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SAGES

Reimagining surgical care for a healthier world

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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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Surgery Type
Bowel
Building Blocks
Case Studies

SAGES Enhanced Recovery

SAGES improves quality patient care through education, research, innovation and leadership, principally in gastrointestinal and endoscopic surgery.

Representing a worldwide community of more than 6,000 surgeons, SAGES sets the clinical and educational guidelines on standards of practice in various procedures, critical to enhancing patient safety and health.

SAGES Support

SAGES gratefully acknowledges Medtronic for its generous educational grant in support of the SMART Enhanced Recovery Program.

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SAGES Smart Task Force

  • Liane Feldman, Chair
  • Thomas Aloia, Co-Chair
  • Gina Adrales
  • Rajesh Aggarwal
  • Joselin Anandam
  • Conor Delaney
  • Diana Diesen
  • Justin Dimick
  • Julio Fiore Jr.
  • Gerald Fried
  • Pascal Fuchshuber
  • I. Gorgun
  • Alexis Grucela
  • Matthew Hutter
  • Edmundo Inga-Zapata
  • Rohan Joseph
  • Deborah Keller
  • Anne Lidor
  • David Liska
  • Sumeet Mittal
  • Charles Paget III
  • Michele Riordon
  • Vadim Sherman
  • Andrew Wright
  • Tonia Young-Fadok
  • Yulia Zak

Contact SAGES

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Los Angeles, CA 90064 USA
webmaster@sages.org
Tel: (310) 437-0544

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