UPMC Children’s Hospital of Pittsburgh QI Project

ERAS Protocol For Pediatric Laparoscopic Cholecystectomy Promotes Safe and Early
Discharge.

Protocol

Pre-operative
• Education regarding:
o Possible discharge at home on the day of surgery.
o Early mobilization to help with shoulder pain.
o Patient may be approached for possible peripheral nerve blocks.

Day of surgery
• Multimodal pain management
o Proposed blocks
§ Rectus sheath nerve block (2 - 3) and transversus abdominis plane
blocks, subcostal approach (total 4 blocks)
§ Bilateral quadratus lumborum block (total 2 blocks)
§ Medication used:
• Ropivacaine (up to 3 mg/kg, 0.5% is preferred)

o Local anesthetic administered via peripheral nerve blocks or at laparoscopic

instrument sites
§ Medication used:
• Ropivacaine (up to 3 mg/kg, 0.5% is preferred)

o Intravenous analgesia
§ Fentanyl is preferred to long-acting opioids such us morphine and
hydromorphone. If morphine or hydromorphone are used, consider
decreased amount.
§ Reduce amount of dexmedetomidine administered at the end of
anesthesia (maximum 12 - 16 mg)
§ Acetaminophen IV 15 mg/kg at the end of surgery (maximum 1000 mg)
§ Ketorolac IV 0.5 mg/kg at the end of surgery (maximum 15 mg, surgeon
must approve)

o To reduce the incidence of shoulder pain, consider the following:

§ Decrease the insufflation pressure.
§ Decrease the amount of residual pneumoperitoneum.

• PONV prophylaxis
o IV hydration with 20 ml/kg isotonic solution
o Ondansetron IV 0.1 mg/kg (maximum 4 mg at the end of surgery)
o Dexamethasone IV 0.15 mg/kg (maximum 8 mg) at the beginning of surgery
o For patients with high risk of PONV (positive for all 4 Apfel criteria*), consider
scopolamine patch and/or TIVA technique.
Postoperative
• Multimodal pain management
o Acetaminophen IV 15 mg/kg (maximum 1000 mg)
o Oxycodone PO 0.1 mg/kg (maximum 10 mg) Q4H PRN for moderate pain
o Hydromorphone IV 5 mcg/kg Q2H PRN for breakthrough pain
o Ketorolac IV 0.5 mg/kg (maximum 15 mg) Q6H (surgeon must approve)
o Diazepam / lorazepam PRN for anxiety
o Comfort and distraction as often as possible
o Light diet on the day of surgery

• PONV
o Ondansetron IV 0.1 mg/kg (maximum 4 mg) IV Q6H PRN for nausea

• Medication for discharge home:

o Oxycodone PO 0.1 mg/g (maximum single dose 10 mg) Q4H PRN for moderate
pain
o Acetaminophen PO 15 mg/kg (maximum single dose 1000 mg) Q6H scheduled
for first 2 to 3 days then Q6H PRN for mild pain
o Ibuprofen PO 10 mg/kg (maximum single dose 800 mg) Q6H scheduled for first 2
to 3 days then Q6H PRN for mild pain

DAY OF SURGERY

PRE-OPERATIVE CLINIC PRE-OPERATIVE HOLDING OPERATING ROOM POST-ANESTHESIA CARE POST-DISCHARGE PERIOD
AREA UNIT

Patient determined to need
a laparoscopic
cholecystectomy
Patient and family education
• Likely same-day discharge
• Early post-operative
mobilization and diet
advancement
• Pain/nausea
management plan
Early OR start time
scheduling
Pre-operative evaluation Pain management
• Peripheral nerve block at
Scopolamine transdermal surgeon’s discretion
patch applied • Fentanyl IV
• Acetaminophen IV
• Ketorolac IV
Nausea management
• Dexamethasone IV
(start of case)
• Ondansetron IV
(end of case)
Pain management Monitoring for ED visits or
• Hydromorphone IV re-admissions
• Oxycodone PO
• Acetaminophen IV
• Ketorolac IV
Early mobilization
Early diet advancement
Discharge medication
• Oxycodone
• Acetaminophen
• Ibuprofen
• Senna

Discharge home if eating and

ambulating with adequate
pain control