ERAS for Cardiac Surgery

ERAS for cardiac surgery. #eras #pain #multimodal #opioids #surgery #cardiac #perfusion #perfusionist

I have been utilizing ERAS in general surgery, OB, and ortho cases.  Diving into one of my more tricky populations, I opted to see what ERAS practices are out there for cardiac surgery.  Careful what you look for my friends.  There’s actually a good amount of information out there!

ACCRAC podcast: ERAS for Cardiac Surgery

ERAS Cardiac Consensus Abstract – April 2018

Enhanced recovery after surgery pathway for patients undergoing cardiac surgery: a randomized clinical trial. European Journal of Cardio-Thoracic Surgery, Volume 54, Issue 3, 1 September 2018, Pages 491–497, https://doi.org/10.1093/ejcts/ezy100

** Audio PPT ** American Association for Thoracic Surgery: Enhanced Recovery After Cardiac Surgery. April 2018

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.  The Journal of Thoracic and Cardiovascular Surgery. April 2018Volume 155, Issue 4, Pages 1843–1852. 

Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018 Jan 31. pii: S1053-0770(18)30049-1. DOI: https://doi.org/10.1053/j.jvca.2018.01.045

ERAS
From Journal of Anesthesiology

Enhanced Recovery After Cardiac Surgery Society

My blog posts:

Key Points

  • Level 1 (Class of recommendation=Strong Benefit):
    • Tranexamic acid or epsilon aminocaproic acid should be administered for on-pump cardiac surgical procedures to reduce blood loss.
    • Perioperative glycemic control is recommended (BS 70-180; [110-150]).
    • A care bundle of best practices should be performed to reduce surgical site infection.
    • Goal-directed therapy should be performed to reduce postoperative complications.
    • A multimodal, opioid-sparing, pain management plan is recommended postoperatively
    • Persistent hypothermia (T<35o C) after CPB should be avoided in the early postoperative period. Additionally, hyperthermia (T>38oC) should be avoided in the early postoperative period.
    • Active maintenance of chest tube patency is effective at preventing retained blood syndrome.
    • Post-operative systematic delirium screening is recommended at least once per nursing shift.
    • An ICU liberation bundle should be implemented including delirium screening, appropriate sedation and early mobilization.
    • Screening and treatment for excessive alcohol and cigarette smoking should be performed preoperatively when feasible.
  • Level IIa (Class of recommendation=Moderate Benefit)
    • Biomarkers can be beneficial in identifying patients at risk for acute kidney injury.
    • Rigid sternal fixation can be useful to reduce mediastinal wound complications.
    • Prehabilitation is beneficial for patients undergoing elective cardiac surgery with multiple comorbidities or significant deconditioning.
    • Insulin infusion is reasonable to be performed to treat hyperglycemia in all patients in the perioperative period.
    • Early extubation strategies after surgery are reasonable to be employed.
    • Patient engagement through online or application-based systems to promote education, compliance, and patient reported outcomes can be useful.
    • Chemical thromboprophylaxis can be beneficial following cardiac surgery.
    • Preoperative assessment of hemoglobin A1c and albumin is reasonable to be performed.
    • Correction of nutritional deficiency, when feasible, can be beneficial.
  • Level IIb (Class of recommendation=Weak Benefit)
    • A clear liquid diet may be considered to be continued up until 4 hours before general anesthesia.
    • Carbohydrate loading may be considered before surgery.

 

ERAS for cardiac surgery. Journal of Cardiothoracic and Vascular Anesthesia

Esophagectomy

The case is booked as an Ivor-Lewis esophagectomy.  Let’s learn a couple of things here from what the surgery will be, to the type of anesthesia, to post-op pain management.

What’s an Ivor-Lewis esophagectomy?

