WHIPPLE CLINICAL PATHWAY

Activities before Surgery

Day -14 Discuss care map IMPACT advanced recovery Mobility: Aim to walk 2 Schedule follow-
Pre-op Consents
with patients and drink each day for 5 days miles/day prior to day up visit for ~2
to -1 clinic visit
set expectations prior of surgery weeks post-op
signed

NPO after midnight. Clear

8 oz apple juice
Day -1 before midnight
liquids up to 4 hours before
surgery

Day 0: Pre and Peri-operative Milestones

8 oz apple juice Heparin Check blood 1000mg Acetaminophen PO Place portable Sequential
Fluids: In Pre-op, If IV
Pre-Op 2 hrs before 5000 Units glucose hourly, pre-op then IV or PO elixir Q6h
in, D5LR at 50 ml/hr
Compression Devices (SCD) in
surgery* SC keep <140 mg/dL scheduled until d/c Pre-Op area
Foley Start preop Abx 2 large (16 Fluid: 2 ml/kg/hr of LR . Heating mattress Check blood
**In case of No
Intra-Op (temp- (levofloxacin) gauge) bore IV Give 500 mL LR bolus or blanket + Bair glucose hourly,
hypotension NGT
ensing) immediately in OR +/- arterial line extra during first 30 min hugger keep <140 mg/dL

Intra-Op : Administer short/long Two TAP block catheters will be placed Initial bolus of ropivicaine 0.2% 15 Initiate TAP catheter infusions
Dr. Park’s TAP acting opiates as needed intraoperatively by the surgical team prior mL per catheter by surgical team; with ropivicaine 0.2% at 5
block pts for adequate pain control to abdominal wall closure total dose not to exceed 2 mg/kg mL/hr per catheter
Dr. Park’s patients: Continue TAP
Fluid: D5LR Target Insulin drip protocol Labs 1 hour after
Foley Dr. Pillarisetty pts: IV infusions of Ropivicaine and start IV
PACU catheter hydromorphone PCA PCA at 0.2 mg bolus, 6 min lockout,
at 1 UOP > 25 if BG > 140 and/or PACU arrival: CBC,
ml/kg/hr mL/hr diabetic Chem10
no continuous infusion or 4 hour limit
Inpatient Milestones: 4SE Target Post-op LOS = 5 days
Chewing Pantoprazole Periop beta IV D5LR/LR rate: 1 Mobility: encourage to sit up on
Antiemetics
Day 0 gum after 40 mg IV blocker if
(Ondansetron)
ml/kg/hr (modify for CHF, edge of bed after last set of post-op
surgery daily indicated*** CRI); UOP >25mL/hr VS (usually 6hrs) with orthostatic VS
For breakthrough pain: Adjust PCA
Incentive spirometer: Urine output + vital Start sips of water Continue Acetaminophen
first as needed. Limit 0.2%
Day 0 10x/hr while awake, signs Q1h x 2; Q2h x 2; and ice chips < 8oz in 650mg elixir PO Q6h
Ropivicaine infusions through TAP
daily until d/c then Q4h 8 hrs scheduled until discharge
catheters to a maximum of 15 ml/hr.
Weigh Heparin Mobility: OOB for all meals. Continue TAP blocks and IV PCA.
Pantoprazole
Day 1 daily until 5000U SC
40mg IV Daily
Walk 3-4 times in the hall— PT consult Transition to po acetaminophen
d/c Q8h goal 9 laps. OOB 6 hr/day after clear liquids started.
Discuss ketorolac(15 mg q6h) IV D5LR/ LR (isotonic), rate: Insulin drip protocol- when patient Clear Labs: CBC, Chem10,
OT
Day 1 or other NSAID with surgeons 0.5 mL/kg/hr (modify for reaches less than 1 unit/hr for 12 liquids 8oz drain & serum
consult
for pain if not contraindicated. CHF, CRI); UOP> 25mL/hr hrs, may change to SC insulin Q8h amylase

*No exceptions for diabetics. All patients get apple juice and glucose is monitored closely.
** The goals of perioperative management is keeping the patient hemodynamically stable with restricted fluids. Hypotension intra-op: Hypotension to be treated with fluid boluses and with phenylephrine up to 0.8
mcg/kg/min. Avoid Vasopressin boluses and infusion by all means. Last updated 11/16/15
***Prior beta blocker use, history of arrhythmia, etc.
0
 WHIPPLE CLINICAL PATHWAY
Inpatient Milestones: 4SE Target Post-op LOS = 5 days
Change from Pharmacy Remove foley catheter at 0600 Change Mobility: OOB for all meals.
SCH to Lovenox consult for on day 2. No Fill and Pull unless Pantoprazole from Walk 3-4 times in the hall—
Day 2 40mg SC Q24h* Lovenox previous failed attempt IV to PO 40 mg goal 18 laps. OOB 6hrs/day
at 2100 teaching, for D/C (complete no later than 1100) daily until d/c until discharge

Advance to Labs: CBC, Start docusate

Nutrition Diabetic IV D5LR 0.45%NS Begin
Whipple diet if Chem 10 200mg PO BID
Consult, IV PCA clear liquid unless tachycardia pancreatic
tolerating CLs (low (others as and senna
POD2 diet or low UOP enzymes ***
fat/diabetic diet)** indicated) 17.2mg PO QHS

Consider D/C Discontinue TAP Discontinue Surgical team to Transition to

If >5kg over preop weight, give
PCA on Day 3 infusion at 0600 ketoralac/start remove TAP oxycodone 5-
Day 3 or Day 4 after if tolerating ibuprofen 600 catheters by 15mg PO Q3h
HLIV Lasix 10mg IV if renal function
adequate
lunch Whipple diet mg PO q6 h mid-afternoon PRN

Labs: CBC, Discuss with Review PT/OT Discuss with nutrition and Hyperglycemic team
Order Whipple Chem10, drain SW to secure recs to assess for pharmacy: diabetic consult if blood sugars
DME Diet & serum lodging SNF or Home education as indicated for uncontrolled or patient
amylase arrangements Health needs insulin regimen is new to insulin

Assess response to Lasix

If still >5kg over preop weight, give If no bowel movement to Consider removing drain if drain
(>750mL UOP during 0600-
Day 4 1400; Inadequate response is
Lasix 10 mg IV, if inadequate
response, give Lasix 20mg IV
date, suppository or enema
as preferred by patient
amylase is <3 x serum amylase or
<318 (whichever is greater)
<500cc UOP in 8 hrs)

No labs
Organize
. Shower with OT except as
needed
discharge****

Follow-up appt is D/C home or local hotel Referral to outpatient dietician as needed for Inpatient team
Goals for D/C
Day 5 are met*****
scheduled for 1-2
weeks from now
if patient lives more than
2 hrs from Seattle
patients who continue to do poorly with intake
or continue to lose weight
communicate with
outpatient team

* Consult pharmacy if renal insufficiency. Continue until 28 days after discharge (only in patients with malignancy).
** 6 small meals/day, suggest starting with cream of wheat or toast
*** If on enzymes before surgery or expected to have reduced pancreatic function: Pancreaze (21,000 units) 2 caps with each meal, 1 cap with snacks
**** 1. Prescriptions filled in evening 2. Med reconciliation 3. Follow up in 1-2 weeks 4. Inpatient discharge form (D/C instructions)
***** 1. Tolerate diet 2. Pain controlled 3. Return of bowel function 4. Ambulate safely 5. Diabetic and pharmacy education completed (if indicated)

Last updated 11/16/15 1