Lap Chole Bundle

[emain86]

It's probably about 50/50 but these patients seem to be the ones that take a long time to get into phase 2 and then when they do get into phase 2 our SD nurses can't seem to get them out and then they end up returning to PACU.

I feel like I handle them appropriately and some nurses hate to give promethazine because then they have to wait longer to get them on room air to meet discharge criteria. I was looking at other post and I know sometimes with nauseous patients sometimes they just need to sleep it off.

I wish they'd give everyone that Emend stuff prior to surgery or at least ones that cause PONV most frequently. If I notice the patient has history of GERD i'll usually try to give pepsid depending on which anesthesiologist is on call ( some are just weird and wont do what i want). Also I like Reglan. I'll only usually give 12.5 of phenergran with all that. Technically I read since they both end in zines it can cause those extrapyramidal side affects, but has anyone ever seen that?

Last for some reason in my PACU we dont use fentanyl. I think that is absurd. We end up giving so much dilaudid because the morphine just doesn't work fast enough. I usually do 10 of morphine switch to dilaudid... I'd much rather do 5 of morphine, 50 of fent, 50 of fent, 5 of morphine. and be done.

What are tricks/tips you use when you recover lap chole? do you guys push fentanyl?

I think this would be a great project/ PI project, patient satisfaction increaser, and patient safety.

[meandragonbrett]

0.2 of Dilaudid q5min up to 3mg. Give them hydro or oxy in PACU and IV acetaminophen.

As far as PONV...hit all of the receptors and make sure they are adequately hydrated. Droperidol and examethasone. Most people get 4mg of Zofran before emergence...so no need to waste time redoing with that class of drugs.

Another thing that can speed up discharge times is whether the surgeons place local when closing. Our real surgery group is generous with the marcaine and that makes it super easy to get them out of the door within 45-60 minutes post op. Usually don't require any IV opioids in phase I. We just get something PO in them in phase I so that they don't get stuck in phase II over pain issues.

[peaches88]

I rarely have to give a lap chole much for pain. This includes three surgeons that all perform the procedure differently. Typically, we give 0.4mg dilaudid q 5 min, up to 2 mg, if needed. I usually end up giving 0.4-0.8 mg total to a lap chole in phase 1. In phase 2, they get their po med, then go home.

As for phenergan, I was taught in my first semester of nursing school that I would NEVER give it IV (lol, right!) because it is so hard on your veins. The policy where I work is that you have to give it diluted or through a running IV line. Sooo... That is why I use it as a last resort, besides the fact that it makes patients drowsy. I try zofran first and if they have a history of PONV, we usually have a scopolamine patch on them anyways (cheap and effective).

[emain86]

If you ever tried to take my phenergran away I'd probably quit this job. I wish ours didn't have pain issues. I don't know what it is. Some days I feel like all I do is slam people with narcotics and they are still screaming for more.

I'll look into the scolpamine thing. I mean nausea is so common in these patient's. They need to try anything.

[MC1906]

I think it would be good to look at some data and show it to the Drs. and your director. They may be unaware that they are taking so long to progress through in Phase II.

Nausea: there are a few things that you can give preop that will help. To add to what's been stated, you can apply a Scopalamine patch for those with known PONV prior to surgery. I usually give Zofran 4mg/IV. They could also be behind on their fluids. Sniffing an alcohol pad sometimes works.

Pain: Fentanyl is awesome, my PACU does it use it much. I like Dilaudid, Demerol, and Toradol. Also they need to really breathe to get the gas out used for the Lap procedure.

If your having lots of problems with PONV and pain management, maybe it could be something going on. I would review the OR sheets to see what are they getting in surgery. Not all patients should be the same. So if they all are coming out with extreme pain, that may be something else that needs looking into.

Good luck!

[azhiker96, BSN, RN]

You might consider borrowing or buying the current ASPAN standards. You can evaluate a patient's risk for PONV and then determine how many interventions/meds should be given for prophylaxis. For example, a female non-smoker with hx of motion sickness who is getting volatile anesthtics and narcotics should have 4 interventions. That could be a liter of iv fluid and scopalamine patch in pre-op along with decadron and famotadine during the case. That leaves zofran, reglan and pheneragan for rescue in PACU. You can also apply P6 accupressure and use aromatherapy such as alcohol wipes, peppermint extract, or ginger oil.

[emain86]

I have a current ASPAN standards book and am fairly familair with the risk factors for PONV. The problem is Anesthesia here does every single case the same. Zofran, Decadron , Ofirmev ( unless contraindicated), and toradol ( if i'm lucky). Some of the better ones will give some longer lasting narcotics throughout the case but a lot dont. They even localize the port sites. Also I usually dont give reglan and pheneragan together.

Lap Chole's to tend to have more PONV than other procedures in my experience. I guess my issue is that we keep getting these patient's returned from Same-Day I give them 12.5-18.75 of phen let them sleep for an hour and then send them on their way. I would like to prevent it more so the patch might be a cheap effective way.