University of California San Francisco â€" East Bay.doc.doc ...

University of California San Francisco – East Bay PROTOCOLS FOR DIVISION OF VASCULAR SURGERY I. INTRAVENOUS FLUIDS: Avoidance of intravascular volume depletion, replenishment of sodium and potassium losses preoperatively and sodium loading prior to arteriographic and operative procedures are crucial to prevent renal failure in vascular patients. A. Arteriography 1. All inpatients are to get IV with D5 ½ normal saline (with or without potassium depending on potassium and creatinine) starting at 8:00 p.m. the night prior to arteriography. 2. Fluids are to run at 80-125 ml per hr nominally depending on weight of patient and clinical condition. Continue IV fluids until adequate p.o. intake is established. (Post-angiogram IV orders by Radiology are usually inadequate and must be checked and/or modified). 3. If patient has severe congestive heart failure, discuss with attending physician and cardiologist to determine rate and need for fluid administration. 4. Patients with renal insufficiency (creatinine > 1.3): If creatinine is > 1.8, check with attending to determine if an arteriogram should be done at all. IVPB (12.5 gm) Mannitol should be given on call to Radiology. An additional 12.5 gm should be sent to Radiology to be given after the contrast. Check with attending physician for indications and dose. Follow-up BUN/Cr should be obtained the next morning. Keep patient hydrated. 5. If patient reports history of contrast allergy, administer Prednisone 50 mg p.o. q6h starting 24 hours before. Send Benadryl 50 mg IV push to x- ray and hang Tagamet 300 mg IVPB on call to radiology. 6. All patients should have pulses documented prior to procedure, and a post procedure note documenting their vascular and neurologic status. Be particularly alert for evidence of brachial plexus problems after transaxillary aortograms. 7. Prior to angiography the patient’s condition, labs, chest x-ray, and EKG need to be reviewed as if they were going to the operating room. 8. Bed rest with hip straight x 6∀ ( if femoral access employed) with or without compression at puncture site, then light activity for a few days after. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

B. Preoperative Fluid Therapy 1. Inpatients receive intravenous fluids the night prior to surgery to avoid volume depletion and subsequent hypotension at the time of anesthetic induction. 2. Type and amount of IV fluid depend on the procedure and the patient’s pre-morbid condition. 3. Procedures involving significant blood loss, aortic cross-clamping, renal vascularization: a. Patients to receive D5 Ringer’s Lactate starting at 8:00 p.m. the night prior to surgery at a rate of 75-150 ml/hr with potassium as needed. Old, debilitated or small patients (< 50 kg) receiving bowel preps will need hydration begun earlier, at appropriately adjusted rates. b. Patients with myocardial compromise may need to be placed in intensive care unit for Swan-Ganz catheter placement the night before the operation with possible optimization of cardiac performance. Aortic cases receive Swan-Ganz catheters preoperatively, usually prior to induction. Consult with attending. c. Individualize the rate of fluid administration to the size of the patient 4. Other procedures (fem-popliteal bypasses, carotid, minor procedures, amputations, etc.) require maintenance fluid appropriate to patient’s size starting at 8:00 p.m. the night prior to surgery with potassium as needed. More fluid may be needed if the patient has third space losses, unusual insensible losses, or is already volume depleted. 5. No one goes to the operating room for elective surgery without having received intravenous fluid in preparation for surgery. II. MEDICATIONS A. Cardiac Medications At the time of admission it is important to obtain and record an accurate list of the patient’s current medications. 1. Routine cardiac medications are given the morning of surgery with a sip of water. This usually includes digitalis preparations, calcium channel blockers, long-acting nitrates, and other antiarrhythmic agents. B. Antihypertensive Medications These are usually given in the morning of operation with sips of water. 1. Diuretics are stopped 24 hours prior to surgery. 2. Always check potassium level of patients on admission. Anyone on long- term diuretics will be potassium depleted even with normal potassium levels. The most sensitive indicator of this is not serum potassium level /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

but the serum bicarbonate level. If the patient is slightly alkalotic she/he will need potassium replacement prior to surgery. C. Antibiotics 1. All patients undergoing procedures in which a prosthetic patch or graft may be placed or the groin is to be entered require preoperative prophylactic antibiotics. Except in unusual circumstances, all vascular procedures get preoperative antibiotics. 2. Antibiotics are started on call to the operating room and continued for 24 hours postoperatively. For patient with prosthetic patches or grafts, antibiotics should be given until the intravascular monitoring lines and Foley catheter have been removed, plus one day. If there is any drainage from an incision involved in the operation, antibiotics are to be continued. If the WBC or differential are not normal, antibiotics are continued. Consult attending regarding the timing of oral antibiotics substitution. Patient should be observed one day off antibiotics prior to discharge. 3. Should a patient have pre-existing urinary tract infection or other sources of bacteremia preoperatively ( such as severely decayed teeth, umbilical infection, foot ulcers, or infection over saphenous vein), this must be treated preoperatively and brought to the attention of the attending surgeon. The skin in the area of the proposed operation should be carefully inspected. Hibiclens showers should be ordered on all inpatients the night before surgery. 4. ANCEF 2 grams IVPB q8 hours is the usual prophylactic antibiotic employed, unless there is a history of serious allergic reaction to penicillin. In these cases Vancomycin is the usual alternative. If the patient has a documented infection sensitive to a specific antibiotic, that antibiotic should be ok. D. Aspirin Carotids and vertebral bypass patients receive 80 mg (baby) aspirin p.o. the evening before operation, as do patients undergoing distal lower extremity bypasses. Those patients already taking aspirin or other Thromboxane inhibitor (Motrin, Ibuprofen, Clinoril, etc.) do not need a baby aspirin. Don’t combine ASA with coumadin. Note that almost all vascular patients go home on ASA unless there is a cogent reason not to. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

III. PREOPERATIVE ORDERS A. General 1. Operative consent form must be filled out and consent obtained and documented. 2. NPO after midnight. This may be appropriately modified for afternoon cases. 3. Preoperative Hibiclens or Betadine shower. 4. Appropriate bedtime sedation should be ordered. 5. Void on call to operating room. If a Foley catheter will be necessary, this normally can be placed after the induction of anesthesia for patient comfort. 6. Type and cross-match for major vascular cases, type and screen for carotids and vertebrals and minor vascular procedures. This will generally have been ordered at the time the case is scheduled, but in emergent situations six units of packed cells are routinely ordered for aortic reconstructions and two units of packed cells for distal and in-situ lower extremity operations 7. Prophylactic antibiotics. 8. Usual oral blood pressure and cardiac medications should be given with a sip of water the morning of operation. 9. Insulin orders for diabetics: In general one-half of the normal insulin dose is given in the morning, and the remaining one-half dose is given in the recovery room. Until the patient is able to resume oral intake, sliding scale insulin is administered. This same regime is used for diabetics undergoing arteriography. 10. Cholesterol evaluation: All vascular patients require cholesterol and triglyceride work-up on first admission to service, if not already done by the patient’s referring physician. If the levels are elevated, consult the dietician and obtain a lipoprotein phenotype. IV. SPECIFIC PREOP ORDERS A. Carotid 1. Patient should have preoperative CT scan, with IV contrast, and neurology consult. (If CT scan can be done immediately following an angiogram, a second dye load can be avoided). 2. An ENT consult should be obtained for vocal cord examination if the patient has had a previous carotid or neck surgery, ipsilateral or contralateral. Note character of voice pre-op. 3. Redo carotids require cell saver. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

B. Femoral-Popliteal-Tibial Bypass Surgery 1. Venous Mapping - schedule with Dave Sayers after arteriogram, prior to surgery. 2. If open foot lesions are present, broaden the spectrum of IV antibiotics. Discuss with attending. C. Aortic or Intra-abdominal Revascularizations 1. Pulmonary preparation is important, as most of the patients are smokers. A spirometer should be ordered and preoperative teaching given. Baseline blood gases and spirometry with and without bronchodilators should also be considered. PFT’s may be needed, especially in thoracic aortic operations. Check with attending. 2. Bowel preparation - 4 l Golytely should be given the evening before operation and then normal saline enemas until clear the morning of the operation If visceral ischemia is felt to be a potential hazard, then formal mechanical bowel prep with antibiotics may be indicated. Check with attending. 3. Accurate preoperative weights are necessary. V. SPECIFIC PROTOCOLS A. Urokinase: Intra-arterial or intravenous 1. The infusions are started in x-ray by the interventional radiologist, but during the infusion patient must be monitored in the ICU. 2. Catheter is positioned under fluoroscopy directly into the thrombus. 3. Prior to starting the infusion the following coagulation parameters are obtained: prothrombin time, partial thromboplastin time, platelet count, and fibrinogen. 4. These are monitored q 6 hrs for the first 24 hours, and q 12 hours thereafter or at any sign of bleeding. 5. The rate of infusion will be determined by the interventional radiologist and your vascular attending (usually 1-4K units/min). 6. Attending is called if fibrinogen level decreases below 100 mg percent or there is any sign of bleeding to discuss stopping infusion. 7. Infusion is continued for 24 to 72 hours with repeat arteriograms every 6 to 24 hours of as indicated clinically. The end point of infusion is failure to achieve clinical success at 72 hours, complications related to infusion, or clearance of clot. 8. Aspirin should not be used during the Urokinase infusion. Heparin is given to minimize catheter induced thrombosis. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

