analgesic regimen.
To whom it applies
Laparoscpic cholecystectomy
Lap inguinal hernia
Lap ventral hernia
Open inguinal hernia
Umbilical hernia
Anorectal surgery
Access Port placement and removal.
Medications
Please check for allergies, contraindications and appropriateness of medications for all patients before ordering.
Meds ordered night before
Pregabalin 75mg PO x 1.
Acetaminophen 1000mg PO x 1
No Gabapentinoids routinely
Consider a holding area huddle:
Huddle between surgical, anesthesia teams and the patient to discuss:
PO meds administered in holding area.
Prescriptions that the patient will take home (so that PACU orders can be coordinated).
Blocks
Usually no blocks indicated
All cases that need a block will be booked as such ( if not booked as a block ,surgeon will infiltrate locally)
Type of Anesthesia
General
General or MAC depending on patient and complexity.
Induction
Dexamethasone 8mg IV SLOW
Dexamethasone 4mg IV SLOW except for the anal condyloma and dysplasia cases
Surgeon
Surgeon to instill local anesthetic at the port sites in laparoscopic at placement and again on removal.
Surgeon to instill local anesthetic into wound if no block has been placed.
Intraop
Consider Ketorolac mins before the end of the case
Ondansetron 4mg IV at end of case.
Minimize IV fluids <1200 ml
Minimal opioids. Short acting (Fentanyl or Dilaudid in low doses).
Voiding
Voiding requirements only for inguinal hernia surgery with any of the following risk factors. Patient will follow the voiding protocol if they have to demonstrate voiding before discharge.
Pts with h/o urinary retention
H/o BPH
Fluid administration >1200 ml for the case and age >65
PACU
PO Opioid as needed when able to tolerate PO.
IV opioid (fentanyl or hydromorphone in low doses) for breakthrough pain, if unable to tolerate PO, or VAS>5.
IV opioid (fentanyl or hydromorphone in low doses) for breakthrough pain, unable to tolerate PO, or VAS>5
Authors
Dana Fugelso M.D, Michael Cahalane M.D, Peter Mowschenson M.D, Sowmya Mahapatra M.D, Irina Fishman M.D, Susan Dorion RN BSN MSN , Eswar Sundar M.D, Cullen Jackson Ph.D., Pete Panzica M.D, Meghan Connolly RN, BSN, ACNP, Mary Ellis RN BSN, Marianne McAuliffe RN, BSN, Kathleen Mulligan RN, BSN, Elena Canacari RN, John Tumolo,