Post-op

Page updated Winter 2021.
Disclaimer: Medicine is an ever-changing science.  We have been witnessing changes in diagnostic and therapeutic modalities and guidelines during last several years. We have used sources believe to be reliable for purpose of this website including AUA guidelines, EAU guidelines, NCCN guidelines, Campbell-Walsh-Wein Urology, UpToDate, Merck Manual, Lexi-Comp, FDA website, and other reputable resources. However, due to possibility of human error or changes in medicine, readers are required to confirm the information provided in this website with other sources. Readers are specially required to read all parts of the product information sheet included in the package of each drug they plan to administer and follow those instructions. Readers are also needed to follow instructions of FDA and other regulatory bodies and their own department in this regard. Authors can cite information provided in our textbooks or they need to cite the original resources. This website serves as a general framework. We and other users would adjust the approach per departments policies and patients situation. Forms can be used by other health care professionals.

Post-op Checklist

Add the patient to the list

Problem List

Add a problem list for this admission, if not done already.

Admission Orders

Patient status:

Inpatient / Observation / Outpatient 

Bed Type

Regular / Surgical Telemetry / ICU

Diagnosis / S/P 

Universal Patient Care Orders

Resuscitation / Rapid Response Team

Hypoglycemia Protocol / Naloxone (Narcan) Protocol

Nursing:

Telemetry/ Vital signs / Monitor SpO2 / Notify MD setting

Input and output (I & O) / Drains

Daily weights

Oral Care Protocol

Activity

Bed rest / Up to chair with assistance / Ambulate with assistance

Oxygen Supplement

Incentive Spirometer 

CPAP 

If patient was on it before surgery.

Urinary Catheter and Irrigation

Foley to gravity

Suprapubic catheter to gravity/ Nephrostomy tube to gravity

Continuous bIadder irrigation to keep urine clear

Intermittent irrigation with 60 mL piston syringe to keep clot free

NG Tube

Wound Care

Nutrition / Diet

NPO / Ice chips / Clear liquids / Full liquids / Regular

Glucose Monitoring / Glycemic Control Order Set 

One Time Labs/ AM Labs / Imaging

IV Fluids

Electrolytes Management

Address each electrolyte according to its level.

Sodium bicarbonate (1-2g, PO, TID)-  after radical cystectomy

Prophylaxis

DVT

Compression stockings (TED hose)

Pneumatic compression device

Enoxaparin (Lovenox) / Heparin - Refer to middle column. 

Antibiotic: per guidelines

GI bleeding: refer to section below.

Meds

Anaphylaxis

Epinephrine: 

IM: 0.3 or 0.5 mg (use 0.5 mg in patients >50 kg) using the 1 mg/mL solution. may repeat every ~5 to 15 minutes (or sooner if clinically indicated) if patient does not adequately respond.
IM, in the anterolateral aspect of the middle third of the thigh
Children dose:  0.01 mL/kg

Glucagon:

In patients taking oral beta-blockers.

1-mg bolus  followed by 1-mg/hour infusion 

Children dose: 20 to 30 mcg/kg 

Antihistamine

May need Inhaled beta-agonists, IV fluids, intubation and vasopressors.

Pain Management

The transversus abdominis plane (TAP) block

Thoracic epidural analgesia: It should be continued for 72 h

Ketorolac (Toradol) - IV

Weight ≥50 kg and <65 years of age: 15 to 30 mg q 6 hr, PRN

Weight <50 kg or ≥65 years of age: 15 mg q 6 hr, PRN

Acetaminophen (Tylenol)-  650 mg PO or PR q 6 hrs PRN

Gabapentin-

Immediate release: Initial: PO, 100 to 300 mg 1 to 3 times daily

Pregabalin-

Immediate release: Initial: PO, 25 to 150 mg/day in 2 to 3 divided doses

Tramadol- If needed. Refer to middle column. 

Opioids : If needed. Refer to middle column. 

Oral is preferred than IV. If IV needed, PCA is preferred.

