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Ambulatory General Surgery CarePath
Laparoscopic
Open
Goals
Reduce PACU length of stay and increase patient satisfaction by reducing post-op pain, PONV, and
sedation by minimizing opioids and incorporating a multimodal analgesic regimen.
To whom it applies
 Laparoscpic cholecystectomy
 Lap inguinal hernia
 Lap ventral hernia
 Open inguinal hernia
 Umbilical hernia
 Anorectal surgery
 Access Port placement and removal.
Medications
 Please check for allergies, contraindications and appropriateness of medications for all patients before ordering.
Meds ordered night  Pregabalin 75mg PO x 1.
before
 Acetaminophen 1000mg PO x 1
 No Gabapentinoids routinely
 Acetaminophen 1000mg PO x 1
Consider a holding
area huddle:
 Huddle between surgical, anesthesia teams and the patient to discuss:
 PO meds administered in holding area.
 Prescriptions that the patient will take home (so that PACU orders can be coordinated).
Blocks
 Usually no blocks indicated
 All cases that need a block will be booked as such ( if
not booked as a block ,surgeon will infiltrate locally)
Type of Anesthesia
 General
 General or MAC depending on patient and complexity.
Induction
 Dexamethasone 8mg IV SLOW
 Dexamethasone 4mg IV SLOW except for the anal
condyloma and dysplasia cases
Surgeon
 Surgeon to instill local anesthetic at the port sites in
laparoscopic at placement and again on removal.
 Surgeon to instill local anesthetic into wound if no block
has been placed.
Intraop
 Consider Ketorolac 30-60 mins before the end of the case
 Ondansetron 4mg IV at end of case.
 Minimize IV fluids <1200 ml
 Minimal opioids. Short acting (Fentanyl or Dilaudid in low doses).
Voiding
PACU
•
Voiding requirements only for inguinal hernia surgery with any of the following risk factors. Patient will follow
the voiding protocol if they have to demonstrate voiding before discharge.
• Pts with h/o urinary retention
• H/o BPH
• Fluid administration >1200 ml for the case and age >65
 PO Opioid as needed when able to tolerate PO.
 IV opioid (fentanyl or hydromorphone in low doses)
for breakthrough pain, if unable to tolerate PO, or
VAS>5.
 PO Opioid as needed when able to tolerate PO.
 IV opioid (fentanyl or hydromorphone in low doses) for
breakthrough pain, unable to tolerate PO, or VAS>5
Authors
Dana Fugelso M.D, Michael Cahalane M.D, Peter Mowschenson M.D, Sowmya Mahapatra M.D,
Irina Fishman M.D, Susan Dorion RN BSN MSN , Eswar Sundar M.D, Cullen Jackson Ph.D., Pete
Panzica M.D, Meghan Connolly RN, BSN, ACNP, Mary Ellis RN BSN, Marianne McAuliffe RN, BSN,
Kathleen Mulligan RN, BSN, Elena Canacari RN, John Tumolo,