OVERVIEW OF THE SERVICE:

The residents that are on periop are the residents assigned to the Perioperative Consult Service and the Acute Pain Service. This is one big team that must work
together and communicate effectively to be successful.

Despite the fact that the residents are all in one group, the services will remain somewhat distinct in that each service will have a separate block list, patient list,
attendings, and will round separately.

We welcome and encourage that you take ownership of this service. If you see a way to improve things that is more efficient or safe then let us know and we can
all make changes and improve the service together.
EDUCATION CONFERENCES:
Resident and Fellow education is a pillar of the service. In addition to clinical teaching, structured teaching occurs in 4 ways:
1) Didactics Day: A lecture series will occur on the first Tuesday of the rotation, typically from 8 am – Noon in CELA or the Resident Library
2) Daily topic discussions: Each day, there is a lecture topic relevant to regional, perioperative, or pain medicine. These 15-30 minute lectures will occur
after first case starts at 7:45-8:15 M,T,Th or 8:15-8:45 W,F. The topic of the day and associated readings can be found on the VSTAR course website
or in the physical folders in the brochure in the pain office. Finishing charting by lecture time will allow lectures to start promptly. Attendings will try to
stay under 30 minutes of lecture to allow for rounds to occur at an appropriate time.
3) Resident-led Lectures: Each CA-1, CA-2, and CA-3 will prepare a brief 15-minute discussion of a topic of interest. This presentation will be given
during the last week of the rotation and may take the form of a lecture or discussion. Residents are expected to cite 2-3 sources, pick a relevant topic
(see VSTAR and folders for ideas), notify the rotation director of their topic choice, and prepare a 1-2 page sheet of discussion questions which will
serve as enduring materials and later be posted on VSTAR. Examples are available on the education website. NO POWERPOINT.
4) Journal Club: Regional anesthesia journal club will occur 8-10 times per year, usually from 5-6:30 pm on a weekday afternoon. Each resident or intern
will be given a paper to read and present with a focus on study design and results. Articles will be distributed within a week of the journal club date.
VStar Course Website: https://vstar.mc.vanderbilt.edu
SOME GENERAL LOGISTICS:
Important #s Periop 1 Pager (for resident to hold): 835-8990
Periop 2 Pager (for resident to hold): 835-5701
Periop Cell Phone: 615-207-1201
R1 number: 615-887-7369
Periop 1 Attending: 835-8991 (you can try paging this # but always more reliable to look up the attending that is on and page them)
E-pump Lock 160 or 080 to unlock pump. 080 to give a clinician bolus.

