Setting Expectations
- Health care team discuss patient understanding of surgery, anticipated length of hospitalization, pain management, mobility limitations, and recovery time.
- Discuss body image issues and motivation for surgery – including complications with previous treatments such as bracing.
- Identify differences in expectations between adolescent and parents regarding pain.
Introducing the Team
Team effort will keep Courtney safe during surgery:
- Physicians
- Neuromuscular monitoring
- Anesthesiologists
- Nurses
Support Courtney’s progress to discharge:
- Pain team – help with pain management intraoperative and immediately post operative, eventually progressing to oral pain medication which will continue after discharge
- Physical Therapy – help with progressing from sitting on side of bed; to getting in a chair; to short walks to the bathroom; to longer walks in the hallway; and a small flight of steps
- Nurses – observe and assess Courtney, administer medications, help with daily hygiene, help with progression of oral intake – fluids and then food, and bladder and bowel issues
Planning for Rapid Recovery
To improve postoperative recovery:
- Gabapentin 600 mg one time preoperative dose
- To reduce postoperative pain and opioid use
- Acetaminophen 650 mg extended release one time preoperative dose
- To reduce postoperative pain
Plan for:
- Active pain management
- Early mobilization and physical therapy
- Accelerated recovery of bowel function
Preparation for Surgery
Courtney and her mom were given written preoperative instructions including:
- Fasting for surgery
- Skin preparation for infection prevention
- Courtney was given 2% Chlorhexidine Gluconate cloths (CHG) to wipe her body with
- Planning for discharge management information
Courtney was given a prescription for:
- Gabapentin 600 mg one time dose – to be taken on the morning of surgery (immediately upon awakening) with a small sip of water
- Acetaminophen 650 mg extended release to be taken on the morning of surgery (immediately upon awakening) with a small sip of water
Courtney’s Pre-Surgical Experience
Courtney answers what she was most worried about before surgery.
Courtney's Medications
Preoperative Medications
Gabapentin 600 mg
- One time dose – to be taken on the morning of surgery (immediately upon awakening) with a small sip of water.
Acetaminophen 650 mg Extended Release
- One time dose – to be taken on the morning of surgery (immediately upon awakening) with a small sip of water.
Intraoperative Medications
Anesthesia
- Propofol
- Remifentanil
- Nicardipine
Clotting Promoter
- Aminocaproic acid
Pain Relief
- Methadone* (start of surgery)
- Morphine (end of surgery)
- Acetaminophen IV (end of surgery)
* Intraoperative methadone believed to reduce potential for hyperalgesia from remifentanil, but not definitively confirmed. Only for use by skilled prescribers.
Antibiotic
- Ancef
Postoperative Medications
For Pain
- Hydromorphone PCA (stop AM day 2)
- Hydromorphone bolus prn – 1x in PACU; 1 pm of day 2
- Oxycodone started 5 mg q6h prn evening of day 1, changed to q4h ATC day 2-4
- Gabapentin 300mg PO q8h
- Ketorolac 15 mg IV q6h day 2-4
ATC– Around the clock PCA- Patient Controlled Analgesia
- Diazepam 2.5mg q6h prn (muscle spasm)
- Docusate 100mg q12h prn (constipation)
- Bisacodyl supp qd prn (constipation)
- Miralax qd prn (constipation)
- Ondansetron 4mg q8h prn (nausea)
- Nalbuphine 2.8mg a4h prn (itching)
- Ancef (antibiotic)
q.h– Every hour q.d– Every day prn- As needed
