Enhanced recovery pathways

[anonperson]

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Since the OBGYN forum is dead, right i would post this here.

Just started out in practice. The place I'm at doesn't have a formal enhanced recovery order set so i carried one over from fellowship.

My current regimen :
Pre op
600mg gabapentin
1000mg po tylenol
400mg celebrex (i think this is not recommended for bowel cases but am unsure)

Intra op
Placed an On Q pain pump with ropivicaine, 0.2% at 6ml/hr

Post op
1000mg tylenol q6h scheduled
Toradol iv or ibuprofen po depending on nausea, scheduled
Prn oxycodone
Ivf run at like 75ml hr and dced when taking in 500ml po

Had a abdominal hysterectomy for an enlarged fibroid uterus (16 week) . Did it through a pfannenstiel incision.

Surprisingly patient did very well. Better than i expected. She didn't require any narcotics post op which was great. Just tylenol and ibuprofen and dced post op day 2.

Ideally I would do cases laparoscopically or transvaginally but for these open cases this worked well.

Any other variations?

 

[doc05]

Stop giving so much Tylenol. It's much more dangerous than we realize.
Consider an epidural. Works much better than that silly On-Q pump.

 

[anonperson]

Stop giving so much Tylenol. It's much more dangerous than we realize.
Consider an epidural. Works much better than that silly On-Q pump.

Supervised tylenol is fine. Have not had any issues with it in patients without liver dysfunction.

Epidural seems like overkill. Plus adds additional time to place it in the beginning of the case. I can place this in under a minute at the end of the case.

 

[AdmiralChz]

My current regimen :
Pre op
600mg gabapentin
1000mg po tylenol
400mg celebrex (i think this is not recommended for bowel cases but am unsure)

Intra op
Placed an On Q pain pump with ropivicaine, 0.2% at 6ml/hr

Post op
1000mg tylenol q6h scheduled
Toradol iv or ibuprofen po depending on nausea, scheduled
Prn oxycodone
Ivf run at like 75ml hr and dced when taking in 500ml po

Great regimen, needs some tweaks as others have alluded. Glad to see you being proactive and not just pounding the narcotics, but not being so rigid to not allow them at all (classic academics these days).

- Too much acetaminophen, many sources now recommend a max daily dose of 3000 mg daily rather than 4000 mg (probably less if you are taking it for a long period of time, not applicable here). So 800 mg to 1000 mg q8h.
- Love the Toradol, much better than PO ibuprofen. Just do it q8h for 24 hours and stop, convert over to PO ibuprofen. Longer (more than 36 hours postop) and you're putting them at risk for AKI.
- Did you place the On Q pump (if so, where?) or is that an anesthesiologist-placed epidural? Who is managing and adjusting the dose? I agree with others that an epidural is probably a bit much for a Pfannenstiel incision. Better for larger midline (e.g. open colectomy) incision with copious bowel manipulation predisposing a patient to ileus... I digress, though.
- You could consider keeping the Celebrex postop instead of PO ibuprofen, it's a fantastic medication and works great. You might get some pushback if it's not on formulary at your place, though.

EDIT: On re-read looks like you are placing an On Q rather than epidural, which is interesting. I think local infiltration with Marcaine should be enough, or if you want to get fancy you can use Exparel if you have it (liposomal bupivacaine, lasts days). Less equipment attached to the patient.

 

[SLUser11]

Since the OBGYN forum is dead, right i would post this here.

Just started out in practice. The place I'm at doesn't have a formal enhanced recovery order set so i carried one over from fellowship.

My current regimen :
Pre op
600mg gabapentin
1000mg po tylenol
400mg celebrex (i think this is not recommended for bowel cases but am unsure)

Intra op
Placed an On Q pain pump with ropivicaine, 0.2% at 6ml/hr

Post op
1000mg tylenol q6h scheduled
Toradol iv or ibuprofen po depending on nausea, scheduled
Prn oxycodone
Ivf run at like 75ml hr and dced when taking in 500ml po

Had a abdominal hysterectomy for an enlarged fibroid uterus (16 week) . Did it through a pfannenstiel incision.

Surprisingly patient did very well. Better than i expected. She didn't require any narcotics post op which was great. Just tylenol and ibuprofen and dced post op day 2.

Ideally I would do cases laparoscopically or transvaginally but for these open cases this worked well.

Any other variations?

