postoperative npo guidelines

Evidence-based surgical care and the evolution of fast-track surgery. Guideline: Preoperative Medication Management 1 . All rights reserved. SLCOA National Guidelines / Pre-operative preparation & Post - operative care69 2 Guidelines on Pre-operative preparation and immediate post-operative care 2.1 Introduction Preoperative preparation of patients undergoing elective and emergency surgical or diagnostic procedures is an important part of peri-operative care. Perioperative hyperglycemia, or blood glucose levels greater than 180–200 mg/dL, is associated with poor clinical outcomes, including infection, increased length of stay, and postoperative mortality 56. In one randomized controlled trial of women undergoing gynecologic laparoscopy, transversus abdominis plane block did not provide statistically significant differences in mean postoperative pain scores 53. Available at: Kalogera E, Dowdy SC. Patients undergoing hysterectomy, which is classified as a clean contaminated surgery, should receive broad-spectrum antibiotics to cover skin, vaginal, and enteric bacteria 23 42. Health care providers should consult their institutional antibiograms to confirm local susceptibility rates to the chosen coverage regimen. Chapman JS, Roddy E, Ueda S, Brooks R, Chen LL, Chen LM. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. ACOG Committee Opinion No. Smoking-related impairment in wound healing decreases and pulmonary function improves within 4–8 weeks of smoking cessation 24. Scarlett M, Crawford-Sykes A, Nelson M. Preoperative starvation and pulmonary aspiration. Scrub time (gentle, repeated back-and-forth strokes) for chlorhexidine-alcohol preparations should last for 2 minutes for moist sites (inguinal fold and vulva) and 30 seconds for dry sites (abdomen), and allowed to dry for 3 minutes 46. In current users of oral contraceptives who have additional risk factors for VTE having major surgical procedures, heparin prophylaxis should be considered 33. The perioperative period is a critical window of opportunity for surgeons to influence behavior and encourage smoking cessation. Barber EL, Clarke-Pearson DL. 1998). Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Institutions considering adoption of ERAS programs should carefully examine their own infrastructure and patient flow through the preoperative and postoperative phases of care. Lastly, preoperative anemia is associated with postoperative morbidity and mortality and should be actively identified and corrected 21. The ACOG policies can be found on acog.org. Notably, in this study, preoperative patient education was delivered by a structured “gynecology school” in which patients attended an hour-long teaching session (with a maximum of 10 participants) that incorporated audiovisual materials and question-and-answer sessions before surgery. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. J Minim Invasive Gynecol 2014;21:83–9. Patients should be provided the opportunity to discuss surgical planning and pain control with the surgical team and the anesthesia team as desired. Wijk L, Franzen K, Ljungqvist O, Nilsson K. Enhanced recovery after surgery protocol in abdominal hysterectomies for malignant versus benign disease. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. The risk of hyperchloremic metabolic acidosis increases with the administration of large volumes of 0.9% normal saline 54. If hair removal is needed, electric clipping is preferred to shaving 23. Clin Nutr 2010;29:434–40. Although some studies showed that the combination of oral antibiotics with a mechanical bowel preparation regimen reduces rates of infection and anastomotic leakage 37 38 39, other data have not demonstrated a significant difference 40. The transversus abdominis plane block (commonly referred to as a TAP block), which involves injection of local anesthetic into the transversus abdominis fascial plane, also has been shown to be effective in some studies for reduction of postoperative opioid use in patients undergoing laparoscopic surgery, as well as women undergoing total abdominal hysterectomy 51 52. It is not intended to substitute for the independent professional judgment of the treating clinician. The complex surgical environment. All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. JAMA Surg 2017;152:784–91. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product. Obstet Gynecol 2013;122:319–28. The amount of fluid given during the first hour should be reduced if children are fasting for a shorter period of time or if the child is … Tanos V, Rojansky N. Prophylactic antibiotics in abdominal hysterectomy. Postoperative Period. The perioperative management of patients with gynaecological cancer undergoing major surgery: a debated clinical challenge. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The implementation of the ERAS program requires collaboration from all members of the surgical team. Johnson MP, Kim SJ, Langstraat CL, Jain S, Habermann EB, Wentink JE, et al. Copyright 2018 by the American College of Obstetricians and Gynecologists. The goals of decreasing surgical stress and helping the body mitigate the consequences of such stress with ERAS pathways are achieved by the implementation of a combination of multiple elements, which when bundled together, form a comprehensive perioperative management program. Opioid use is associated with postoperative nausea and vomiting, impairment of bowel function, delayed mobilization, and increased pulmonary morbidity, all of which can delay recovery and negatively affect patients’ perception of the surgical experience. Br J Surg 2005;92:1354–62. Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial. Perioperative hyperglycemia, or blood glucose levels greater than 180–200 mg/dL, is associated with poor clinical outcomes, including infection, increased length of stay, and postoperative mortality 56. Intravenous Fluids. Successful ERAS pathway implementation across the spectrum of gynecologic care has the potential to improve patient care and health care delivery systems. Enhanced Recovery After Surgery (ERAS) pathways were developed with the goal of maintaining normal physiology in the perioperative period, thus optimizing patient outcomes without increasing postoperative complications or readmissions. : CD001544. Span of Perioperative Nursing Practice C.3.1. In: Drug facts and comparisons . Enhanced recovery in gynaecology. ), Table 1. Carney J, McDonnell JG, Ochana A, Bhinder R, Laffey JG. For patients at risk of VTE, the Caprini score or Rogers score may be used to provide further risk stratification Table 2. If intravenous fluids must be maintained, total hourly volume should be kept no higher than 1.2 mL/kg to prevent volume overload. American College of Obstetricians and Gynecologists. By using evidence-based protocols for perioperative and postoperative care, surgical stress can be reduced, healing optimized, and the patient experience improved. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice in collaboration with committee member Amanda N. Kallen, MD. Gynecol Oncol 2016;140:323–32. Ohman KA, Wan L, Guthrie T, Johnston B, Leinicke JA, Glasgow SC, et al. Perform preoperative surgical site skin preparation with an alcohol-based agent unless contraindicated 45. Committee on Gynecologic Practice:This document is endorsed by the American Urogynecologic Society. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS[R]) society recommendations—Part II. However, the ideal target range remains controversial because of potential adverse events related to hypoglycemia, which itself may lead to morbidity (including seizures, brain damage, and cardiac arrhythmia). Philp S, Carter J, Pather S, Barnett C, D’Abrew N, White K. Patients' satisfaction with fast-track surgery in gynaecological oncology. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines [published erratum appears in Chest 2012;141:1369]. Cohort Control Study. Obstet Gynecol 2014;123:562–7. Scientific Impact Paper No. Prophylactic antibiotic dosage should be increased in obese patients (BMI [calculated as weight in kilograms divided by height in meters squared] greater than or equal to 30) and, in surgical cases with excessive blood loss, a second dose of the prophylactic antibiotic may be appropriate 44. Data from the anesthesia literature have demonstrated that intake of clear fluids up until 2 hours before surgery does not increase gastric content, reduce gastric fluid pH, or increase complication rates 23. Implementation of enhanced recovery after surgery (ERAS) pathways in gynecologic oncology. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. C.3. It is not considered necessary to discontinue combination oral contraceptives before laparoscopic tubal sterilization or other brief surgical procedures. Impact of mechanical bowel preparation in elective colorectal surgery: a meta-analysis. Traditional components of perioperative care include bowel preparation, cessation of oral intake after midnight, liberal use of narcotics, patient-controlled analgesia use, prolonged bowel and bed rest, the use of nasogastric tubes or drains, and gradual reintroduction of feeding. AORN is committed to promoting excellence in perioperative nursing practice, advancing the profession, and supporting the professional perioperative registered nurse (RN). Symptoms often associated with postoperative ileus include vomiting, abdominal tenderness/distention, nausea, a… Thus, clear fluids should be allowed up to 2 hours before induction of anesthesia and solids up to 6 hours prior. Ann Surg Oncol 2007;14:3435–42. Here is PARC PREOPERATIVE MEDICATION GUIDELINES Author: Genevieve D’souza, MD Updated: July 31, 2013 In general, the perioperative management of medications will most often require direct communication between surgery and anesthesiology often with input from cardiology or medicine. Requests for authorization to make photocopies should be directed to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: An updated report. NPO Guidelines . Art. The descriptive an Although most guidelines do not specifically define “excessive,” data suggest an additional dose of cefazolin when blood loss exceeds 1,500 mL 44. Appropriate risk stratification is an important component of enhancing surgical recovery. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. A NOGGO-AGO* survey of 144 gynecological departments in Germany. AORN is committed to promoting excellence in perioperative nursing practice, advancing the profession, and supporting the professional perioperative registered nurse (RN). Available at: Al-Niaimi AN, Ahmed M, Burish N, Chackmakchy SA, Seo S, Rose S, et al. Protocols that emphasize early feeding (a return to regular diet within 24 hours), with use of laxatives as needed, promote the earlier return of bowel function and improve patient satisfaction. A patient’s blood glucose levels should be maintained between 180 mg/dL and 200 mg/dL 54. In: Drug facts and comparisons . A possible complication following surgery influencing the nutritional status of a patient is postoperative ileus. ACOG practice Bulletin No. Available at: Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. World J Gastroenterol 2018;24:519–36. Patient-tailored handouts may be helpful in communicating the goals of ERAS and helping patients understand the active role they may play in their care. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product. Povidone iodine—topical. Obstet Gynecol 2016;127:1135–44. Siedhoff MT, Clark LH, Hobbs KA, Findley AD, Moulder JK, Garrett JM. The goals of decreasing surgical stress and helping the body mitigate the consequences of such stress with ERAS pathways is achieved by the implementation of a combination of multiple elements, which when bundled together, form a comprehensive perioperative management program. 750. Obstet Gynecol Clin North Am 2016;43:551–73. Regimens designed to minimize postoperative opioid use also may include the use of scheduled acetaminophen, gabapentin, and nonsteroidal antiinflammatory drugs. 1. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Perioperative RNs use AORN guidelines as a foundation for practice and specialized edu-cational preparation. It is well known that surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and altered pulmonary and gastrointestinal function 3. Include the following in the patient’s preoperative education: Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Scarborough JE, Mantyh CR, Sun Z, Migaly J. By reading this page you agree to ACOG's Terms and Conditions. Sorensen LT. Gynecol Oncol 2016;141:371–8. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. West Indian Med J. Ketorolac does not increase perioperative bleeding: a meta-analysis of randomized controlled trials. 195. Arch Intern Med 2011;171:983–9. Ann Surg 2007;245:867–72. It is well known that surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and altered pulmonary and gastrointestinal function. With this in mind, ERAS pathways were developed with the goal of optimizing patient outcomes by introducing interventions that are data supported and have been proved either to decrease surgical stress or help the body mitigate the negative consequences of such stress 2. Anaesth Crit Care Pain Med 2017;36:195–200. Even with the addition of a formal teaching session and a newly hired specialist “Enhanced Recovery” nurse, the ERAS protocol was associated with a cost savings of nearly 10% 17. However, if using povidone-iodine scrubs for abdominal preparation, recommended scrub time can be as long as 5 minutes 47. J Am Coll Surg 2017;225:465–71. It includes but is not limited to a series of recommendations for: Fasting in adults and children Fasting in infants Oral carbohydrates Fasting in obstetric patients Ethical Guidelines for the Anesthesia Care of Patients with Do-Not-Resuscitate orders Guidelines for Ambulatory Anesthesia and Surgery Guidelines for Delineation of Clinical Privileges in Anesthesiology Wan KM, Carter J, Philp S. Predictors of early discharge after open gynecological surgery in the setting of an enhanced recovery after surgery protocol. Guidelines. ADBA . Risk Stratification for Venous Thromboembolism, American College of Obstetricians and Gynecologists Implementation of ERAS protocols has not been shown to increase readmission, mortality, or reoperation rates 20 21. Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection: an analysis of colectomy-targeted ACS NSQIP. Preemptive medication strategies (eg, medications given to the patient before surgery), including paracetamol and acetaminophen, gabapentin, nonsteroidal antiinflammatory drugs, and COX-2 inhibitors, have been shown to decrease total narcotic requirements and improve postoperative pain and satisfaction scores in women undergoing total abdominal hysterectomy 49. Patient involvement and engagement are key, and patient education is associated with improved outcomes 6. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy. Components Which May Be Considered in the Design and Implementation of an Enhanced Recovery After Surgery Program*, Table 2. POST-OPERATIVE NUTRITION. •After “bowel function” returns, remove NGT, start ice chips or clear liquid diet and then “advance as tolerated”. Institutions considering adoption of ERAS programs should carefully examine their own infrastructure and patient flow through the preoperative and postoperative phases of care. Designated nurses specializing in ERAS care may be helpful 30. Enhanced recovery in gynecologic surgery. Crit Rev Oncol Hematol 2010;73:126–40. For laparoscopic surgeries that do not involve genitourinary or digestive contamination, no antibiotic prophylaxis is necessary 23. The ACOG policies can be found on acog.org. This consensus statement presents a comprehensive and evidence-based set of guidelines for the care of postoperative nausea and vomiting (PONV) in both adult and pediatric populations. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. Sharma A, Sharp DM, Walker LG, Monson JR. Predictors of early postoperative quality of life after elective resection for colorectal cancer. There are various protocols to achieve glycemic control, but the data are too limited to recommend one specific protocol over another. Hospital discharge should be criteria-based and include assessment for ambulation, adequate pain control with oral analgesics, and tolerance of diet. (Modified from Ergina PL, Cook JA, Blazeby JM, Boutron I, Clavien PA, Reeves BC, et al. Patients with good hemodynamic function may undergo relatively minor noncardiac surgery on an ambulatory basis and are not automatically excluded because of their cardiac disease. Enhanced recovery pathways in gynecologic oncology. The descriptive an, Association of periOperative Registered Nurses, 2170 South Parker Rd, Suite 400, Denver CO 80231. A patient’s blood glucose levels should be maintained between 180 mg/dL and 200 mg/dL 54. Enhanced Recovery After Surgery is a comprehensive program, and data demonstrate success when multiple components of the ERAS pathway are implemented together. Guidelines for Adults and Teenagers. Ann Surg 2014;259:1056–67. | Terms and Conditions of Use. AORN promotes safe care for patients undergoing operative and other invasive procedures by creating this collection of evidence-rated perioperative guidelines. Enhanced recovery pathways for improving outcomes after minimally invasive gynecologic oncology surgery. Antiemetics should be incorporated to combat postoperative nausea and vomiting. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Minimally invasive approaches should be undertaken whenever possible and incisions kept as small as possible 30. The implementation of an ERAS program may require major changes to clinical interventions and supporting clinical systems. heath care team regarding updating evidence-based preoperative fasting guidelines, nurse should measure blood glucose level and blood pressure for the non-diabetic as well as the diabetic patients before the surgical procedure and further studies are needed to determine the optimal fasting time and its effect on postoperative Wound infiltration with liposomal bupivacaine, a long-acting anesthetic medication effective over 72–96 hours, also has been proposed as an alternative approach 2; although more data are needed on the benefit of its use. Perioperative Care of the COVID-19 Patient, Guidelines and Tools for the Sterile Processing Team, AORN Guideline and FAQs for Autologous Tissue Management, ASC Infection Prevention Policies and Procedures, Design and Maintenance of the Surgical Suite, Ambulatory Supplement: A Safe Environment of Care, Ambulatory Supplement: Retained Surgical Items, Ambulatory Supplement: Transmission-Based Precautions, Introduction to the AORN Guidelines for Perioperative Practice, AORN Research Evidence Appraisal Tool – Study, AORN Research Evidence Appraisal Tool – Summary, AORN Non-Research Evidence Appraisal Tool. HCUP Statistical Brief #186 . Fingar KR, Stocks C, Weiss AJ, Steiner CA. Am J Obstet Gynecol 2016;215:445.e1–9. Any necessary hair removal should be done immediately before the operation 44. Int J Clin Exp Med 2014;7:2966–75. Benefits of ERAS pathways include shorter length of stay, decreased postoperative pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction. Integration of a multidisciplinary approach is important to ensure buy-in and compliance with these guidelines from all members of the surgical team. Pierre S, Rivera C, Le Maitre B, Ruppert AM, Bouaziz H, Wirth N, et al. Benefits of ERAS pathways include shorter length of stay 16 20 21, decreased postoperative pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction 22. Alcoholic beverages should be avoided within 8 … Art. Nothing by Mouth (NPO), Minimum Fasting Period. When ERAS pathways have been implemented for benign gynecologic and gynecologic oncology surgeries (using open and minimally invasive approaches), results have been encouraging 13 14 15 16 17 18 19. Anesth Analg 2008;107:2056–60. following nil per os (NPO) guidelines, preoperative as well as early postoperative PO hydration is very important and can have significant benefits in the recovery period. Stricter control may be considered in select patients because maintenance of postoperative blood glucose levels less than 139 mg/dL has been shown to lower the surgical site infection rate by 35% in women with diabetes mellitus and postoperative hyperglycemia 56. Clin Nutr 2009;28:618–24. Royal College of Obstetricians and Gynaecologists. For lengthy procedures, additional intraoperative doses of the chosen antibiotic, given at intervals of two times the half-life of the drug (measured from the initiation of the preoperative dose, not from the onset of surgery), are recommended to maintain adequate levels throughout the operation 44. Counseling should start as early as the initial preoperative visit, with an explanation of the rationale behind ERAS and a discussion of patient expectations. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. 750. However, a randomized controlled trial of 146 women assigned to laparoscopic hysterectomy either with or without mechanical bowel preparation showed no difference in surgeries rated as “good” or “excellent” visualization 41. In order for an ERAS program to be sustainable, it should be embedded as a standard model of care in a health care delivery system. Each recommendation As an alternative to the administration of opioids, ketorolac is effective in controlling postoperative pain and does not increase postoperative bleeding 48. Rockville (MD): Agency for Healthcare Research and Quality; 2014. It is not intended to substitute for the independent professional judgment of the treating clinician. Share this. Ann Surg 2002;236:643–8. Gobble RM, Hoang HL, Kachniarz B, Orgill DP. Congenital HI Patients . In order for an ERAS program to be sustainable, it should be embedded as a standard model of care in a healthcare delivery system. The basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis.

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