Where to go - Perioperative Anesthesia Services Work Room– this is in the preop holding area near the pharmacy – code to get in is “3”
(physical At night there is a call room on the 4th floor – code to get in the suite of call rooms is “4” – you call room is labeled “anesthesia resident” – you
locations) walk in and turn right
Sharepoint Some teams have used sharepoint to make a periop 1 list, periop 2 list, or block list (sharepoint is an icon on the clinical workstation desktop).
Lists -click on VPIMS web
-click CPS sharepoint
-In the upper right hand corner, click "Gucuws, Generic User". Then click "Sign in as different user"
-Click "CPS" and then click on "CPS and Regional 2015"
-There are tabs at the bottom for the lists for each service. "CPS" is the inpatient list for periop2. "Regional" is the periop2 blocks for the day.
"Sheet16" is periop1 inpatient list.
To Print To print the list
SharePoint -File --> download a copy --> open copy
Lists -print preview --> page setup --> landscape --> adjust to 55%--> OK
-PRINT! (change # of copies) (make sure that only the pages you want printed are going to be printed)
WIZ Lists There is a WIZ list for periop 1 called: Acute Pain Consults (we know this doesn’t make any sense, working on changing name)
(Scratch There is a WIZ list for periop 2 called: CPS
Census) To add to your census
…modify census
…switch to another group census. It is incredibly important that the patient lists be kept up to date. It is everyone's responsibility make
sure these lists are complete. If you block someone you are responsible for adding them to the list. Interns please help keep the lists
up to date as well.
VPEC VPEC—all VPEC charts need to be reviewed daily. All CA1s, CA2s, CA3 residents should help with this task daily. Review cases then discuss
them with periop 1 attending. How to get to VPEC chart view: VPIMS web VPEC Sharepoint upper right hand corner “sign in as different user”
left hand side: Vanderbilt Preoperative Evaluation Program left hand side: “Case reviews-residents”
Periop resident responsibilities include: Review all cases (NP will have seen patient and will provide a question …Under sharepoint/VPEC (see
how to get there above) …Click on Case Reviews Residents on left hand side …NPs in VPEC will ask a “Question for MD” and you should
review the chart, talk about it with the Periop 1 attending, and type a response in the “Response to NP” column
Again the cases must be reviewed in entirety each day. If this cannot be achieved ask for help from the attending who can help triage.
**Consults for preoperative clearance of surgical patients now come to the PCS instead of the R1 or PACU resident. Please always take the
information and say that someone will evaluate the patient (ALWAYS SAY YES). It is ok to send the VPEC sRNA to evaluate the patient and
they can then run them by you. If the consult is for preoperative clearance and pain management they should be seen by a resident.
Notes Daily progress notes and consult notes and procedure notes (under "StarForms" on starpanel)
-Periop 2: (consultation note, daily progress note-med, daily progress note-regional)
-Periop 1: (daily progress note, initial consultation note)
-Procedure Notes: (regional/neuraxial)
WIZ Orders WIZ Order Set: Currently, there is no order set in Wiz for periop. Hopefully, an order set will eventually be added. For now, you can add your
own personal order set and play it back. To make your own order set for periop1 -Wiz-->other...-->enter personal orders-->create -orders to put
in: -acetaminophen 1000mg PO tid -gabapentin (300 or 600mg) PO tid -hydromorphone 0.5mg IV q4h prn "for second line; pain >3/10" -
ondansetron 4mg IV q6hprn "for nausea and vomiting" -oxycodone 5mg PO q4h prn "for pain >3/10" -If it asks you put in a weight, just delete the
order -enter a name for your order set; you can make other order sets with different names depending on the meds you want to order To open
your order set: -open your patient's wiz-->click on the bar with patient room, name, MRN, age...--> playback orders -DOUBLE CHECK YOUR
ORDERS TO MAKE SURE THEY ARE CORRECT -you cannot add phenergan IV ("second line for nausea and vomiting") or lidocaine drip to
your personal orders. Lidocaine orders will ask for a recent potassium. A way around this in the past was selecting the option for arrhythmia
management- DO NOT do this- patients have had critically low potassium orders that needed replaced which we found out after the lidocaine
drip had been on. Patients will need a current potassium before starting the drip. Epidurals & Perineural Catheter: -Every patient that gets an
epidural or peripheral nerve catheter needs a pump ordered in wiz. -Type in “CPS ” and fill in the appropriate boxes in the advisor
Connect In the OR pharmacy on the 3rd floor they will make and program pumps for us for the patient that we put catheters in. Postoperatively we pick up
Pumps to these pumps (electronic pumps or “onQ ball”) and connect them to the patients. Remember this is a good opportunity to assess how the patient
Patients is doing.
Consent All patients need to be consented for surgical procedures prior to any sedation/anxiolysis.
Forms Block consent forms are located in the periop work room in the preop holding area.
Block carts These are located in the preop block room. They do not leave this room. Preop, postop, and floor ultrasound blocks will be sent to this room.

Bag of There is a bag of random supplies and local anesthetic in the periop team room (3rd floor in preop holding area). It is helpful to take on rounds
supplies and to take with you when you go to assess a patient overnight. It should be stocked by the resident overnight.
Efficiency Don't delay cases. Be efficient in calling for patients, consenting them, setting up...
This requires a lot of communication with surgeons and in room providers about when their first case will be closing, and with the holding room
nurses about when to call for patients.
If you feel like you might delay a case (there is only 15 minutes to perform a block) then do the block in the OR while going to sleep if possible
(abdominal plane blocks) or do postoperatively. Efficiency is our number one commodity to the surgeons and pain control is second. There is
no pain service without efficiency. The attending will take over blocks performed when less than 15 minutes remain until OR ready time.
Holding As much as you can communicate with the holding room charge nurse the better. You need to be asking to have patients "sent for" (called up to
room holding) early if they are getting a block (first case starts & throughout the day). I would recommend you find out who the holding room charge is
every day & communicate with them about your needs. Regardless of the holding room, patients that require ultrasound blocks will be
transported to the block rooms bays (33, 34R1-6). Bring their brick of monitors with them.
Before each block perform a time- out asking confirming patient ID by 2 identifiers, block side and site, surgical and procedural consent,
allergies, operation, and any anticoagulants, presence of procedural and emergency equipment. You should review labs prior to performing the
Time Out procedure as well.
There will be an intern and a resident on each weekend day. One person will round on each service. The intern should stay until 6. On Sunday
WEEKENDS the resident can leave if they want and come back at 6pm for night float.
Add pts to the list that you block
This is very important since there are two services and many providers and patients can get lost in the shuffle if they are not added to the lists.
Daily email Daily send an email with the next day’s periop patient list, relevant information, and a link to the periop protocols to the following people:
to the next
day’s teams -Periop team
-In room providers and attendings
This email -Periop 1 Attending + Periop 2 and Regional Attending
will be sent -McEvoy and King (always)
by CA2 and -Brent Dunworth
CA3 -Holding room providers (will get patients up to holding more quickly):
- ..patrick.connor@Vanderbilt.Edu
(can - ..rhonda.barfield@Vanderbilt.Edu
alternate
days or Greetings,
weeks You will all be caring for patients on the anesthesiology perioperative consult service on XXX. Please see the attached list for all patients that
depending will be followed by the perioperative service. Be aware, rooms and times may change between now and Monday - please confirm your
on their scheduled patients again on Sunday night.
preferences) Please take note of whether your patient is a periop 1 or periop 2 patient (most leftward column).
Note that some periop 2 blocks are only possible blocks (see "status" column).
**************************************************
For Periop 1 Patients:
- preop: periop 1 team will order premeds and perform regional or neuraxial blocks
- intraop: there are clinical guidelines to help guide your management (please review these guidelines
https://www.mc.vanderbilt.edu/vunet/vumc.php?site=anesfaculty&doc=38656)
- postop: in room anesthesia team writes their own postop orders (see protocols for guidance, please write for PACU lidocaine infusion if
appropriate)
**************************************************
For Periop 2 Patients:
- preop: periop 2 team will perform regional or neuraxial blocks (some blocks may be listed as "possible" pending communication with the
surgical team)
- intraop: no specific protocol for management
- postop: in room anesthesia team writes their own postop orders
**************************************************
We are here to help provide optimal care for your patients, not to trump your own clinical judgement and patient management. If you have any
advice or requests for us on how to best care for your patients or concerns about the protocols, please communicate with us.

Do not hesitate to contact us via the NEW phone number

615 207 1201 (both periop 1 and 2)

or the team pagers:

- periop 1: 835.8990
- periop 2: 835.5701

Thanks from the periop team!

Periop Plan Daily email to the entire periop team, periop 1/periop 2/regional attending, and your anesthesia tech if you have one describing the plan for first
email case starts. This should be sent in the afternoon/evening.

This email Hi Team,

will be sent
every Teams tomorrow:
afternoon/ev
ening by the -P1: Merrick Miles (attending), Obi (CA1), Chad Green (intern), Clayton Savage (NP)
CA3
-P2: Vik Bansal (attending), Jeremy Walker (CP fellow), Melissa Murphy (CA1), Leah Parrish (NP), Crystal Parrish (NP)
....There is unfortunately no periop 2 intern all this week.