Sugar free chewing gum! Costs almost nothing and reduces ileus (23 hours) just as much as Entereg ($90/pill). There is some chewing gum literature for gynecology, but I haven't reviewed it for about 8-10 years.

I use the pfanny all the time as well and love it, although my incision is likely smaller (5cm for extraction or 8cm for hand-assist) if you have big fibroids to remove. Low transverse muscle-sparing incisions have less pain, lower rates of SSI, lower rates of hernia, and better cosmesis when compared to lower midline incisions...OBGYN figured this out way before we did.

Instead of an on-Q pump, I tend to have anesthesia perform a TAPP block. They often use Exparel for this, although there's no convincing data for or against it.

Just glancing at the rest, I think you probably could just give 300 of Neurontin preop. You could also consider carb loading preop (maltodextrin-based) and even prehab. Fluid management in the OR is just as important as your postop mgmt. You should also employ all the other components of ERAS not mentioned here (early ambulation, diet as tolerated, foley removed POD 0-1).

Many ERAS protocols exist, but I would look at ones published by Conor Delaney (most pubs from Case Western but recent ones from Cleveland Clinic) as his protocol is very mature and very effective.

There's nothing wrong with using epidurals for open surgeries, but they don't have any benefit in laparoscopic colorectal surgery, so I've been using TAPPs in my patients. Still, a well-placed epidural can be done with good analgesia and usually you don't need to leave the foley in place.

Remember that you can write up a beautiful protocol, but the biggest issue is compliance, so you need to educate other members of your team (nurses in your office, floor nurses, anesthesia, residents, etc). Otherwise it will never reach its full potential.

 

[ThoracicGuy]

I love exparel, but the hospital system has banned it from use because of costs. Nevermind that I did intercostal nerve blocks with it on a few people before the ban and they had minimal pain afterwards and went home early from a thoracotomy and decortication...

But its $300/vial vs $10/vial of plain marcaine.

 

[Psai]

I love exparel, but the hospital system has banned it from use because of costs. Nevermind that I did intercostal nerve blocks with it on a few people before the ban and they had minimal pain afterwards and went home early from a thoracotomy and decortication...

But its $300/vial vs $10/vial of plain marcaine.

Whats wrong with bupi with dex

 

[ThoracicGuy]

Whats wrong with bupi with dex

That's what I use now. It doesn't seem to work as well as exparel.

 

[idiot07]

Since the OBGYN forum is dead, right i would post this here.

Just started out in practice. The place I'm at doesn't have a formal enhanced recovery order set so i carried one over from fellowship.

My current regimen :
Pre op
600mg gabapentin
1000mg po tylenol
400mg celebrex (i think this is not recommended for bowel cases but am unsure)

Intra op
Placed an On Q pain pump with ropivicaine, 0.2% at 6ml/hr

Post op
1000mg tylenol q6h scheduled
Toradol iv or ibuprofen po depending on nausea, scheduled
Prn oxycodone
Ivf run at like 75ml hr and dced when taking in 500ml po

Had a abdominal hysterectomy for an enlarged fibroid uterus (16 week) . Did it through a pfannenstiel incision.

Surprisingly patient did very well. Better than i expected. She didn't require any narcotics post op which was great. Just tylenol and ibuprofen and dced post op day 2.

Ideally I would do cases laparoscopically or transvaginally but for these open cases this worked well.

Any other variations?

I do something similar for thoracic cases. Bigger dose of Neurontin, intraop toradol instead of Celebrex. Our anesthesiologist got us to add .2 mg po of clonidine preop, as well, if the patient's heart rate is greater than 60. Difficult to tell if it helps much, but certainly hasn't caused any issues, even with an epidural.

Thoracic Guy, I'm in same boat with the hospital banning exparel. Though given the cost, I tend to agree with them, particurlarly for vats cases. The guys that sell the cryo-probes for afib ablation were trying to get me to use it to ablate the intercostal nerves instead of blocking them. Supposedly, you get 6 weeks or so of pain control with this. I thought it seemed a little crazy and out of bounds with regard to costs. Do you have any experience with this?

 

[MediCane2006]

I'm working on something like this for our plastics patients - the two biggest changes have been intraoperative injection of the pec fascia (in breast) or TAP block (in abdomens) with marcaine, and postop toradol (I've gotten a ton of pushback on this, but I use toradol on all my cases and actually have a much lower postop hematoma rate than my partner, so I'm trying to bolster it with both anecdotal and published data 😉). Our anesthesiologists are also pretty aggressive about premedicating patients and doing preop blocks when possible.

