|
Pre-operative management
|
| Pre-op medication |
Acetaminophen 1000 mg; gabapentin 600 mg (hold for CKD w/GFR <60, age >70 yrs) |
|
Intraoperative management
|
| Pre-procedure sedation |
Midazolam per anaesthesiologist (ideally <2 mg); fentanyl per anaesthesiologist (ideally <100 μg) |
| Lumbar spinal |
15 mg of isobaric bupivacaine (3 cc 0.5% bupivacaine, preservative free); 10–25 μg fentanyl; injected 1 space |
| Sedation |
Propofol titrated to Ramsay Sedation Scale score of 2–3 (25–50 μg/kg/min); ketamine 2 μg/kg/min; limit opiates; |
| Alternate options |
dexmedetomidine, fentanyl/midazolam |
| Blood pressure support |
Consider fluid bolus; phenylephrine gtt vs ephedrine to maintain MAP 65 mm Hg or 80% baseline |
| Nausea prophylaxis |
Dexamethasone 4 mg IV × 1 (hold for patients w/diabetes mellitus) |
| Surgical infiltration given as a TLIP block) |
Infiltration of 10 ml of liposomal bupivacaine (20 ml of 1.3% liposomal bupivacaine diluted w/20 ml of normal saline to total vol of 40 ml) to each incision/percutaneous screw tract |
| For inadequate analgesia after 2 h |
Re-inject 1 ml of 0.5% bupivacaine w/24-gauge pencil-tip spinal needle on surgical field |
|
Postop management
|
| Pain control |
Avoid PCA; acetaminophen 1000 mg q4h ATC; gabapentin 300 mg PO TID; oxycodone 5 mg PO q3h PRN |
| Voiding |
Check bladder in PACU, consider single shot catheterization when necessary |
| Mobilization |
Physical therapy day of surgery |
| Discharge |
w/in 24 h |
