Rectal resection with protectiveileostomy /
Beforeadmission
/ INPATIENT PHASEDay of admission / Day ofoperation / Postopday 1 / Postopday 2 / Postopday 3-6 / DISCHARGE
Postopday 7 / AFTERCARE
Postopday 10
DIAGNOSTICS / MONITORING / □History
□Clinical assessment
□Basic lab values (hemogram, “internal order set”, coagulation, HbA1c in diabetics, CEA, CA 19-9)
□Colonoscopy, biopsywhereindicated
□Rectalendosonography + rectoscopy
□MRI ifrectalendosnonographyunclear
□Abdominal sonography, if suspicious -> MRI
□Chest x-ray, if suspicious -> CT
□Multidisciplinary tumor board after completion of staging
□Anesthesiological assessment (including consent for epidural), if needed further exams (e.g. cardiological assessment)
□Fix date of admission / surgery / □Basic lab values (hemogram, “internal order set”, coagulation, HbA1c in diabetics, CEA, CA 19-9), if no recent values available
□Prepare two units of packed red blood cells / Intraoperative
□Monitor vitalsigns
□Monitor relaxation
□Monitor CVP (if CVCin place)
Postoperative
□Surgeondecides ICU/normal ward
□Monitor vitalsigns
□Monitor diuresis
□Monitor drainage fluid (if drainage in place)
□At night: hemogram, „basic order set“, coagulation
□Chest x-ray if CVC was placed
□Check dressings
□Check epiduralline / □Monitor vitalsignstwicedaily
□Monitor drainage fluid (if drainage in place)
□Hemogram, „basic order set“, coagulation, CRP / □Monitor vitalsignstwicedaily
□Monitor drainage fluid (if drainage in place) / □Monitor vitalsignstwicedaily
□Monitor drainage fluid (if drainage in place)
□Hemogram, „basic order set“, coagulation, CRP (POD 6)
□Flexible rectoscopy in order to check the anastomosis (POD 6)
□Discuss further treatment at multidiscplinary tumor board once histology available / □Monitor vitalsigns in the morning / □History
□Clinical assessment
□Vital signs
□If symptomatic: hemogram, „basic order set“, coagulation, CRP
□Ifsymptomatic: abdominal sonography
ANAESTHESIA
Catheters
Urinarycatheter / □iv antibiotics (2g cefazoline- or 400mg ciprofloxacin if allergic to penicillins - and 500mg metronidazole) 30-60min before surgery
□Prewarming
□ITN
□G16 venouscannula
□CVC
□Arterial line in high-risk patients
□Place gastric tube intraoperatively, remove upon extubation
□Thoracic epidural line (Th 8-10) / □Remove arterial line if placed / □Remove CVC if placed
□Removevenous line
□Foley after induction of anesthesia / □Removefoleyafterepiduralremoval
Intraopposition
Drains / □Supine position, right arm attached, left arm abducted
□EasyFlow drain to anastomosis / □Remove Easy Flow if in place and secretion normal(POD 6)
Nutrition / □No restriction, encourage sufficient intake / □Liquidsonly / □Sweetened tea until 2 hours preop (6 am if no exact time of operation known)
□Start tea 2 hours postop (max 1500 ml); 2 cups of yoghurt / □No restriction (specific diet for diabetics)
□Drink >1500 ml / □No restriction (specific diet for diabetics)
□Drink >1500 ml / □No restriction (specific diet for diabetics)
□Drink >1500 ml / □No restriction (specific diet for diabetics)
□Drink >1500 ml / □No restriction (specific diet for diabetics)
INFUSIONS / □Aimat intraoperative normovolemia
□Postop isotonic electrolyte solution (saline in patients with renal failure), < 500 ml i.v / □none / □none / □none / □none
STOOL/BOWEL PREPARATION / □Bowelpreparation / □Magnesium oxidesolution tid until first stool passed / □Magnesium oxide solution tid until first stool passed / □Magnesium oxide solution tid until first stool passed / □Magnesium oxide solution tid until first stool passed
MEDICATION / □Continuepreviousdrugregimen
□Stop vitamin K antagonists, replace with nadroparin 0.1 ml/10kg bodyweightbid.