 

[Dr G Oogle]

I'm working on something like this for our plastics patients - the two biggest changes have been intraoperative injection of the pec fascia (in breast) or TAP block (in abdomens) with marcaine, and postop toradol (I've gotten a ton of pushback on this, but I use toradol on all my cases and actually have a much lower postop hematoma rate than my partner, so I'm trying to bolster it with both anecdotal and published data 😉). Our anesthesiologists are also pretty aggressive about premedicating patients and doing preop blocks when possible.

I’ve anecdotally found abdominal binders placed before patient leaves the OR to significantly minimize narcotic use even for laparoscopic cases.

 

[anonperson]

Great regimen, needs some tweaks as others have alluded. Glad to see you being proactive and not just pounding the narcotics, but not being so rigid to not allow them at all (classic academics these days).

- Too much acetaminophen, many sources now recommend a max daily dose of 3000 mg daily rather than 4000 mg (probably less if you are taking it for a long period of time, not applicable here). So 800 mg to 1000 mg q8h.
- Love the Toradol, much better than PO ibuprofen. Just do it q8h for 24 hours and stop, convert over to PO ibuprofen. Longer (more than 36 hours postop) and you're putting them at risk for AKI.
- Did you place the On Q pump (if so, where?) or is that an anesthesiologist-placed epidural? Who is managing and adjusting the dose? I agree with others that an epidural is probably a bit much for a Pfannenstiel incision. Better for larger midline (e.g. open colectomy) incision with copious bowel manipulation predisposing a patient to ileus... I digress, though.
- You could consider keeping the Celebrex postop instead of PO ibuprofen, it's a fantastic medication and works great. You might get some pushback if it's not on formulary at your place, though.

EDIT: On re-read looks like you are placing an On Q rather than epidural, which is interesting. I think local infiltration with Marcaine should be enough, or if you want to get fancy you can use Exparel if you have it (liposomal bupivacaine, lasts days). Less equipment attached to the patient.

Will probably redose to the tylenol to a 1000 q8hr.

I place the pump right before closure of the fascia. It is a surgeon placed device. The catheter goes subfascial. The pump settings can be adjusted by the physician. In my brief experience with it, I have typically used the a standard dosing, ropivicaine at 6mL/hr. I know some of the surgeons abandoned using it when they were getting pain relief with subcutaneous placement of the pump.

Regarding the marcaine, are you talking about injecting just below the skin or the fascia itself? I haven't gotten a chance to use exparel before. I looked and it appears to be on our formulary but I would want to talk with some of the anesthesia docs before using as I don't have a lot of experience with it.

 

[anonperson]

Sugar free chewing gum! Costs almost nothing and reduces ileus (23 hours) just as much as Entereg ($90/pill). There is some chewing gum literature for gynecology, but I haven't reviewed it for about 8-10 years.

I use the pfanny all the time as well and love it, although my incision is likely smaller (5cm for extraction or 8cm for hand-assist) if you have big fibroids to remove. Low transverse muscle-sparing incisions have less pain, lower rates of SSI, lower rates of hernia, and better cosmesis when compared to lower midline incisions...OBGYN figured this out way before we did.

Instead of an on-Q pump, I tend to have anesthesia perform a TAPP block. They often use Exparel for this, although there's no convincing data for or against it.

Just glancing at the rest, I think you probably could just give 300 of Neurontin preop. You could also consider carb loading preop (maltodextrin-based) and even prehab. Fluid management in the OR is just as important as your postop mgmt. You should also employ all the other components of ERAS not mentioned here (early ambulation, diet as tolerated, foley removed POD 0-1).

Many ERAS protocols exist, but I would look at ones published by Conor Delaney (most pubs from Case Western but recent ones from Cleveland Clinic) as his protocol is very mature and very effective.

There's nothing wrong with using epidurals for open surgeries, but they don't have any benefit in laparoscopic colorectal surgery, so I've been using TAPPs in my patients. Still, a well-placed epidural can be done with good analgesia and usually you don't need to leave the foley in place.

Remember that you can write up a beautiful protocol, but the biggest issue is compliance, so you need to educate other members of your team (nurses in your office, floor nurses, anesthesia, residents, etc). Otherwise it will never reach its full potential.

Thanks for sources. Will look into it.

Will typically remove foley 12 hours post op and can eat whatever they want.