Esophagectomy

Anesthetic monitors:

  • Central line (Cordis for volume in emergency)
  • Vigileo/FloTrac – SVI, SVV, SVR, CO great markers for fluid management
  • BIS
  • UOP

Anesthetic technique:

  • Induction: lidocaine, Propofol, rocuronium/sux (dependent upon if blockage from tumor necessitating RSI or not)
  • Maintenance: sevoflurane
  • Extubation: attempt in OR
  • Fluid management
    • Colloid vs. crystalloid
    • CVP vs. Esophageal doppler vs. pulse pressure vs. stroke volume variation
      • Keep SVI >35 mL/m2 to decrease risk of AKI
  • OLV
    • To reduce lung damage and ARDS
    • 4-6 cc/kg ventilation strategy (lung-protective)
    • Pressure-controlled
    • Optimization of PEEP
    • PIPs <35mmHg, Plateau pressure <25mmHg
  • Pain Management
    • Pre-op adjuvant pain meds:
      • Oxycodone XR 20mg PO if <70y/o or 10mg if >70yo
      • Celecoxib 400mg PO if <70y/o or 200mg if >70yo
      • Pregabalin 150mg PO if <70y/o or 75mg if >70yo
    • Thoracic Epidural: Improved blood flow to anastomotic site, earlier extubation times, reduced pneumonia rates.
  • Vasopressors: phenylephrine. Consider norepinephrine (improved CO), vasopressin if needed.

Case:

40-something year old female who was newly diagnosed with squamous cell cancer of her distal esophagus about 2 months prior.  Presented to ED with N/V, epigastric pain, malnourishment.  Had underone chemo and radiation.  PMH achalasia, endometriosis.  NKDA. Scheduled for Ivor-Lewis esophagectomy.  Pt appeared cachectic, on TPN, 45kg, 5’5″.  L chest port-a-cath in place.

In OR, pt received T7 epidural.  RSI w cricoid pressure throughout.  37Fr L DLT placed gently without resistance.  31cm at teeth noted after fiberoptic bronch check.  20g L radial a-line placed.  Surgeon stated no cervical approach needed, therefore, I placed a R IJ cordis and CVP.  FloTrac for SVI, SVR, SVV, CO.

Albumin for IVF.  Goal SVI >35, CVP 5-10. Phenylephrine for SBP >90.  OGT (resistance met prior to first dark marking on tube that was expected with 6 cm tumor).  BIS goal 40-60.  Epidural initially dosed with 5ml 2% lido with epi.  Another dose given roughly 30 minutes later.  Remaining dosing throughout case with 4ml 0.25% bupi.  Acetaminophen IV 1000mg prior to incision.  Fentanyl IV for abdominal laparoscopy.

Abdominal laparoscopy –> tumor unable to be freed/resected via laparoscopy.  Converted to laparotomy.  Tumor adhered to pericardium.

R thoracotomy: OLV at 200ml TV, RR 21 (volume-restrictive ventilation strategy 4-6ml/kg).  Good lung isolation.  Good anastamosis of tissues.  Two lung ventilation according to surgeon.  Recruit lungs to decrease atelectasis.

Emergence: + Pressure support through DLT.  Extubate in OR.

Lessons learned:

  1. Early communication with surgeon(s).
  2. Lung-protective strategies
  3. Volume restriction for IVF
  4. Appropriate pressor choice
  5. Pain control: thoracic epidural (0.125% bupiv + hydromorphone 10mg/ml), IV low dose ketamine (0.1-1mg/kg/hr), precedex if tolerated, if PO then preop pain meds above.  If not PO, then IV acetaminophen RTC, IV ketorolac RTC (if ok with surgeon).  Continue baseline pain regimen if patient is a chronic pain patient.
  6. Setup is key.  Discuss which side for the cervical approach (if doing) prior to doing neck lines so not in the surgical field.

Resources:

 

Enhanced Recovery After Surgery (ERAS)

srv160008f1

Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’  Session: Poster Presentation. Program Number: P613

46210

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

13012_2017_597_fig6_html

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

hqdefault

I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

Enhanced Recovery After Surgery (ERAS)

Enhanced recovery after surgery #ERAS #anesthesia #pain #recovery

srv160008f1

Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’  Session: Poster Presentation. Program Number: P613

46210

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

13012_2017_597_fig6_html

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

hqdefault

 

I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

Ketamine for intraoperative and postoperative analgesia

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

ketamine_hydrochloride_050

Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min

What I’m using nowadays:

  • Oct 2017:
    • Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed. Patients seem to require less postoperative narcotics. Looking at time to extubation to see if this is improved.  Time to extubation seems the same as my prior non-ketamine patients because RT and RNs follow a weaning protocol.  Patients are more comfortable and require less pain medication.
  • Dec 2018:
    • Cardiac open hearts: induction bolus = 0.5 mg/kg + another 0.5 mg/kg bolus when re-warming; infusion 0.2 mg/kg/hr stopping when last dressing placed.

