IBD with Surgical Intervention: Pre- and Postoperative Management

Phase I: Preadmission, Preoperative, and Intraoperative Management Draft

8/11/17

Inclusion and Exclusion Criteria

Inclusion: Patients with IBD receiving ileocecectomy, colectomy, proctectomy, J pouch reconstruction, or stoma closure by a general pediatric surgeon
Exclusion:
· Patients with motility disorders from the Colorectal clinic (may use protocol but will need modifications for motility issues)
· Newborns and patients < 1 year old (for now).
· Cardiac and Neonatal ICU patients
· Cerebral Palsy patients
· Thoracotomies for non-neonatal conditions (sarcoma met resections)
· Acute Care Surgery patients (appendectomies, gallstone pancreatitis, bowel perforations from trauma, etc.)
· Patients deemed to need more customized care by the surgeon
· Anorectal malformations (ARM) with significant motility issues

• Detailed counseling by APP (Including preset discharge criteria)

• Surgeon and APP to follow-up with phone instructions: Encourage parents to watch ERAS
Preadmission
Lego video and provide PPT/printed materials
• Consults: Child Life, Pain, Psych, WOC

• Encourage clears up until 2 hours before operation

• Preoperative carbohydrate loading: 20 oz Gatorade or apple juice completed 2 hours before
operation
Preoperative • Place (SCDs) for patients age 12 or greater
• Ensure patients and their parents have done the following: Taken pre-op medications,
watched ERAS Lego video, and consumed clear liquids

Preoperative Medications
Medication Dosage Max Dose Comments
Decadron 0.15 mg/kg IV 5 mg
Ondansetron 0.05-0.1 (Max
mg/kgDose:
IV 4 mg) 4 mg
Acetaminophen 10 mg/kg PO 1000 mg Consider
Neomycin 10 mg/kg PO TID 1000 mg Bowel Preparation
Cefazolin 25 mg/kg PO x1 2g
Metronidazole 250 or 500 mg PO 500 mg Bowel Preparation

• Antibiotic prophylaxis: <1 hour prior to incision

• Laparoscopic technique (or minimize trauma)
• Avoidance of nasogastric tubes and perianastomotic drains
Intraoperative • Regional anesthesia: placement of TAP block or mid-thoracic epidural by anesthesia
• Minimization of opioids
• Maintenance of normothermia
• Maintenance of near zero fluid balance: limit fluids to 3-4 mL/kg/hr

Developed through the efforts of Children's Healthcare of Atlanta and physicians on Children’s medical staff in the interest of advancing pediatric healthcare. This is a general guideline and does not represent a
professional care standard governing providers' obligation to patients. Ultimately the patient’s physician must determine the most appropriate care. © 2017 Children’s Healthcare of Atlanta, Inc.
IBD with Surgical Intervention: Pre- and Postoperative Management
Phase II: Postoperative Management Draft
8/11/ 17

Surgery Day POD 1 POD 2 POD 3 POD 4

• Ambulation: OOB x4 • Ambulation: OOB x4 • Ambulation: OOB x4

• Encourage patient to • Encourage patient to • Encourage patient to
Activity Early Ambulation: OOB x1 Ambulation: OOB x4
ambulate, shower, and ambulate, shower, and ambulate, shower, and
dress independently dress independently dress independently

• Early oral intake

starting with juice in
PACU, then advance diet
Nutrition as tolerated
• Encourage chewing gum
and gummies
• Maintenance of near
zero fluid balance: limit
Fluids/ unecessary boluses
Drains • May saline lock PIV
when patient tolerating
PO
Aggressive pulmonary
Respiratory toilet: start incentive
spirometry
Care collaboration with
Consults Pain, Psych, WOC, Child
Life as needed
• Normal diet according
to tolerance
• Encourage chewing gum
and gummies
• Remove Foley Catheter
• May saline lock PIV
when patient tolerating
PO
• Encourage PO fluid
intake
Incentive spirometry
Care collaboration with
Pain, Psych, WOC, Child
Life as needed
• Normal diet according
to tolerance
• Encourage chewing gum
and gummies
• Encourage aggressive
oral intake
• Monitor PO fluid intake
and output from stoma
and urine to create
positive oral fluid
balance
Incentive spirometry
Care collaboration with
Pain, Psych, WOC, Child
Life as needed
• Normal diet according
to tolerance
• Encourage chewing gum
and gummies
Monitor PO fluid intake
and output from stoma
and urine to create
positive oral fluid
balance
Incentive spirometry
Care collaboration with
Pain, Psych, WOC, Child
Life as needed
• Normal diet according
to tolerance
• Encourage chewing gum
and gummies
Monitor PO fluid intake
and output from stoma
and urine to create
positive oral fluid
balance
Incentive spirometry
Care collaboration with
Pain, Psych, WOC, Child
Life as needed

Patient demonstrated
Nurse to perform stoma WOC Nurse to involve Nurse to involve patient Nurse to involve patient
Stoma Care competent changing of
care patient in stoma care in stoma care in stoma care
ostomy device

Consider transition to
oral medications. If so,
Minimize narcotic use if
Pain possible
assess if pain is being
controlled with oral
medications
• Remove epidural
• Consider transition to
Assess if pain is being Assess if pain is being
oral medications. If so,
assess if pain is being
controlled with oral controlled with oral
medications medications
controlled with oral
medications

Postoperative Medications
Medication Dosage Max Dose Comments
Ketorolac 0.5 mg/kg
(Max IV
Dose:
q6h30
x 72
mg)
hrs 30 mg
Gabapentin 10
(Max
mg/kg
Dose:
PO600
q8hmg)
x 72 hrs 900 mg Loading Dose
Acetaminophen 10 mg/kg
(MaxPO
Dose:
q6h 650 mg) 650 mg/dose
Morphine 3 mg IV q3h PRN Breakthrough pain only
Ondansetron 8 mg IV q8h 24 mg/day Nausea and Vomiting

· Discharge Criteria · Discharge Planning

• Ambulated successfully • APP to schedule clinic follow-up appointment
• Able to dress and shower independently at home (or as before • Provide patient with all prescriptions including pain medications
surgery) or has assistance • If stoma present, ensure patient has all the necessary supplies and is
• Demonstrated competent changing of ostomy device comfortable caring for the stoma at home
• Positive fluid balance (intake > output of urine and stoma by 500 cc) • Provide wound care education and ensure dressing is dry
• Tolerating diet • Answer all questions and provide all paperwork and handouts
• Pain is well controlled by oral meds
• No fevers

Developed through the efforts of Children's Healthcare of Atlanta and physicians on Children’s medical staff in the interest of advancing pediatric healthcare. This is a general guideline and does not represent a
professional care standard governing providers' obligation to patients. Ultimately the patient’s physician must determine the most appropriate care. © 2017 Children’s Healthcare of Atlanta, Inc.