Oral options:

Hydromorphone (Dilaudid)

Oxycodone (Oxycontin)

Oxycodone / acetaminophen (Percocet 5 / 325mg)

Hydrocodone

Hydrocodone and acetaminophen (Norco)

IV options:

Hydromorphone (Dilaudid) / Morphine/ Fentanyl 

Insomnia 

Melatonin- 0.1 - 0.5 mg PO

Trazodone- immediate release: PO,  50 mg to 100 mg at bedtime

Zolpidem (Ambien)-  5 mg PO q.h.s PRN

ENT 

Sore throat

Chloraseptic spray: 2 sprays q 2hrs PRN

Pulmonary:

Acute Asthma :

Albuterol (Ventolin, ProAir):

Metered-dose inhaler: Initial: (90 mcg/actuation): 2 inhalations qid, PRN

Fluticasone (Flovent):  Metered-dose inhaler: Initial: 88 mcg bid

Gastrointestinal 

Nausea and vomiting:

Ondansetron (Zofran)-  4 mg IV / PO q 6 hrs PRN

Promethazine (Phenergan)- 12.5 mg IV q 4-6 hrs PRN

Metoclopramide (Reglan)- 10 mg IV /PO q 6 hrs PRN

Hiccups

Baclofen-initial: 5 to 10 mg, PO, 3 times daily 

Metoclopramide, Pantoprazole , and  Gabapentin may also be tried.

Reflux:

Famotidine (Pepcid): 20 mg, IV / PO, bid

Pantoprazole (Protonix): 40 mg IV / PO daily or bid

  • Calcium carbonate (Tums)- Chewable Tablets- 1000 mg orally up to 4 times a day 

Ileus:

Chewing gum: helps to prevent ileus

Alvimopan (Entereg)- 12 mg PO, bid-  after radical cystectomy

Do not give if patient took opioids >7 days before starting this.

Constipation:

Docusate (Colace): 50 to 300 mg PO daily divided in 1 to 4 doses

Bisacodyl (Dulcolax): Suppository:10 mg daily, PO : 5 to 15 mg  daily

Senna: 2 tablets once a day. Tablets are 8.6 mg  

MiraLAX (polyethylene glycol):

17 g (diluted in 8  ounces of water or juice, or soda) orally once a day

Fleet enema (sodium phosphates)- 120 mL ,rectally as a single dose. 

Diarrhea- if not infectious:

Loperamide (Imodium): Oral: Initial: 4 mg, followed by 2 mg after each loose stool (maximum: 16 mg/day)

Diphenoxylate/ atropine (Lomotil): 5 mg diphenoxylate/0.05 mg atropine (2 tablets) PO q6hr

Opium tincture: Oral: 6 mg (0.6 mL) of undiluted opium tincture (10 mg/mL) 4 times daily

Urinary:

Bladder spasm

Oxybutynin (Ditropan)- immediate release: 5 mg 2 to 3 times daily

Belladonna & Opium- suppository- 16mg -60mg, once or twice daily

Urised

Dysuria 

Phenazopyridine (Pyridium)- 200 mg orally 3 times a day

Itching: 

Diphenhydramine (Benadryl)- 25 to 50 mg orally or IV

Disease Specific Meds

Like transplant immunosuppressive 

Pre-op Meds Reconciliation 
DVT Prophylaxis

Extended prophylaxis for 4 weeks should be carried out in patients at risk.

Options:

One or combination of following measures depending on patient risk:

Early ambulation

Compression stockings (TED hose)

Pneumatic compression device

Heparin:

5000 units q8h or q12h SC

BMI ≥30: 5000 units q8h 

Enoxaparin (Lovenox) 

40 mg  SC daily

If CrCl <30 mL/min: 30 mg SC daily

BMI ≥40: 40 mg twice daily


Contraindications to Prophylactic Heparin 

Hypersensitivity to heparin

Severe thrombocytopenia

History of heparin-induced thrombocytopenia

History of heparin-induced thrombocytopenia with thrombosis

Uncontrolled active bleeding


Heparin Dose: Altered Kidney Function

No initial dosage adjustment necessary


Heparin Dose: Hepatic Impairment

No dosage adjustment required



Contraindications to Prophylactic Enoxaparin 

Hypersensitivity to enoxaparin, heparin, and pork products

History of heparin-induced thrombocytopenia (HIT)

Active major bleeding

Spinal/epidural anesthesia

Epidural catheter 

Intra-cranial Pressure (ICP) Monitor 


Enoxaparin Dose: Altered Kidney Function

CrCl <30 mL/minute: 30 mg once daily.

Enoxaparin: Hepatic Impairment

There are no dosage adjustments provided in the manufacturer’s labeling


Epidural

Enoxaparin:

Hold prophylaxis for 24 hours prior to epidural placement.

Should not be used while epidural is in place.

Heparin: 

Hold dose for 6 hours prior to epidural placement.

Hold dose for 4 hours prior to epidural removal.

Resuming prophylaxis:

May initiate subcutaneous heparin or enoxaparin 2-4 hours after epidural removal.


Opioids 

Should prescribe the lowest effective dose of immediate-release opioids.

Should carefully reassess risks and benefits when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day. 

