Colorectal Enhanced Recovery - Anaesthetic Quick Reference Card

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Colorectal Enhanced Recovery - Anaesthetic Quick Reference Card


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Colorectal Enhanced Recovery - Anaesthetic Quick Reference Card

  1. 1. Colorectal Enhanced Recovery - Anaesthetic Quick Reference Card Theatre Epidural • Epidural for all cases including laparoscopic unless contraindicated or refused. Site at appropriate thoracic dermatome e.g. T9-10 right hemicolectomy, lower for AP resection. • Pump comes with patient from ward. Codes are 700 (set rate) and 855 (for bolus) Induction • As deemed appropriate (for rapid recovery) by anaesthetist. Maintenance • O2/Air mix & ensure FiO2 ≥ 80%. Desflurane (Sevo if unavailable) or TIVA with propofol/remifentanil. Analgesia • Establish block with low-dose mix (LDM) or 0.25% bupivacaine. Ideally run LDM intra-op, or use remifentanil (if so, establish epidural block BEFORE arrival in recovery) • IV Paracetamol in theatre & prescribe postop. IV Diclofenac unless C/I or pre-op renal impairment. Antiemesis • IV Ondansetron + IV dexamethasone & prescribe postop PRN. Monitoring • As standard plus Oesophageal Doppler, temperature probe. Arterial / CVC line only if indicated. Fluids • Maintenance – Hartmann’s at 5 ml kg-1 hr-1. Bolus – Gelofusine 250ml. Keep Hb ≥ 8.0 g/dl. Optimise Stroke Volume (SV) with oesophageal doppler • Give discrete 250ml bolus and if SV shows ≥10% rise, repeat until SV no longer rises by 10%. Do not give further bolus unless SV falls or patient loses blood volume. Document SV & response to boluses on anaesthetic chart. • Hypotension is likely when epidural used intraoperatively. Corrected Flow Time (FTc) is likely to be high (>360ms). If hypotension persists after optimisation of SV use vasoconstrictor by bolus or infusion. Consider inotropes if Peak Velocity (PV) low and the clinical picture is suggestive of poor ventricular function. Temperature • Fluid warmer and hot air blanket for all patients. Do not remove hot air blanket until leaving theatre. Transfer • Epidural pump attached and running. Warn recovery and obtain ‘trauma’ mask (mask with non-rebreath reservoir bag). Use at 15l/min flow to deliver FiO2 ≥ 80% for transfer. • Send hot air blanket round with patient if temp <360 C. Recovery Respiratory • High flow O2 via ‘trauma’ mask for 2 hrs irrespective of saturations. After 2 hrs, O2 via nasal cannulae only if needed to maintain SpO2% ≥ 95%. Circulation • Keep MAP ≥ 65mmHg. 250ml Gelofusine and anaesthetic review if BP low. Fluids • Oral fluids ASAP. Hartmann’s 2 ml kg-1 hr-1 until drinking. Mobilisation • Give oral ephedrine 30mg ½ hour prior to sitting out if epidural in situ • Sit out in chair for ≥ 15 mins before leaving recovery. Watch for hypotension – 250 - 500ml fluid bolus and medical review if it occurs. Discharge • If stable after sitting out in chair. Version 2 November 2006 Page 1 of 1