Colorectal – Case pathway for lap and open bowel resection

Open Abdominal Surgery ERP
POST OPERATIVE/
PACU
POST OP
DAY 1
POST OP
DAY 2
  • Ketorolac 15-30mg

Q 6hr ATC (HOLD FOR POOR RENAL FUNCTION OR BLEEDING)

  • Oral acetaminophen 650mg every 6 hours ATC once able to tolerating oral meds
  • Morphine or hydromorphone PCA (no basal dose)
  • Prophylactic antibiotics ARE NOT CONTINUED, unless specific therapeutic indication
  • Steroid Taper- hydrocortisone if steroids within the last 6 months
  • Heparin 5000 units SQ Q8, SCDs
  • Sips/chip, advance to clears as tolerated
  • CBC, BMP QOD, unless indicated
  • Maintenance IVF@ 50cc/hr
  • PCA Pump
  • Oral acetaminophen 650mg Q 6 hrs ATC
  • Ketorolac 15-30mg Q6 hr x 10 doses ATC (hold for poor renal function, bleeding)
  • Alvimopan 12mg po BID x 14 doses, if given preop
  • Gabapentin 150-300mg po TID, while in house (hold for dizziness)
  • OOB, ambulate x5
  • DC Foley- unless otherwise indicated
  • Chewing gum 1 stick TID prn
  • PT assessment prn
  • ET consult for new ostomy
  • Ondansetron 4mg IV Q6hr prn nausea
  • Famotidine 40mg IV Q6 GERD
  • Zolpidem 5mg QHS prn sleep
  • Heparin 5000 units SQ Q8
  • SCDS
  • Clear liquids
  • Boost BID
  • Advance diet to soft if tolerating clears
  • DC Foley if not POD #1, (document appropriately)
  • DC PCA
  • Acetaminophen 650mg po Q 6hr ATC,
  • Ibuprofen 800mg po TID (DC ketorolac)
  • Oxycodone 5mg po Q4hr prn
  • Hold IV Narcotics, used for break through only
  • CRP
  • IVF @ KVO
  • Start appropriate home medications
  • OOB
  • Ambulate 5x day
  • Begin discharge planning to assess for barriers
Open Abdominal Surgery ERP
POST OP
DAY 3
POST OP
DAY 4
POST OP
DAY 5
  • Heparin 5000 units SQ Q8
  • SCDS when in bed
  • Low Residue diet/soft diet
  • If ostomy-remove rod if loose
  • Continue oral pain medications, prn
  • DC IV narcotic analgesia
  • CBC, BMC
  • OOB
  • Ambulate 5x day
  • Heplock IV (keep IVF if ostomy)
  • Initiate loperamide (if watery ileostomy output. DC alvimopan if initiated loperamide
  • PO medications/

Resume appropriate home medications

  • Discharge planning to assess barriers:

Initiate placement forms, begin precertification if needed for placement

  • Assess suitability for discharge
  • Heparin 5000 units SQ Q8
  • SCDS when in bed
  • Advance diet to soft if not already, encourage oral intake
  • Continue oral pain medication, prn
  • DC IV narcotic analgesia
  • All meds to po
  • OOB
  • Ambulate 5x day
  • Ostomy- rod out, if not done on POD

# 3

  • If IV steroids- convert to oral prednisone
  • Discharge Planning assess for barriers
  • Discharge planning: complete placement forms for home/HC/SNF based on needs
  • Heparin 5000 units SQ Q8
  • SCDS
  • OOB
  • Ambulate 5x day
  • CBC, BMP (avoid routine labs if discharge planned for today)
  • Discharge planning
  • DC alvimopan, gabapentin prior to discharge
  • Make follow up appointment prior to discharge
Laparoscopic Abdominal Surgery ERP
POST OPERATIVE/
PACU
POST OP
DAY 1
POST OP
DAY 2
POST OP
DAY 3
  • Ketorolac 15-30mg Q 6hr ATC
  • Acetaminophen 650mg po Q6 hrs ATC
  • Prophylactic antibiotics ARE NOT CONTINUED, unless specific therapeutic indication
  • Steroid Taper- hydrocortisone if steroid within the last 6 months.
  • Clear liquid diet
  • Heparin 5000 units sq Q8hr
  • SCDs daily
  • Clear liquids in am, advance to soft diet as tolerated
  • Boost 1 can BID
  • Maintenance IVF 10-50cc/hr
  • Continue oral acetaminophen 650mg po Q6 hrs ATC
  • Gabapentin 150-300mg TID (while in hospital– HOLD FOR DIZZINESS)
  • Oxycodone 5mg Q4 hr break through pain, HOLD IV
  • Ibuprofen 800mg po TID (DC IV KETOROLAC)
  • CBC, BMP, then QOD unless otherwise indicated
  • Start appropriate oral home meds
  • OOB, ambulate 5xday
  • DC Foley
  • Chewing gum 1 stick TID
  • Avoid alvimopan
  • Discharge planning to assess barriers
  • Assess Suitability for discharge
  • Heparin 5000 units sq Q8hr
  • SCDs daily
  • Soft diet
  • Continue oral acetaminophen 650mg po Q6 hrs ATC
  • OOB at least 4-6 hours
  • Ambulate 5x day
  • CRP
  • All medications to po, resume all home medications not already started as appropriate
  • Discharge planning, assess for barriers
  • Assess for suitability for discharge
  • Heparin 5000 units sq Q8hr
  • SCDs daily
  • Soft diet
  • CBC, BMP (avoid routine labs, if planning for discharge today)
  • If ostomy: remove rod
  • Discharge planning
  • Make follow up appointment prior to DC
  • DISCHARGE MEDS
  • Acetaminophen 650mg po Q6hr ATC
  • Ibuprofen 800mg po TID
  • Oxycodone 5mg Q4-6 hr prn (DC meds in reverse order)

Figure 4 and 5 abbreviations: ATC – around the clock; DC – discontinue; HC – home care; IVF – intravenous fluids; KVO – keep vein open (low flow rate); OOB – out of bed; PCA – patient controlled analgesia; SCDs – sequential compression devices; SNF – skilled nursing facility; SQ – subcutaneously



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