9. There should not be any IM injection or arterial punctures. Venous punctures sites should be held with pressure for 15 minutes. B. Deep Vein Thrombosis 1. Baseline platelet count, PT, PTT. 2. Ask attending re: intravenous loading dose of Heparin 100-150 units per kilo given as bolus. 3. Bed rest for 7 days with the leg elevated above the level of the heart. 4. At the same time start continuous heparin infusion via IVAC. 5. The dose of Heparin necessary will vary with size of patient and the extent of the thrombotic process. As a rule approximately 15u/kg/hr is a good starting dose. Patients with extensive thrombotic problems (PE, iliofemoral DVT, advanced thrombosis) may need as much as 20-30 u/kg/hr. 6. Check the PTT 8 hours after starting the infusion and q6h until level is stable at 2-2.5 times control PTT and daily thereafter. 7. Continue treatment in routine cases for 7-10 days depending on clinical setting. 8. Platelet counts are needed every other day during heparin therapy. Be alert for the development of thrombocytopenia. 9. Check with attending regarding use of Coumadin. Order PT to establish baseline and to determine therapeutic dosage. Coumadin generally is started on the third day of heparin treatment if it is therapeutic. 10. When the leg edema is reduced, the patient is measured for a custom fitted, below knee, elastic Jobst stockings with 30-35 mm Hg compression pressure. (Check pulses to insure adequate arterial inflow prior to ordering any compression stocking). Make 2 pairs (or 2 stockings if one leg is involved). Have the stockings mailed to the patient’s home address. (It takes several weeks for these to be made). C. Balloon Angioplasty 1. LES - Baseline to measure preangioplasty pressures. 2. Patient receives fluid as for arteriography night prior to procedure. 3. Patient is given 1 grain of aspirin orally night prior to procedure and 1 grain daily thereafter. 4. Occasional patients may need heparin post angioplasty. Check with attending. 5. LES done prior to discharge. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

D. Postoperative Arteriography Check with the attending regarding the need to obtain prior to discharge in all patients who have had: • vertebral reconstruction • aortic arch surgery • disobstruction of completely occluded ICA • bypass of the branches of the aortic arch, visceral or renal vessels • any bypass where a completion arteriogram could not be performed E. Postoperative Surveillance Consult attending on follow-up duplex examinations after vascular reconstructions. GUIDELINES FOR VASCULAR ACCESS Objectives: To provide durable hemodialysis access for patients with end stage renal disease. 1. A Green Service surgery resident/ staff member will evaluate patient ASAP and immediately insure that no arterial or venous punctures or cannulations are done in the upper extremities. Subclavian central venous lines should not be placed and an IJ catheter should be used when needed if possible. Assess upper extremity arterial blood pressures in both arms and visually describe the brachio-cephalic venous system under tourniquet control. Review with staff prior to writing a consult. Communicate with nephrology fellow. 2. All patients will require pre-operative upper extremity vein and axillo- subclavian venous duplex to assure adequacy of venous outflow. 3. All patients will receive segmental arm and finger pressures with waveforms. 4. If a duplex exam could not be performed or is not available, an arteriogram and/or venogram should be done. Consult attending before you do this. 5. The evening prior to surgery all patients should have a Hibiclens, Betadine, or other antimicrobial scrub. 6. Patient should be dialyzed before surgery. Please coordinate with nephrologist. 7. Once patient is medically stable, either a primary radial artery/cephalic vein arteriovenous fistula (end of vein to side of artery) or a PTFE bridge shunt will be constructed. 8. PTFE grafts will not be inserted until intercurrent infection processes are adequately treated. 9. Unless contraindicated, perioperative antibiotic will be Vancomycin, to be ordered by the operating surgeon. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

10. All incisions should be closed in at least two layers. The skin over the graft must be air-and water-tight, and a 4-0 interrupted nylon vertical mattress stitch should be employed. 11. A completion arteriogram will be done to document technical perfection of the anastomosis and outflow. 12. The tunnel maturation period for a new PTFE loop fistula is 18-21 days; primary A-V fistulas require 4-6 weeks to arterialize. 13. All patients post fistula construction should have a duplex evaluation at 3 - 5 days, 21 days, 6 weeks, 12 weeks, and every 3 months after that indefinitely. Under ideal circumstances, duplex exam should precede all first attempts to use fistula-- with estimation of fistula flow rate. 14. Keep operated extremity elevated prn if swelling is present to avoid breakdown of the incisions and hand ischemia. VASCULAR ACCESS COMPLICATIONS 1. Thrombosed Fistulas and PTFE Grafts To be admitted by the medical service on call and evaluated by the surgical team on call. Every attempt to revise an existing fistula grafts will be made. If possible, a duplex scan will be performed prior to revision to assess possible factors such as arterial or venous stenosis as an etiologic factor in graft failure. 2. Timing of Revision of Uncomplicated Thrombosis of Grafts In the absence of the need for urgent dialysis that could only be done via the graft, #1 should be done prior to revision which will be scheduled during normal elective operating time. If just cause can be given (by medicine chief resident of higher) for the revision to be done as an emergency case, it will be done in order with other emergency cases, realizing that the triage of care might preclude immediate operative intervention. 3. Infected Grafts Cases will be individualized. If surgical intervention is needed, it will be done as an emergency. A permacath or other device can be inserted at the same time if needed. 4. Pseudoaneurysms Depending on the site(s) and size of graft and/or anastomotic aneurysms, some will need revision. Consult you attending. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

ARTERIOGRAPHY To facilitate timely arteriography and to assure that the information provided by this study is useful, please adhere to the following guidelines. 1. Consult your surgical attending before requesting arteriographic studies; 2. Senior level residents (3rd year and above) should preferably confer with the radiologist regarding what information is needed; 3. During off hours and night-time, a house officer must accompany the patient to the angio suite and stay with the patient until completion of the study. ROUTINE POSTOP ORDERS Carotid Endarterectomy Meds Orders 1. IV D5- ½ N.S. w/20 mEq KCI @ 1. Condition 75 - 125 cc/hr 2. Demerol 50-75 mg IM q 3-4 h prn 3. Vital signs q 1 h w/neurocheck till pain. stable, then q 4 h 3. Tylenol #3 1-2 tab p.o. q 3-4 h prn 4. Activity - up with assistance pain. 5. Diet - clear liquid when fully awake, 4. Patient’s current medications ( in all then resume normal diet as patient cases, review and continue all pre- requests, or by day #1. op medications, if appropriate). 6. CBC. lytes in PAR & AM 5. Dextran 40 in N.S. @ 50 cc/hr x 3 hr then D/C 7. Jackson-Pratt flat drain, left or right neck, to bulb suction 6. One baby aspirin each day p.o. 8. Call HO if: 7. The most important aspect of postoperative management both in • BP syst > 160 or < 90 terms of avoiding postop cardiac or • Resp > 28 or < 10 cerebral morbidity is in ensuring normal • No void by 4h postop BP. If systolic BP falls below 90, notify • Bright red blood saturated attending. If pressors needed, use a dressings neo-synephrine drip ( 10 mg in 250 • Change in neuro status D5W) administered via IVAC. Systolic • > 100 cc from JP BP > 160 can usually be regulated with a nitroglycerine or nimide drip. Wild fluctuation in BP is just as 9. CT of head without contrast if dangerous as severe hypertension or patient has symptoms indicating hypotension. change in neuro status. 2. Allergies: /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

10. Consult ENT before second 11. Report post-op hoarseness or facial contralateral operation/cord function weakness/asymmetry to surgeon Vertebral Reimplantation Meds Orders As for carotid endarterectomy 1. Same as for carotid endarterectomy plus: Port CXR in PAR 2. Check with attending about schedule post-op single injection arteriogram to view the L/R carotid system. Aortic and /or Mesenteric Operations 1. NG tubes a. Keep NGT patent q 2 hr. b. Check pH q 4 hr. Keep > 5.5 with cimetidine ± antacids. c. Ask attending whether suction or gravity drainage. d. Keep NGT until passing flatus or stool and NG output acceptable 2. Ventilation a. Specify TV, IMV rate, F1O2, PEEP. b. Specify frequency of routine ABG, VS, and whom to call for changes. c. Suctioning as needed 3. Extubated patients a. DB q 1-2 hr, cough as necessary. b. Incentive spirometer q 1 hr while awake. c. Nasotracheal suction if patient unable to cough or raise secretions. 4. In PAR a. EKG, CXR for line and ET tube placement -- look for pneumothorax. b. PCW, CVP measurements q 1 hr in ICU/PAR c. Cardiac output q 4 hr with SVR d. Specify parameters for calls to HO for PCW, CVP, SVR, CO, SBP, DBP. 5. Activity a. Bed rest while in ICU. Out of bed when hemodynamically stable. b. Warming blanket till euthermic. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

