Ether Resources for Anesthesia Research and Education

Gyn/Gyn Oncology ERAS pathway

By Aileen Adriano, MD
Task Force:  Ed Riley, MD; Steve Lipman, MD; Jean-Louis Horn, MD; Einar Ottestad, MD

The following guidelines have been developed in collaboration with our gyn-oncology surgical colleagues and our department.  It is meant to streamline the anesthetic clinical pathway.

  1. Pre-operative


    Labs Patients arriving for surgery will have gone through standardized pre-op lab testing which has been determined by our pre-op clinic in collaboration with our surgical colleagues.   
    Analgesia

    Premed (ordered by surgery preop)

    • Gabapentin 600 mg PO once
    • Acetaminophen 1000 mg PO once
    • Celebrex 200 mg PO once
    • Entereg 12 mg PO once (in bowel resection cases)

     

    *For major open tumor debulking surgeries and prior to administration of midazolam, please consent for T 8 – T 10 epidural and document in chart

     

    *For those undergoing laparoscopic procedures and prior to administration of midazolam, please consent for post-op TAP/rectus sheath block should procedure be converted to open prior to midazolam administration and document in chart

    IV Access 18 g peripheral IV should be placed for all gyn-onc surgeries
    Anxiolysis Midazolam 1 – 2 mg, age adjusted
    DVT Prophylaxis Heparin 5000 U SQ (please confirm it was given)


  2. Intraoperative


    DVT Prophylaxis Please confirm that SCD’s are on and functioning during the case
    PONV Prophylaxis

    Dexamethasone 4 mg IV once

     

    Zofran 4 mg IV once, 30 minutes prior to closure

     

    *For those with PONV history, place scopolamine patch;  consider low dose Propofol infusion

    Antibiotics

    Cefazolin dose: 2 g IV (3 gram dose for patients > 120 kg)  Redose every 4 hours. 

     

    For bowel, surgery: 

    Flagyl 500 mg IV.  Redose every 12 hours.

     

    PCN allergy?       

    Clindamycin 900 mg IV.  Redose every 6 hours.

     

    Gentamycin 5 mg/kg.  One time dose


     *(2- 5 mg/kg for pts. with decreased creatinine clearance)

    Access For major tumor debulking surgeries please place large second peripheral IV (14g or 16g)
    Monitors

    Standard non-invasive monitors

     

    *Arterial line placement should be considered for those with preexisting anemia undergoing extensive tumor debulking

     

    *Central line placement as dictated by patient’s additional comorbidities or difficult IV access

    Anesthesia

    Standard induction with propofol (or etomidate  as dictated by patient’s comorbidities) and rocuronium

     

    Maintenance with volatile anesthetics at 1 MAC

     

    Lung protective ventilation (6 – 8 ml/kg based on predicted body weight) to start and adjust as necessary during laparoscopic procedures

    Analgesia

    *For exploratory laparotomy/major tumor debulking surgeries, T8 – T10 epidural dosed with 0.6 – 1 mg dilaudid pre-incision.

     

    **Per Regional team, if time permits, please demonstrate level prior to induction with 3 cc Lido 1.5% with epi (in epidural kit).  A level should be attained within 10 minutes. If no level demonstrated, replace epidural.  If epidural placement is difficult, please ask for assistance after 3 failed attempts at placement.

     

    ***Because of the risk of blood loss during major tumor debulking surgeries, exercise caution when running a local anesthetic through the epidural during the case. Begin loading with Bupivacaine 1/8 % 10 – 15 cc 45 minutes prior to extubation. Call pain service to manage postoperatively. 

     

    *For robotic/laparoscopic procedures or epidural contraindicated,  ketamine 0.25 mg/kg load before incision, and 0.1 mg/kg/hr infusion during case to be stopped 1 hour before emergence. 

     

    If Celebrex not given in pre-op area, Toradol 30 mg IV for patients with normal creatinine and minimal blood loss during surgery. Please confirm surgeon prior to Toradol administration

     

    If patient did not take Acetominophen in pre-op area, please administer Tylenol 1000 mg IV.