 

fg01_e6952
Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care. Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia. J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

Ketamine for Perioperative Pain Management. Anesthesiology 2005; 102:211–20.

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY. NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial. HSS Journal: Volume 4, Number 1.

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature. Pain Medicine Volume 16, Issue 2, pages 383–403, February 2015.

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review. BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

Ketamine in Pain Management. CNS Neuroscience & Therapeutics 19 (2013) 396–402.

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059.

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

00213
Acute and Chronic Post-Thoracotomy Pain, modes of treatment

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.


***UPDATE July 8, 2018 ***

AnesthesiologyNews: July 2018: New Consensus Guidelines Issued for Use of IV Ketamine for Acute Pain.

  • Question 1: Which patients and acute pain conditions should be considered for ketamine treatment?
    Conclusion: For patients undergoing painful surgery, subanesthetic ketamine infusions should be considered. Ketamine also may be warranted for opioid-dependent or opioid-tolerant patients undergoing surgery, or with acute or chronic sickle cell pain. For patients with sleep apnea, ketamine may be appropriate as an adjunct to limit opioid use.
  • Question 2: What dose range is considered subanesthetic, and does the evidence support dosing in this range for acute pain?
    Conclusion: Ketamine bolus doses should not exceed 0.35 mg/kg, whereas infusions for acute pain generally should not exceed 1 mg/kg per hour in settings lacking intensive monitoring. However, dosing outside this range may be indicated because of an individual patient’s pharmacokinetic and pharmacodynamic factors and other considerations, such as prior ketamine exposure. However, ketamine’s adverse effects prevent some patients from tolerating higher doses for acute pain; therefore, unlike for chronic pain management, lower doses in the range of 0.1 to 0.5 mg/kg per hour may be necessary to achieve an acceptable balance between analgesia and adverse events.
  • Question 3: What is the evidence to support ketamine infusions as an adjunct to opioids and other analgesic therapies for perioperative analgesia?
    Conclusion: There is moderate evidence to support using subanesthetic IV ketamine bolus doses up to 0.35 mg/kg and infusions up to 1 mg/kg per hour as adjuncts to opioids for perioperative analgesia.
  • Question 4: What are the contraindications to ketamine infusions in the setting of acute pain management, and do they differ from chronic pain settings?
    Conclusion: Patients with poorly controlled cardiovascular disease or who are pregnant or have active psychosis should avoid ketamine. Similarly, for hepatic dysfunction, patients with severe disease, such as cirrhosis, should not take the medicine; however, ketamine can be given with caution for moderate disease by monitoring liver function tests before infusion and during infusions in surveillance of elevations. On the other hand, ketamine should not be given to patients with elevated intracranial pressure or elevated intraocular pressure.
  • Question 5: What is the evidence to support nonparenteral ketamine for acute pain management?
    Conclusion: Intranasal ketamine is beneficial for acute pain management by achieving effective analgesia and amnesia/procedural sedation. Patients for whom IV access is difficult and in children undergoing procedures are likely candidates. But for oral ketamine, the evidence is less convincing, although anecdotal reports suggest this route may provide short-term advantages in some patients with acute pain.
  • Question 6: Does any evidence support IV ketamine patient-controlled analgesia (PCA) for acute pain?
    Conclusion: The evidence is limited to support IV ketamine PCA as the sole analgesic for acute or periprocedural pain. There is moderate evidence, however, to support the addition of ketamine to an opioid-based IV PCA regimen for acute and perioperative pain therapy.

New guidelines for the use of IV ketamine infusions for acute pain management have been published as a special article in Regional Anesthesia and Pain Medicine (2018;43[5]:456-466).

The guidelines were jointly developed by the American Society of Regional Anesthesia and Pain Medicine (ASRA), the American Academy of Pain Medicine and the American Society of Anesthesiologists.


Update Nov, 30, 2018

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 456–466

Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists.  Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 521–546

Ketamine for intraoperative and postoperative analgesia

Ketamine for improving intraop and postoperative pain. #ketamine #pain #anesthesia #analgesia #meded

I’m always looking for ways to improve myself. Lately, I’m looking at various clinical elements of my practice and select certain endpoints that will better my practice of medicine.

This time, I’ve focused on cutting back on opioids intraoperatively for pain. I’m looking specifically at ketamine, an old drug with multiple benefits (and some downsides). Not only does ketamine help with intraoperative pain, but it also helps with postoperative pain. I’d like to incorporate some type of ERAS model for all of my patients and surgeries.

ketamine_hydrochloride_050

Ketamine: (different doses I’ve seen in the literature below)

• Induction: 0.2-0.5 mg/kg

• Infusion: 0.1mg/kg/hr before incision

◦ 2mcg/kg/hr x 24hr (spine)

◦ 0.1-0.15mg/kg/hr x 24-72hrs (UW)

◦ 2mcg/kg/min

◦ 2-8mcg/kg/min

What I’m using nowadays:

  • Oct 2017: Cardiac open hearts: induction bolus=0.5mg/kg; infusion=0.1mg/kg/hr and stopping when last stitch placed.  Patients seem to require less postoperative narcotics.  Looking at time to extubation to see if this is improved.

 

fg01_e6952
Is intravenous ketamine effective for postoperative pain management in adults? Medwave2017;17(Suppl2):e6952 doi: 10.5867/medwave.2017.6952

Ketamine: Current applications in anesthesia, pain, and critical care.  Anesth Essays Res. 2014 Sep-Dec; 8(3): 283–290.

Effect of intraoperative infusion of low-dose ketamine on management of postoperative analgesia.  J Nat Sci Biol Med. 2015 Jul-Dec; 6(2): 378–382.

 

Ketamine for Perioperative Pain Management.  Anesthesiology 2005; 102:211–20. 

CLINICAL GUIDELINE FOR USE OF KETAMINE AS AN ADJUVANT ANALGESIC FOR USE BY ANAESTHETISTS ONLY.  NHS Royal Cornwall Guidelines June 2015.

Ketamine as an Adjunct to Postoperative Pain Management in Opioid Tolerant Patients After Spinal Fusions: A Prospective Randomized Trial.  HSS Journal: Volume 4, Number 1.  

The Use of Intravenous Infusion or Single Dose of Low-Dose Ketamine for Postoperative Analgesia: A Review of the Current Literature.  Pain Medicine Volume 16Issue 2pages 383–403February 2015. 

 

Role of Ketamine in Acute Postoperative Pain Management: A Narrative Review.  BioMed Research International. Volume 2015; Article ID 749837, 10 pages.

Ketamine in Pain Management.  CNS Neuroscience & Therapeutics 19 (2013) 396–402. 

Ketamine for the Management of Acute Pain and Agitation in the ICU: Future, Fiction or Just another Drug-Induced Hallucination? Ann Pharmacol Pharm. 2017; 2(11): 1059. 

Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults: an international, multicentre, double-blind, randomised clinical trial. Lancet 2017; 390: 267–75.

A comparison between intravenous lidocaine and ketamine on acute and chronic pain after open nephrectomy: A prospective, double-blind, randomized, placebo-controlled study. Saudi J Anaesth 2017;11:177-84.

00213
Acute and Chronic Post-Thoracotomy Pain, modes of treatment

 

Another project I’m working on is the effect of lidocaine infusions on intraoperative and postoperative pain.

Lidocaine infusions for pain

From Anesthesiology 2017

BJA Educ, April 2016. Intravenous lidocaine for acute pain: an evidence-based clinical update

Lidocaine Infusion for Perioperative Pain Management – Vanderbilt

Cocharane Library, July 2015. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.

Perioperative Use of Intravenous Lidocaine. Anesthesiology 4 2017, Vol.126, 729-737.

30tt01

Open Access Journals, Jan 2017. Lidocaine Infusion: A Promising Therapeutic Approach for Chronic Pain.

Anesthesiology, April 2017. Perioperative use of IV lidocaine.

From Jama Surgery 2017

Here’s what I’m currently using:

  • October 2017
    • Lidocaine bolus: 1.5mg/kg on induction
    • Infusion: 2-3mg/kg/hr after induction to end surgery
    • If cardiac on CPB: bolus 1.5mg/kg on induction; Infusion: 4 mg/min x 48 hrs or discharge from ICU; On CPB bolus 4 mg/kg.

I’m also currently working on ERAS protocols for my practice as well as the use of ketamine infusions for intraoperative and postoperative pain and recovery.