Perioperative period | Components | Adjustments/Notes |
---|---|---|
Preoperative | Gabapentin: 300–600 mg PO >1 hour before OR time | - Reduce to 300 mg PO in patients >65y - Consider not giving or reducing to 100 mg PO in patients >75y - Consider dose reduction in patients with OSA |
Acetaminophen: 1000 mg PO >1 hour before OR time | - Reduce to 650 mg PO if <70kg - Don’t use if h/o significant liver disease | |
Bilateral TAP Blocks ± rectus sheath blocks OR thoracic epidural catheter | - TAP - ropiv 0.25% + dex 4mg (25–30mL/side) - Rectus sheath - ropiv 0.25% + dex 2 mg (10–12mL/side) [add rectus sheath blocks for if any portion of incision [e.g. periumbilical handport] or large ports above umbilicus] - Thoracic epidural used for midline incision extending from above T8 to below umbilicus [use during intraoperative period] | |
Intraoperative | No induction opioids; minimize opioid use during anesthetic | - Volatile agent or propofol anesthetic in addition to ketamine - Esmolol for heart rate control |
Ketamine: 0.5 mg/kg with induction bolus plus 5mcg/kg/min until fascia closure. | - Consider reducing bolus (0.25mg/kg) or not using bolus in elderly patients >65 years of age. | |
Lidocaine: 1.5 mg/kg bolus with induction then 2mg/min drip from induction to case end | - Contraindications: Unstable heart disease, recent MI, heart block, heart Failure, electrolyte disturbances, liver disease, seizure disorder, current anti-arrhythmic therapy [e.g. amiodarone, sotalol] | |
Ketorolac: 30 mg IV at fascia closure | - Reduce to 15 mg IV if >65y, CrCl < 30, or patient weight <50kg. - Consider avoiding for h/o renal dysfunction or GI bleed | |
Methadone: Consider methadone 10–20 mg IV with induction for patients with chronic opiate use; may consider higher doses based on home opioid regimen. | - If opioids required, consider methadone on emergence or in PACU (5 mg IV boluses) q5–10 min prior to using other opioids. | |
Postoperative | Gabapentin: 300-600 mg PO TID starting DOS until discharge | - Use lower dose for >65y or if patient having sedation/dizziness - Post-discharge: final inpatient dose PO TID × 7 days, then half dose PO TID × 7 days [2 week post-op course total] |
Acetaminophen: 1000 mg PO Q8hr starting DOS until discharge | - Reduce to 650 mg PO Q6h if <70kg - Post-discharge: 500–1000mg PO Q8h × 3 days and then PRN | |
Lidocaine | Continued from PACU or after thoracic epidural catheter removed Order for PACU to continue 24h: 1 mg/min IV if <70 kg; 1.5 mg/min IV if 70–100 kg; 2 mg/min IV >100 kg. Contraindications as above | |
Ketorolac: 30mg IV q6h × 3 days | - Reduce to 15 mg IV Q6h in patients >65y, CrCl < 30, or weight <50kg - Hold if evidence of acute kidney injury | |
Opioids: as needed (PRN) | Example: Oxycodone 5mg PO Q4 PRN pain >4/10; consider opioid PCA or PRN bolus for breakthrough pain, but not a standard order. - Post-discharge: short course of short-acting opioid (e.g. oxycodone 5mg q6h PRN × 3days) unless chronic pain/opioid use concerns to address. | |
Thoracic Epidural | If used, continue with local anesthetic (e.g. bupivacaine 0.1%) +/- opioid if needed for denser quality block (e.g. hydromorphone 10mcg/mL) |