    Fentanyl/Dilaudid as needed throughout the case, although this need should be minimized if utilizing neuroaxial technique during procedure

    Fluid balance

    Goal is to maintain intraoperative euvolemia

     

    Maintenance fluids should suffice especially with robotic/laparoscopic procedures. Additional fluids as needed to replace blood and insensible losses in more extensive tumor debulking surgeries. 

     

    After 2 liters of crystalloids, consider colloid administration

     

    *For open procedures/major tumor debulking surgeries, insensible losses can be substantial and there can be unrecognized blood loss in laps and drapes. Please exercise vigilance in tracking the blood loss from “slow, steady, oozing” especially in those patients who are being re-operated. If invasive monitoring in place, utilize PPV or CVP to help guide fluid administration. 

     

    *Consider blood transfusion if HCT falls below 25 (or at a higher HCT as dictated by patient’s comorbidities or clinical picture in OR)


    Other

    Please place orogastric tube with intermittent suction for all laparoscopic procedures

     

    Maintain and monitor patient’s temperature with warmed room prior to entering with patient, warming pad on bed set to at least 40 C, and upper body forced air warmers. Once forced air warmers are on, the room may be cooled.

     

    Because of positioning during robotic procedures and risk of corneal abrasion, consider blue-colored Medi-choice eye protectors



  3. Post-operative Period


    PACU

     

     

     

     

     

     

     

     

     

    Monitors:

    Standard procedures

    Analgesia:

    If epidural in place, per pain service. Usually will run Bupivacaine 1/8% @ 6 cc/hr and Dilaudid 0.05 – 0.2 mg/hr with PCEA with either fentanyl 15 – 25 ug bolus or combo Bupivacaine 1/8% with fentanyl 4 ug/cc at 3 cc

     

    Otherwise, Fentanyl/Dilaudid in PACU as needed.

     

    Toradol 30 mg IV q 6hr

     

    Rescue TAP/rectal sheath blocks or epidurals or rescue IV lido and Ketamine if needed

    Post-PACU Pain regimen

    Gabapentin age adjusted dose, Tylenol, NSAIDS for up to 3 days post-op



  4. Special Considerations


    Procedure converted to open? Contact Regional team to arrange for TAP/Rectus sheath block either in OR or PACU
    Chronic Pain?

    Premedicate with Gabapentin/Celebrex/Tylenol as indicated in pre-op section

     

    For open procedure, T8 – T10 epidural for post-op pain to be used intraop and/or bolused with Bupivicaine 0.25% at least 10 cc 1 hour prior to extubation

     

    Ketamine 0.5 mg/kg load prior to incision and 0.25 mg/kg/hr infusion during the case to be stopped 1 hour before emergence for all cases

     

    Lidocaine infusion 1 mg/kg/hr to be stopped 45 minutes prior to emergence if no epidural and rescue TAP block not to be performed


References:

  • Gustafsson UO, Scott MJ, Schwenk W. Guidelines for perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society. World J Surg 2013;37:259-84.
  • Nisanevich V, Felsenstein I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesth 2005;103:25-32.
  • Finfer S. A comparison of albumin and saline for fluid resuscitation in intensive care unit. N Engl J Med 2004;350:2247-56.
  • De Oliveira Jr GS, Castro-Alves LJ. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery. Anes Analg 2014;118:545-63.
  • Achuthan S, SinghI, Varthya SB, Srinivasan, Chakrabarti A, Hota D.
    Gabapentin prophylaxis for postoperative nausea and vomiting in abdominal surgeries:  a quantitative analysis of evidence from randomized controlled clinical trials.  Br. J Anaesth. 2015 Apr; 114 (4):588-97.
  • Eleftheria Kalogera, MD et al.  Enhanced Recovery in Gynecology Surgery.  Obstet Gynecol. 2013 August; 1222(2 0 1): 319 – 328.

Footer Links: