Anton Bilchik, MD
Dr. Bilchik requests that the anesthesiologist assigned to his room please text him night before
so he can communicate any concerns directly to anesthesiologist
MALS (Median Arcuate Ligament Syndrome) Patients
1. Please contact the Pain Service (424-305-6095) the night before surgery and request a pre-operative consult. Pain Service will see the patient in the morning before surgery and assist with post-operative pain orders.
2. Pre-medicate the patient with Tylenol and Gabapentin. See ERAS protocol for dosing. Also can use Lyrica (50-150 mg) if patient is intolerant to Gabapentin.
3. INTRATHECAL DURAMORPH for all of his MALS patients. It's up to each individual anesthesiologist if they also want to use spinal Bupivacaine during the case (but remember that he also wants general anesthesia on top of the spinal so if I do use local anesthetic in the spinal I reduce the dose to avoid hypotension).
Doses for IT Duramorph:
- Age < 50: up to 0.3 mg
- Age 50-59: 0.2 mg
- Age 60-69: 0.15 mg
- Age 70-79: 0.1 mg
- Age > 80: Not recommended
4. General anesthesia with ETT. Keep the patient well paralyzed throughout the case. OG tube to decompress the stomach. Standard anti-emetics. Limit additional opioids. Toradol towards the end of the case (unless contraindicated).
5. Fluid management: ERAS protocol recommends goal-directed or restricted fluid management to prevent bowel edema. Standard suggestions are less than 500 mL/hour or 2 liters total for a case. Not as imperative for these cases as they are not doing any bowel anastamosis.
6. Bilateral TAP blocks at the end of the case. He does not use Exparel for these cases so you can use Bupivacaine or Ropivacaine. Max dose for Bupivacaine and Ropivacaine are 2-3 mg/kg. 2.5 mg/kg of either of those local anesthetics and then dilute that volume out into a total of 40cc using normal saline. Then use 20cc on each side of the TAP Block.
7. Other considerations: If the patient is on opioids at home or you feel like they are going to have pain control issues post-operatively, consider using a Ketamine gtt during surgery. A recommended dose is 20 mg IV with induction and then run a gtt at 5-10 mg/hr.
8. As a courtesy, you might want to give some kind of sign out / report to the Pain Service as they will be following the patient. Also make sure the Pain Service wrote for post-op pain management orders. If they haven't had time to, please communicate to the surgical team that they are responsible for putting those orders in. Basically, Dr. Bilchik just wants some consistency with pain management for these patients so that patient's are not admitted to the floor without any pain medication orders.
ERAS Protocol for Abdominal Cases
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)
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 after the procedure – if you don’t do TAP blocks, call AIC and they will assign someone to
perform TAP block, use Exparel in block
Narcotic-Sparing Pain regimen
Surgeons write their own preoperative medications
Caution in patients with liver disease
do not exceed 4g in 24 hours
start at least 6 hours after last dose
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