Should avoid  dosage  ≥90 MME/day.

Three days or less will often be sufficient.

More than seven days will rarely be needed.

Should avoid prescribing opioid  and benzodiazepines concurrently.

Morphine Milligram Equivalents (MME)

Opioid (doses in mg/day except where noted)Conversion Factor
Codeine0.15
Fentanyl transdermal (in mcg/hr)2.4
Hydrocodone1
Hydromorphone4
Methadone:
1-20 mg/day4
21-40 mg/day8
41-60 mg/day10
>=61-80 mg/day12
Morphine1
Oxycodone1.5
Oxymorphone3


Oxycodone/acetaminophen (Percocet)

Oral:

Immediate release

Dose

Based on oxycodone content:

2.5 to 10 mg every 4 to 6 hours PRN

Elderly >70 years:

Decreasing the initial dose by 25% to 50%.

Dosing: Altered kidney function 

There are no dosage adjustments provided in the manufacturer’s labeling.

Dosing: Hepatic impairment

There are no dosage adjustments provided in the manufacturer’s labeling.


Hydromorphone (Dilaudid)

Oral: 

Immediate release

2 to 4 mg every 4 to 6 hours PRN

IV: 

 0.2 to 1 mg every 2 to 3 hours as needed PRN

Patient-controlled analgesia (PCA) 

Loading dose: 0.4 mg

Demand dose: Range: 0.1 to 0.4 mg

Lockout interval: 10 minutes

Dosing: Altered kidney function 

CrCl 30 to <60 mL/minute: Administer 50% of usual initial dose.

CrCl <30 mL/minute:

Administer 25% of usual initial dose and extend dosing interval by 25% to 50%.

Dosing: Hepatic impairment

Mild to severe impairment: Initiate with 25% to 50% of the usual starting dose depending on the degree of impairment. 


Morphine

IV

1 to 4 mg every 1 to 4 hours PRN

Dosing: Altered kidney function 

CrCl 30 to <60 mL/minute: Consider use of an alternative opioid analgesic. If necessary, administer 50% to 75% of usual initial dose; may also consider extending dose interval.

CrCl 15 to <30 mL/minute: Avoid use. If necessary, administer 25% to 50% of usual initial dose; may also consider extending dose interval.

CrCl <15 mL/minute: Avoid use.

Dosing: Hepatic impairment

There are no dosage adjustments provided in the manufacturer's labeling.


Fentanyl

Used for analgesia and sedation in critically ill patients in the ICU.

Loading dose: IV: 25 to 100 mcg or 1 to 2 mcg/kg

Continuous infusion:

After initial loading dose  begin continuous infusion.

Initial rate: 25 to 50 mcg/hour

Titrate every 30 to 60 minutes to clinical effect  pain control and/or sedation)

Usual dosing range: 50 to 200 mcg/hour  m

Dosing: Altered kidney function 

CrCl <50 mL/minute:

No dosage adjustment necessary when single or infrequent bolus doses are used.

For more frequent dosing, use small, incremental doses to titrate.

Dosing: Hepatic impairment

There are no dosage adjustments provided in the manufacturer’s labeling.

Tramadol

 ≤3 days is often adequate

 >7 days is rarely needed

Immediate release: Initial: 50 mg, PO, every 4 to 6 hours PRN

The dose may be increased as needed and tolerated to 50 to 100 mg every 4 to 6 hours (maximum: 400 mg/day) 

Dosing: Altered kidney function 

CrCl <30 mL/minute:

Immediate release: Increase dosing interval to every 12 hours; maximum: 200 mg/day. 

ER formulation should be avoided.

Dosing: Hepatic Impairment

Severe impairment: 

Immediate release: : 50 mg every 12 hours.
Discharge Ward Patient Checklist

Case Manager or Discharge Planner 

Assign a case manager or discharge planner to the patient.

Discharge Planning

Include the patient and family in the discharge planning.

Caregiver 

Identify the caregiver who will be at home with the patient.

Primary Care Provider (PCP) 

Make sure patient has an active PCP.

Find a PCP if patient does not have PCP.

Inform PCP about the patient status.

Arrange post discharge PCP follow‐up appointment.

Patient's Discharge Checklist and Booklet

Will be taken care of by patient advocate, nurse, discharge planner, and physician.

Education

Educate the patient and family about the patient’s condition, the discharge process, and next steps.

Explain tests results. 

Go over stuff patient needs to do at home.

Go over medications.

Explain warning signs and problems.

Explain when patient should visit ED.

Pharmacist teaching

Wound care teaching

Foley, JP,  and other tubes or drains teaching

Diabetes teaching

Care Transition From Hospital to Another Facility 

Home-based Care

Special Equipment Needs

Coordinate home-based care and special equipment needs.

Diabetes Supplies:

Glucose meter: Accu-Chek

Blood Lancets

Diabetic Test Strips

Follow-up Appointments

Will be taken care of by patient advocate, nurse, discharge planner, and physician.

Discharge Order

Medication Reconciliation 

Reconciled Medications Review by Pharmacy

Discharge Instructions

Hospital Contact Person

Write the name, position, and phone of the hospital person to contact if there is a problem after discharge.

Discharge Summary

Outpatient Investigations 

Labs, radiology

Post-discharge Follow‐up Phone Call 

Arrange for post-discharge follow‐up phone calls.


EPIC Discharge Workflow 

Steps:

1- Admission/Discharge/Transfer (ADT) Navigator

Click on it. It is used for any of above actions.

2- Discharge Tab

Click on it. Then while inside this tab, follow as below:

1- Problem List subtab

Add problems if not done already.

Choose one of the problems as principal problem for this hospitalization.

2- Follow-Up subtab

Internal follow-up appointments can be added here, if not done already during the hospitalization. 

3- Patient Instructions subtab

Place your instructions here if your department does not have a special instruction section in discharge order set. If there is such a segment in discharge order set, MD  who is discharging the patient can put instructions there.  Other teams would put instructions here. 

4- Med Rec/Orders subtab

1- Reconcile medications

2- New orders

Appointment requests are made here, if not done already on the floor.

3- Discharge Order Set: 

Notice: You need to place following orders or instructions separately, if your department does not have this order set.

1- ADT( Admission/Discharge/Transfer : Discharge patient

2- Notify

2- Activity

4- Diet

5- Special instruction

6- Other orders, per department preferences

4- Summary- Review all orders before signing them.

6- Discharge pharmacy: Send meds to discharge pharmacy.

5- Sign

5- Preview AVS- Preview After Visit Summary

6- Discharge summary:

Write discharge note here.

PACU Orders:

All PACU orders are done by anesthesia. 

Discharging From PACU

Follow the same procedures as if the patient was ward patient.

Discharging Come and Go Surgical Patients:

Put discharge medications under Outpatients Meds and send them to discharge pharmacy.

Bedside Care Checklist & Supplies

Procedure Consent Sheet/ Next of Kin /Contact Person

Face Masks/ N95 Respirator/ Face Shield

Surgical Cap/ Sterile Surgical Gowns/ Sterile Gloves

Hand Sanitizers / Non-sterile Gowns/ Non-sterile Gloves

ChloraPrep- Chlorhexidine Swabs / Alcohol Pads

Drapes/ Sterile Towels/ Ultrasound Probe Cover

Ultrasound Machine/ Ultrasound Probes/ US Conductive Gel

Bandages / Gauze Sponges / Gauze Rolls / Petrolatum Gauze

Packing Strip / Cotton Tipped Applicators

Tegaderm Transparent Wound Dressings 

Medical Tape / Steri-Strips / Benzoin Tincture 

Abdominal (ABD) Gauze Pads / Abdominal Binder

Adhesive Remover / Lidocaine Spray

Lidocaine 1 % for Local Injection- Max dose 4.5 mL/10 kg

Syringe / 25 Gauge Needle

Saline Flush 

Saline Irrigation Solution (Sodium Chloride 0.9%)/ Emesis Basin

Silver Nitrate Sticks

Suture Removal Kits/ Skin Staple Remover / Scissors 

Suture / Needle Holder / Forceps /Scalpel / #11 Blade /#15 Blade

Bedpan/ Sheet / Restraint

Tongue Depressor

Catheterization

Foley Catheter Kits/ Three-Way Foley Catheter

Straight Catheter/ Council Tip Catheter / Coudé Tip Catheter

Urojet (Sterile Xylocaine Jelly) / Lubricant Gel

Intermittent Bladder Irrigation

Mask with a Face Shield / Non Sterile Gloves, Gown

Alcohol Swabs

Disposable Sterile Irrigation Tray

Toomey Syringe (60 ml Catheter Tip Syringe}

Sodium Chloride 0.9% for Irrigation

Continuous bladder irrigation (CBI) 

Mask with a Face Shield / Non Sterile Gloves

Three-Way Foley Catheter (20-24 French)

Irrigation Set- Y Type

3 Liter Sodium Chloride 0.9% Bags / 4 Liter Urinary Drainage Bag

Waste Disposal

Non-infected Materials / Sharps / Biohazard Waste