□Plan to stop oral antidiabetics on day of admission / □Continue previous drug regime with described exceptions
□Insulin scheme: glucose 140-200 mg/dl: 4 iU; 200-280 mg/dl: 8 iU; > 280 mg/dl 12 iUrapid acting insulinsc, check glucose level after 2 hours / □Continue previous drug regimen with described exceptions
□Insulin scheme: glucose 140-200 mg/dl: 4 iU; 200-280 mg/dl: 8 iU; > 280 mg/dl 12 iU rapid acting insulin sc, check glucose level after 2 hours
□Premedication as ordered by anesthesist
□Nadroparin 0.3 ml scat night (or weight adapted dose if full anticoagulation) / □Continue previous drug regimen with described exceptions
□Insulin scheme: glucose 140-200 mg/dl: 4 iU; 200-280 mg/dl: 8 iU; > 280 mg/dl 12 iU rapid acting insulin sc, check glucose level after 2 hours
□Pantoprazol 40 mg po 1-0-0
□Nadroparin 0,3 ml sc at night (or weight adapted dose bid if full anticoagulation) / □Continue previous drug regimen with described exceptions
□Insulin scheme: glucose 140-200 mg/dl: 4 iU; 200-280 mg/dl: 8 iU; > 280 mg/dl 12 iU rapid acting insulin sc, check glucose level after 2 hours
□Pantoprazol 40 mg po 1-0-0
□Nadroparin 0,3 ml sc at night (or weight adapted dose bid if full anticoagulation) / □Continue previous drug regimen with described exceptions
□Insulin scheme: glucose 140-200 mg/dl: 4 iU; 200-280 mg/dl: 8 iU; > 280 mg/dl 12 iU rapid acting insulin sc, check glucose level after 2 hours
□Pantoprazol 40 mg po 1-0-0
□Nadroparin 0,3 ml sc at night (or weight adapted dose bid if full anticoagulation) / □Continue previous drug regimen with described exceptions
□Insulin scheme: glucose 140-200 mg/dl: 4 iU; 200-280 mg/dl: 8 iU; > 280 mg/dl 12 iU rapid acting insulin sc, check glucose level after 2 hours
□Pantoprazol 40 mg po 1-0-0
□Nadroparin 0,3 ml sc at night (or weight adapted dose bid if full anticoagulation) / □Continue previous drug regimen with described exceptions
□Restart vitamin K antagonists 14 day postop with overlap
TRANSFUSIONS / □only ifhb < 8 mg/% or cardiopulmonary instability / □only if hb < 8 mg/% or cardiopulmonary instability / □only if hb < 8 mg/% or cardiopulmonary instability / □only if hb < 8 mg/% or cardiopulmonary instability
ANALGESIA
iv / Intraop.
□Acetaminophen 1 g iv
Post-op.
□Acetaminophen1 g iv
□Piritramid 7.5 mg ivin epidural “failure” / □avoid / □avoid / □avoid
po
Epiduralcatheter
Postopcare / □Ibuprofen 2x400 mg po (replace with acetaminophen 3x1g if renal failure or history of ulcer); metamizole 4x1 g po, avoid systemic opioids
□Oxycodone/naloxone 10/5 mg if needed / □Ibuprofen 2x400 mg po (replace with acetaminophen 3x1g if renal failure or history of ulcer); metamizole4x1 g po, avoid systemic opioids
□Oxycodone/naloxone 10/5 mg if needed / □Ibuprofen 2x400 mg po (replace with acetaminophen 3x1g if renal failure or history of ulcer); metamizole 4x1 g po, avoid systemic opioids
□Oxycodone/naloxone 10/5 mg if needed / □Ibuprofen 2x400 mg po (replace with acetaminophen 3x1g if renal failure or history of ulcer); metamizole4x1 g po, avoid systemic opioids
□Oxycodone/naloxone 10/5 mg if needed
□Thoracic epidural line (Th 8-10) with continuous infusion: ropivacain 0.2% + 20 μg sufentanil(46 ml Naropin 0.2% + 4 ml sufentanil = 0.4 μg sufentanil/ml), flow 3-7 ml/h / □Thoracic epidural line with continuous infusion (see before) / □Thoracic epidural line with continuous infusion (see before), remove on postop day 3 / □Remove epidural (POD 3)
□Apply for postop rehab treatment if no adjuvant therapy planned
QUALITY CONTROL / DOCUMENTATION / DRG / □Verify correct shipment of histological samples (responsible: surgeon)
□Write and print brief report of operation and postop orders (surgeon)
□Dictate report of operation (surgeon)
□Code performedprocedure(surgeon) / □Check histology
□Fix aftercareappointment
□Preparedischargereport / □Hand discharge report to patient; forward to consultant for signature
□DRG coding
PATIENT INFORMATION / EDUCATION / □Recommend smoking and drinking cessation 14 days prior to surgery
□Inform patient and relatives about planned surgery and principles of enhanced recovery scheme (information leaflet) / □Informedconsent
□Re-emphasize principles of enhanced recovery scheme (information leaflet)
□Ask which contacts to inform directly postop
□Recruit in clinical studies where applicable / □Call designatedcontacts (surgeon)
□Call referringphysician (surgeon)
□Inform patient once fully awake / □ Discharge information, communicate histology and further treatment recommendation if already available