Will have to see if we can get that going regarding the gum chewing.

Will have to talk with anesthesia about going easy on the fluids as well. These are typically healthy patients so they don't need to be flooded.

 

[DoctwoB]

I'm working on something like this for our plastics patients - the two biggest changes have been intraoperative injection of the pec fascia (in breast) or TAP block (in abdomens) with marcaine, and postop toradol (I've gotten a ton of pushback on this, but I use toradol on all my cases and actually have a much lower postop hematoma rate than my partner, so I'm trying to bolster it with both anecdotal and published data 😉). Our anesthesiologists are also pretty aggressive about premedicating patients and doing preop blocks when possible.

I’ve done the lit review. There is 0, as in none whatsoever, evidence that toradol increases post op hemorrhage or blood loss. There is good evidence that toradol does not increase bleeding even in bloody operations e.g partial nephrectomy. Toradol also has minimal effect on egfr and creatinine post operatively even after renal surgery.

 

[DoctwoB]

But there is evidence of an association between toradol and anastomotic leaks...

To be fair I was looking at it from the perspective of renal and prostate surgery. Color me skeptical though about the anastamotic data. Any randomized data? The studies I saw were all retrospective registry reviews. Retrospective reviews of registries have an inherent bias that patient with more pain and thus get toradol may have had a more extensive surgery or may have an early leaking anastomoses causing pain or other factors that you can’t control for on a multi variable analysis. I would take the theoretical risk of a slightly increased leak rate over a higher risk of narcotic addiction.

 

[mikeGR]

To be fair I was looking at it from the perspective of renal and prostate surgery. Color me skeptical though about the anastamotic data. Any randomized data? The studies I saw were all retrospective registry reviews. Retrospective reviews of registries have an inherent bias that patient with more pain and thus get toradol may have had a more extensive surgery or may have an early leaking anastomoses causing pain or other factors that you can’t control for on a multi variable analysis. I would take the theoretical risk of a slightly increased leak rate over a higher risk of narcotic addiction.

Some of the studies were randomized, comparing ERAS vs non-ERAS, and ad hoc analyses looked at toradol. Overall the literature on NSAIDs and leaks is very heterogeneous and limited, however it seems like there may be an association between the two. Pathophysiologically it makes some sense. There are so many other factors that affect leak rates more than the administration of toradol and those (realistically) cannot be standardized in the context of a study (ie technique, perfusion of the anastomosis, gut microbiota etc). For this reason I don't think we will ever get good studies to look at this topic.

The way I see it, NSAIDs may have a very weak association with leaks (and other complications such as dehiscence etc). I may try to avoid them in specific circumstances (ie kidney disease, gastric surgery, very high risk anastomosis) but other than that they work great.

 

[AdmiralChz]

I love exparel, but the hospital system has banned it from use because of costs. Nevermind that I did intercostal nerve blocks with it on a few people before the ban and they had minimal pain afterwards and went home early from a thoracotomy and decortication...

But its $300/vial vs $10/vial of plain marcaine.

Totally fair argument about Exparel, to be honest I've only used it myself a couple of times given high limitations.

But $300 a vial (for our institution its > $500) approaches the cost of some OnQ therapy (we use the ball, which ends up at around $200-250), and doesn't leave an infectious nidus behind. Something to consider if the hospital is giving you a hard time.

I’ve done the lit review. There is 0, as in none whatsoever, evidence that toradol increases post op hemorrhage or blood loss. There is good evidence that toradol does not increase bleeding even in bloody operations e.g partial nephrectomy. Toradol also has minimal effect on egfr and creatinine post operatively even after renal surgery.

Perhaps not for general surgery, there is spine and neurosurgical literature showing increased bleeding which is enough to give some of our general surgeons pause for routine use.

The low renal effects are true for 24-36 hours of therapy, continuing beyond that definitely has an incidence of AKI. I'll look for the literature, I believe it's fairly dated from the 90s or before.

Will probably redose to the tylenol to a 1000 q8hr.

I place the pump right before closure of the fascia. It is a surgeon placed device. The catheter goes subfascial. The pump settings can be adjusted by the physician. In my brief experience with it, I have typically used the a standard dosing, ropivicaine at 6mL/hr. I know some of the surgeons abandoned using it when they were getting pain relief with subcutaneous placement of the pump.

Regarding the marcaine, are you talking about injecting just below the skin or the fascia itself? I haven't gotten a chance to use exparel before. I looked and it appears to be on our formulary but I would want to talk with some of the anesthesia docs before using as I don't have a lot of experience with it.

Perfect. I was just wondering if you were placing these OnQs for your transvaginal procedures which doesn't seem like such a strong choice, but I think I read your OP a little too fast to catch what you were saying.

 

[Psai]

But there is evidence of an association between toradol and anastomotic leaks...

Oh sure blame toradol, not the sutures

 

[SLUser11]

Actually I blame the microbiome

Me too! In my opinion, microbiome research is the most fascinating stuff going on right now, and has the most potential to revolutionize the way we approach a variety of illnesses.

 

[VincentAdultman]

I used to be a big fan of exparel...but the data with joints suggests that it's no more effective than plain bupivicaine.

Big fan of toradol tho.

 

[Psai]

I used to be a big fan of exparel...but the data with joints suggests that it's no more effective than plain bupivicaine.

Big fan of toradol tho.

You should see our orthos pour it into joints like water

 

[ThoracicGuy]

I used to be a big fan of exparel...but the data with joints suggests that it's no more effective than plain bupivicaine.

Big fan of toradol tho.

I'm not sure you can extrapolate its effectiveness in all uses from just joint use data. I had 4 patients I gave thoracotomies to for decortications. None had epidurals, but all had exparel nerve blocks. They all had minimal to no postop pain and pain med usage and went home a day or two earlier than average. Nothing I've personally done before or since has been close.

 

[VincentAdultman]

I'm not sure you can extrapolate its effectiveness in all uses from just joint use data. I had 4 patients I gave thoracotomies to for decortications. None had epidurals, but all had exparel nerve blocks. They all had minimal to no postop pain and pain med usage and went home a day or two earlier than average. Nothing I've personally done before or since has been close.

Yeah but I don't do thoracotomies 🙂

 

[ThoracicGuy]

Yeah but I don't do thoracotomies 🙂

My hospital system banned it and used the joint study as their justification.

 

[VincentAdultman]

My hospital system banned it and used the joint study as their justification.

I mean...that's just dumb.

 

[Winged Scapula]

My hospital system banned it and used the joint study as their justification.

My hospital banned it because there was no evidence in breast augmentation, despite the fact that I'm not doing breast augs.

Apparently "no data" = "it doesn't work despite clinician experience".

 

[Psai]

My hospital banned it because there was no evidence in breast augmentation, despite the fact that I'm not doing breast augs.

Apparently "no data" = "it doesn't work despite clinician experience".

Just pump out a crappy 1 center nonrandomized study with terrible endpoints and poor inclusion criteria. The suits won't know any better and your resume will look that much prettier.

 

[AdmiralChz]

My hospital system banned it and used the joint study as their justification.

Probably by a committee without any physician membership, or if present far outvoted by RNs, pharmacists and (especially) non-medical administrators. Sad.

 

[ThoracicGuy]

Probably by a committee without any physician membership, or if present far outvoted by RNs, pharmacists and (especially) non-medical administrators. Sad.

It was totally a pharmacy decision. When I had a chance to use it, I was actually going to do a little trial of doing these blocks on all my cases and skip the epidurals. That alone would save the money. Add in shorter stays and less narcotic usage and exparel looks really cheap. But that vial costs more than a vial of marcaine, so banned!

 

[Psai]

It was totally a pharmacy decision. When I had a chance to use it, I was actually going to do a little trial of doing these blocks on all my cases and skip the epidurals. That alone would save the money. Add in shorter stays and less narcotic usage and exparel looks really cheap. But that vial costs more than a vial of marcaine, so banned!

Just shake up some bupi and prop

 

[kidthor]

My hospital during residency did a study on exparel in TAPs and there was nearly no difference between bupivicaine 0.25% and exparel. A well placed TAP (or QL) block with bupivicaine seems to work rather well. Some surgeons suggest they can do them in the field, but with all due respect they just don't (they're not injecting 20ml in just the right spot with ultrasound proof after all).

A PECS-1&2 block works great for breast surgeries and many surgeons seem to suggest that if we anesthesiologist do them pre-incision then it'll help pre-dissect out muscle planes.

I agree that's a lot of acetaminophen. 3 grams a day max should be plenty

 

[boogaaloo]

I used to be a big fan of exparel...but the data with joints suggests that it's no more effective than plain bupivicaine.

Big fan of toradol tho.

Yeah, Toradol >>> Ibuprofen.