c. Air sequential stocking and/or SQ heparin while in bed. 6. Pain Management a. Consider use of PCA with morphine as first choice and IV push morphine as second choice (1 to 7 mg IV q 1-2 hrs prn). b. Pain management is individualized to ensure patient’s comfort. 7. Labs 8. IV Fluids a. The bulk of IV fluid should be administered as Lactated Ringer’s solution first 24 hr. Usual D5 ½ N.S. thereafter with appropriate potassium supplementation. Titrate rate to expected third spacing and maintenance needs vs. PCW and urine output. b. Specify whether to monitor certain symptoms in detail, i.e., distal pulses (± Doppler) for grafts to iliacs or femorals, renal function for renal bypasses, non-incisional abdominal pain or elevated liver function tests for mesenteric grafts, etc. c. Monitoring postoperative weight is essential following aortic reconstructions, or any operation where there are major fluid shifts. Be sure an accurate preoperative weight is recorded. d. Be alert for signs of bowel infarction, i.e., abdominal pain, diarrhea, blood per rectum, acidosis, or sepsis. Call chief resident and attending if bowel infarction suspected. e. Be alert to post-op pancreatitis in abdominal aortic reconstructions. 9. Diet a. Feed 1 day after NGT removed. Begin with clear liquids, then advance to appropriate solid diet if tolerated. Femoral-Popliteal 1. Liquids as tolerated after spinal anesthesia if no N/V. Solid diet appropriate for the patient’s disease during the following day. 2. Activity a. Bed rest for 6 hours after spinal or epidural anesthesia, then out of bed when hemodynamically stable. Gradually resume activity. Many patients will have peripheral edema on the side operation and will need that leg elevated. 3. Routine IV maintenance fluid. 4. No pillows behind knee because it compresses the popliteal vessels. Raise FOB. 5. Foley out as soon as can manage with bedpan, commode, or bathroom. 6. Nursing staff to check distal pulses by palpation and/or Doppler on admission to the unit and q 1h x 12 /q 2h x 6 and call HO immediately for loss of pulse. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

7. Wound care and staple/suture removal as per aortic operations. 8. For infrainguinal (femoro-popliteal or femoral-tibial) give one baby aspirin (80 mg) tablet per day p.o.. Start night before operation. 9. LES study two days post-op or when edema has resided and definitely before patient leaves hospital. 10. If unexplained graft thrombosis, obtain hypercoagulable work-up (Prot C & S, AT-III, Lupis anticoagulant, anticardiolipin Ab, PT, PTT, plt count). Wounds 1. GLOVES ARE TO BE WORN FOR ALL DRESSING CHANGES 2. Especially groins - must be inspected every day and kept dry. All groin wounds use dry dressings until sutures are removed. Inform chief resident of any drainage. 3. Sterile dressing technique must be used for all patients with fresh wounds or draining wounds. Keep sterile dressing on at least 24∀ but < 48∀ from OR if wound was clean and a wound infection is not suspected. 4. Staple/ suture removal: a. Neck: on discharge Steri-Strip b. Abdomen: 7 days Steri-Strip if neither tension nor edema are present. c. Legs: consult attending d. Amputation stumps: 2-4 weeks. e. For diabetics, patients with renal failure, or patients on steroids or in poor nutrition, extend the length of time staples/sutures are in place in abdominal and leg incisions. f. If abdomen distended, limb/neck swollen, or inflammation present, check with attending before removing staples/sutures. Amputation 1. Consult physiatrist (prior to amputation if possible) for immediate prosthesis and for patient teaching. 2. No pillows supporting stump post-op. 3. Ace bandages on stump to keep swelling down, but be mindful not to wrap an ischemic limb too tightly. 4. Subcutaneous heparin 5,000u q 12h post-op. 5. Overhead trapeze for assistance with mobility. 6. Out of bed in chair with stump supported post-op day #1 7. Consult physical therapist immediately post-op. Addendum All women of childbearing age require a pregnancy test if scheduled for an arteriogram or an operation. Appropriate foot protection should be ordered for patients with lower extremity ischemia, i.e., vascular boots, air mattress, and a foot board to keep the covers off the feet. Review all medications twice a week. /home/pptfactory/temp/20101020123208/university-of-california-san-francisco-east-baydocdoc3385.doc

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