Tracy Childs, MD

(General Surgery)

ERAS Protocol for Abdominal Cases - colon resections, laparotomy, large incisional hernias

Patient is already given instructions they can drink Apple Juice and Gatorade up to 4 hours before surgery
Pre-med with acetaminophen +/-gabapentinoid +/-NSAID (note: gabapentin causes more post-op drowsiness than Lyrica/pregabalin). No Gapapentinoid with duramorph
Do a spinal with DUROMORPH (unless contraindicated, see dosing suggestion) – put in order set “Anesthesia Neuraxial Single dose” when you do this procedure. This will include orders for continuous pulse oximetry as well as medications for respiratory depression and pruritus

Intrathecal Morphine Dose by Age

< 50: 0.3 mg

50-59: 0.2 mg

60-69: 0.15 mg

70-79: 0.10 mg

> 80: not routinely recommended, use judgement

4. Give less IV fluids if patient can tolerate it

5. Consider TAP block in patients who are not a candidate for spinal– if you don’t do TAP blocks, call AIC and they will assign someone

Narcotic-Sparing Pain regimen

Surgeons write their own preoperative medications
Acetaminophen:
- Caution in patients with liver disease
- do not exceed 4g in 24 hours
- start at least 6 hours after last dose
NSAIDs
- Caution in patients with prior GI bleed or renal dysfunction
- All patients: celecoxib 400mg x1/ibuprofen 600mg x 1/naproxen 500mg x1
- Patients >65 yrs, <50kg, or CrCl 30-50 ml/min: celecoxib 200mg x1/ibuprofen 400mg x1/naproxen 250mg x1
- Creatinine >1.5, CrCl <30ml/min – no NSAID recommended
Gabapentinoids (Gabapentin & Lyrica)
- Consider lower dose or patients with OSA, age >65, or neuroaxial opioids
- All patients: Gabapentin 300-600mg x1, Lyrica 75-150mg x 1
- Patients >65, CrCl 30-50 mL/min, h/o OSA or STOP BANG 5 or greater: Gaba 300mg, Lyrica 75mg
- Patients Cr>1.5, CrCl <30mL/min: no gabapentinoid agent recommended
- Do no use in combination with Duramorph Spinal