Table 2 Enhanced recovery for radical cystectomy pathway
Preoperative management | |
Patient educated about the pathway in the surgical clinic | |
Preoperative bowel preparation is not routinely used | |
Patients allowed clear fluids until 2 h before the start of surgery | |
500 mL carbohydrate drink 2 h before surgery (Clearfast) | |
Oral adjunctive analgesics given preoperatively: acetaminophen, gabapentin | |
Alvimopan given preoperatively | |
Transdermal scopolamine patch applied in preoperative holding unless contraindicated | |
Low thoracic epidural placed with small amount of IV fentanyl and/or midazolam for sedation | |
Heparin 5000u SC given after epidural placement and before incision | |
Antibiotic prophylaxis: cefazolin or clindamycin if penicillin allergic | |
Intraoperative management | |
Induction: lidocaine, propofol, fentanyl up to 150 μg, neuromuscular blocking drug of choice | |
Goal is to avoid IV opioids, no IV opioids after induction without discussion with attending anesthesiologist | |
Dexamethasone 4 mg IV after induction | |
ASA standard monitors and arterial line with cardiac output monitor | |
Volatile anesthetic titrated to keep BIS 40–60 | |
Option for epidural hydromorphone 0.4 mg at induction | |
Epidural infusion bupivacaine 0.0625–0.25% ± hydromorphone 10 μg/mL run at 3–6 mL/h | |
Ketamine infusion 4 μg/kg/min may be used in chronic pain patients | |
Ondansetron 4 mg IV given at the end of surgery | |
Acetaminophen 1 g IV and ketorolac 15 mg IV given towards end of the case if appropriate | |
Fluid management: | |
Maintenance crystalloid infusion (LR) 3 mL/kg based on ideal body weight | |
Goal-directed fluid therapy—colloid boluses to maximize stroke volume | |
Record initial stroke volume (SV) | |
After incision, give 250 mL colloid bolus over < 15 min | |
If SV increases by > 10%, repeat bolus | |
If SV increases by < 10%, patient does not require a further bolus | |
Record peak value achieved | |
If still hypotensive, consider phenylephrine bolus or infusion | |
Give a further colloid bolus when SV drops 10% from peak value | |
Repeat cycle | |
Blood products transfused as needed | |
Postoperative management | |
Epidural bupivacaine 0.0625–0.125% ± hydromorphone 10 μg/mL run at 4–6 mL/h for up to 72 h | |
(Hydromorphone 10 μg/mL alone may be used in hypotension is a problem) | |
Scheduled adjunctive analgesia with acetaminophen and NSAIDs whenever possible | |
Patients transitioned to oral opioids after removal of epidural catheter | |
Patients encouraged to drink liquids immediately after surgery | |
Alvimopan given postoperatively for 5 days or until first stool | |
IV fluids discontinued once adequate oral intake is achieved, usually the first morning after surgery | |
All preoperative medications are restarted when patients tolerate oral intake | |
Patients cared for in an environment that encourages early mobilization | |
Encouraged to be out of bed on the day after surgery and for at least 6 h on every subsequent day | |
Patients are asked to maintain a diary of their activity and sleep |