□ Call referringphysician / □ communicate histology and further treatment recommendation
NURSING
Admission / discharge
Ward rounds
Documentation
Patient care
Mobilisation / physiotherapy
Patient checks
Wounds / drainages / ostomy / □ Welcome and inform patient
□ Nursing history / Postoperative:
□ Inform patient
□ Copy postoperative orders into daily chart / □ Prepare discharge documents, fix relevant appointments
□Providedischargeinformation / □ Providedischargeinformation
□ Participate in rounds
□ Copy orders into daily chart
□ Insert lab sheets into daily charts / □Participate in rounds
□ Copy orders into daily chart
□ Insert lab sheets into daily charts / □Participate in rounds
□ Copy orders into daily chart
□ Insert lab sheets into daily charts / □Participate in rounds
□ Copy orders into daily chart
□ Insert lab sheets into daily charts / □Participate in rounds
□ Copy orders into daily chart / □Participate in rounds
□ Copy orders into daily chart
□ Insert lab sheets into daily charts
□Insert CP sheet into patient file / □Insert CP sheet into daily chart / □Document DRG codes relating to nursing activities
□ Document nursing activities in daily chart / □ Document DRG codes relating to nursing activities
□ Document nursing activities in daily chart / □ Document DRG codes relating to nursing activities
□ Document nursing activities in daily chart / □ Document DRG codes relating to nursing activities
□ Document nursing activities in daily chart / □ Document DRG codes relating to nursing activities
□ Document nursing activities in daily chart
□ Personal care according to nursing plan
□ Prepare drugs, assist in intake if needed / □ Personal care according to nursing plan
□ Prepare drugs, assist in intake if needed / □ Personal care according to nursing plan
□ Prepare drugs, assist in intake if needed
□ Pneumonia prophylaxis (incentive spirometry, mucolysis, patient education)
□ Mechanical DVT prophylaxis / □ Personal care according to nursing plan
□ Prepare drugs, assist in intake if needed
□ Pneumonia prophylaxis (incentive spirometry, mucolysis, patient education)
□ Mechanical DVT prophylaxis / □ Personal care according to nursing plan
□ Prepare drugs, assist in intake if needed
□ Pneumonia prophylaxis (incentive spirometry, mucolysis, patient education)
□ Mechanical DVT prophylaxis / □ Personal care according to nursing plan
□ Prepare drugs, assist in intake if needed
□ Pneumonia prophylaxis (incentive spirometry, mucolysis, patient education)
□ Mechanical DVT prophylaxis
□5 hours postop: walk on aisle, mobilise in armchair for 2 hours, / □Walk on aisle at least twice, mobilise out of bed for >8 hours
□Physiotherapy in patients with COPD, walking impairment, bedridden patients / □Walk on aisle at least twice, in bed only for afternoon nap and at night
□Physiotherapy in patients with COPD, walking impairment, bedridden patients / □Walk on aisle at least twice, in bed only for afternoon nap and at night
□Physiotherapy in patients with COPD, walking impairment, bedridden patients / □Walk on aisle at least twice, in bed only for afternoon nap and at night
□ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10) / □ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10) / □ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10) / □ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10) / □ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10) / □ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10) / □ Vital signs (heart rate, blood pressure, temperature)
□ VAS forpain (1-10)
□ Checkdressings
□ Ostomy care / □ Checkdressings
□ Ostomy care / □ Change dressings
□ Ostomy care / □Change dressings
□ Ostomy care education (POD 3)
□ Remove Easy Flow upon physician order (POD 6) / □ Change dressings
□ Ostomy care / □ Remove sutures/staples upon physician order
J. Hardt*, M. Schwarzbach**, T. Hasenberg*, S. Post*, P. Kienle*, U. Ronellenfitsch* The effect of a Clinical Pathway for enhanced recovery rectal resections on perioperative quality of care
International Journal of Colorectal Disease
*Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, **Department of Surgery, Klinikum Frankfurt Höchst, Gotenstrasse 6-8, 68150, Frankfurt a. M., Germany
Corresponding author: Ulrich Ronellenfitsch; Email address:
Rectal resection with protective ileostomy /Beforeadmission
/ INPATIENT PHASEDay of admission / Day ofoperation / Postopday 1 / Postopday 2 / Postopday 3-6 / DISCHARGE
Postopday 7 / AFTERCARE
Postopday 10
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© University Medical Centre Mannheim, Dpt. of Surgery, 2007