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I will start a group text in the morning so we can all optimize communication throughout the day.
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DAILY PLAN:
 6am: SIGN OUT in CPS room

FIRST CASE STARTS:

We have only 4 (possiblye 5) first case starts tomorrow.

1. Review your patients’ co-morbidities and labs, making sure there are no block contraindications (the block list is only a cursory review)
2. Order pump in wiz for peripheral catheters or epidural catheters.
3. Assist with PIV placement if needed to improve efficiency
4. Consents
5. Premeds
6. Put patients on monitor (EKG, pulse ox, BP cuff)
7. Take their monitor brick and chart and bring them to block room.
8. Call attending when patient is positioned and you are ready to perform block
9. Perform time out prior to performing block (block, surgery, monitors, access, significant labs or meds or co-morbidities, allergies, is pump
ordered)
10. Have your own sedation drawn up and available (fentanyl/versed)
11. If you block a patient you are responsible for making sure they are added to the list.
123. Procedure note & consult note

MANDATORY AM LECTURE: There is a schedule for these lectures.

ROUNDS: First stop will be the ortho NP/PA to round on the ortho patients and make recs on fluids, nausea, pain, home meds, etc.

MORE BLOCKS:
-Fellows/Seniors will assign blocks throughout the day.
-If you are assigned a block - communicate with Rhonda/Tom about having them called up to holding in advance (be nice to win their affection)
-Review med history / Gather equipment / Consent / Put on Monitors / Position / Have sedation ready / Call for your attending / Put on List / For
Periop 1 Patients write consult note

FOLLOW UP POST OP:

Everyone watch the board so that we can follow up on patients in PACU when they get out of the OR and hook up their pumps if ned be.

15:00 RUN THE LIST - Block list and Team 1 and 2

Meet in team room to run the lists.

VPEC:
Please review a few cases then talk about them with Dr. Miles

CASE CANCELLATION REVIEW:

There are >100 cases here. If anyone ever has any downtime - start looking at this list (in sharepoint) and writing some summaries of why the
cases were cancelled.

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REMINDERS:

**There is always something to learn and always something to teach with every block - even if you aren't the primary one performing the block. If
you do a block and there are other more junior people available have them put on gloves and learn how to set up the kit or perform one side of
the TAP block, etc. Interns and CA1s - learning how to set up the kit for an epidural or peripheral nerve catheter is an extremely valuable thing to
learn.

**If you add a patient to the p2 wiz list - please also add them to sharepoint list (likewise if you remove a pt from wiz, remove from sharepoint).
Commented [BA1]: Are we still using sharepoint?
**Please do not curl up the ultrasound cords - this can break them - and they are incredibly expensive.**

SOME GUIDELINES FOR THE PERIOP 1 SERVICE:

How to Create the next The NPs will be making periop 1 list. We will review their lists and make any changes (make sure to check if they are outpatient (SAS)
day’s Periop 1 List: or being admitted. We do not want to place TECs in an outpatient. We will look at the schedule for the next day for Periop 2 and make
the list. This will also be an important job for the overnight resident since ortho trauma adds patients throughout the night.
Some helpful insights:
1. Ventral Hernia Repairs: only do blocks (TECs) on patients who are boarded for early morning admits.
2. Do not do TECs on the colorectal patients or Parikh (surg onc) without specific indication. Desire to place a TEC should be
discussed with the attending on service and the surgeon.
3. The TRAM/DIEP flap cases are usually done in MCE. Please email the in room provider. They will perform their own block.
Make sure the patient ends up on the wiz list. The easiest way to remember them is to add them to our block list at the
bottom.
Protocols https://www.mc.vanderbilt.edu/vunet/vumc.php?site=anesfaculty&doc=46969 (copy paste this link into browser)
This is a link that takes you to all of the protocols
Pain meds For Periop 1 patients we put in all post op pain medication orders
Surgery Chiefs Every day we should run the periop 1 list with the surgery chiefs for colorectal, GiLap and Onc/Endo to discuss updates and plans. It
is a good idea to know who the chiefs are for the services and communicate with them frequently about how you are managing their
patients. This should occur every day!
Home Calls There is a list of patients that need to be called daily. This can be done by periop 1 interns, periop 1 junior, upper level residents or
nurse practitioners.
SOME GUIEDELINES FOR THE PERIOP 2 SERVICE:
Chronic Pain / Med This should be the principle responsibility of the nurse practitioners, but when an NP is not available the periop 2 intern and periop 2
Management junior will be responsible for helping with these consults. The nurse practitioners should be seeing these consults during the day.
Home Calls All patients with catheters get called at home daily until the catheter comes out (leave note in starpanel to document call).
How to Create the next VPIMS-->Anesthesiology--> Clinical-->APS OR Schedule
day’s Periop 2 Block -look at all blocks for VOR3
List: - ignore Shiner blocks
-if a Holt case is consulted, email to make sure she wants the case blocked
 Clinical-->OR schedule--> VOR3
Clinical  APS Consultation list
-look for patients who are candidates for blocks (always check OR 34 for thoracic cases)
-review ortho trauma patients and CPT codes to block
-ortho, big EGS ex-laps (not protocol patients), skin grafts (especially Burn cases--preop consent them for postop blocks)
Possible blocks Responsibility of the periop team to contact the attending surgeon and in room providers to request blocks for non-protocol patients. If
the in room provider would like a block it is their responsibility to discuss this with the surgeon.
Pain meds For periop 2 patients we put in the orders for epidurals/on-q pumps and we make recommendations about pain medications but we do
not put in the orders for the pain medications
Afternoon Block Sign 3pm regional sign out. Everyone that is available (residents that did any blocks that day, attendings, fellows, and interns should try to
Out be there to make sure the list is up to date)

SOME EDUCATIONAL RESOURCES:

VStar Course Website: https://vstar.mc.vanderbilt.edu
MARAA Book Project: http://www.dvcipm.org/clinical-resources/dvcipm-maraa-book-project
NYSORA: http://www.nysora.com/educational-tools/videos/index.1.html
NIGHT FLOAT:
Intern Resident should notify on call upper levelattending about all consults.
When you get calls about increased pain or nausea you should assess the patient and if you have questions about the management plans you can call the upper level.
On call upper level comes in to assess patients that seem like they need a block and perform block if needed.
Intern Overnight resident should immediately notify the R1 and the on call upper levelattending for all patients with the following concerns: Severe refractory hypotension, Concerns
about local anesthetic toxicity, Concerns about high epidural (hypotension, shortness of breath), Concerns about epidural hematoma (back pain, LE weakness), Concerns about
epidural abscess (fever, back pain), Concern for patient PE or MI.
Know who your R1 and R2 are (ask your upper level to introduce you before they leave) and go to them for advice/help if you h ave any questions. You are not alone.
If NF intern resident feels unsure of their exam (not confident in their ability to check a level) it would may be appropriate for them to ask the R1 or 22 to come assess the patient with
them to check a level. Also always appropriate for them to call the on call upper level to come in to assess a levelattending to discuss.
If an epidural is not working overnight it will need to be replaced, so contact senior to discuss optionsattending, including replacement overnight or IV narcotics.
Patient should have monitors on and BP taken before epidural bolus and q5 min BP for 230 min.
Bedside nurse should be informed of all interventions performed before the NF walks away.
SOME NIGHT FLOAT GUIDANCE: Please make decisions with your feel comfortable with and upper level on call someone if you are unsure of management. The surroundingis
information is to help guide you, but is not a replacement for discussing with your upper levelsomeone more experienced.
DISTAL 1. Check alligator clip to ensure catheter is seated correctly
OCCLUSION 2. Check tubing to ensure no kinks
Anything ..if there is a kink that can be cut away, use sterile technique to cut off the kink (sterile gloves, sterile scissors, clean with chloraprep) to cut off the kink then reattach
below the to alligator clip
pump 3. Catheter can get kinked according to pt position. If pt is sitting up or walking; have them lie back in the bed or change position to more relaxed position to see if it
will bolus (using saline).
PROXIMAL 1. Check where the catheter goes into the cassette to ensure there is a right connection to the pump (the cassette switch should be on the “drops” icon)
OCCLUSION 2. Ensure the bag is not empty and tubing attached to the bag is not being kinked
EPIDURAL PT - Assess site to ensure catheter is not subQ. Some leaking can be normal; however, a large amount of leaking is not and could mean catheter has been dislodged
C/O PAIN from epidural space. In that case, you could still bolus; however pt may need a PCA overnight until TEC can be replaced. If need for PCA call the attending on call.
- Unilateral block: pull catheter (sterilely – use sterile gloves, chloraprep, can often do without lifting tegaderm) back 1cm and bolus
- Needs to spread level: bolus epidural with dilute local +/- increase rate
- Need to make block denser: concentrate local +/- add adjuncts (dilaudid, clonidine) [order new bag formulation in wiz]
BOLUSING *typically the limiting factor is hypotension (or high block) which are both serious so wait at bedside at least 15 minutes after bolus to monitor for hypotension and
EPIDURALS check level.
- Can start with 3-5 mLcc 0.125% bupivacaine (may need to use less concentrated and less volume if hypotensive)
BOLUSING - 10 mLcc 0.25% bupivacaine or 0.5% ropivicaine on operative day only (this provides an almost anesthetic level of pain relief so would set unrealistic expectations
PERIPHERAL post op)
CATHETERS - 10 cc mL 0.125% bupivacaine or 0.25% ropivicaine on postoperative days
CALLED FOR - Assess patient status, patient anesthetic level, and their pain control
HYPOTENSIO - Occasionally a fluid bolus would be appropriate (include surgery team in your decision making). If need for more than fluid bolus please alert attending on call.
N - If you decide the epidural is contributing to hypotension:
…remove clonidine if it is added toin the epidural conconctionsolution
…you can consider decreasing the epidural rate (on pump and on wiz)
…you can consider decreasing the epidural concentration (order new bag in wiz)
Occasionally a gentle reminder to the surgical team that all hypotension is not epidural related is appropriate. However if y ou are going to make a statement like this
you should have thoroughly evaluated the patient and clinical situation yourself.
Overnight responsibilities/cheat sheet:
*** Call your seniorsomeone more experienced if you feel confused or over your head (senior resident, R1, R2, fellow, attending), nobody will be mad!
[ ] arrive by 6pm and get sign out
[ ] roll pagers (835-5701 and 835-8990)
[ ] make a list of people to hook up onQ/epumps and pick them up from pharmacy
[ ] make a list of patients to visit/check up on
[ ] hook up all onQ/epumps and do PACU checks first
[ ] make evening rounds
[ ] respond to all consults - it helps to call the call back # prior to seeing the patient to ask what they want if the consult isn't clear (these should take priority over evening rounds if you
get one early)
[ ] respond to all pages re: pain and make a note of any changes made either in an "Anesthesia Encounter Note" under Star notes, a free text note under "Enter Data" then
"TypeNewDocument", or in the overnight events and synopsis of the daily note
[ ] draft notes and update the synopsis so the list is updated ----- [ ] draft all periop 1 consult notes
[ ] prepare and print the lists in the morning (including the Sharepoint list)
[ ] draw up drugs for first case starts (more info below) + [ ] restock carts
[ ] sign out at 6am to team
[ ] remind interns to roll the pagerscharge the pain phone
Commented [BA2]: Are we still rolling pagers?
Hooking up onQ pumps:
- Don't forget the brochure to give to the patient and record a phone number to follow up after discharge
- Enter the phone number in the Sharepoint list
- Make sure to prime the onQ pump prior to hooking it up (unclamp, and take cap off and wait)
- Set at a rate ~8cc8 mL/hr (they come set at 14 mLcc/hr)
Trouble shooting e-pumps:
- Lock code: 080
- Air- in- line error message: get key, open pump, take out cartridge, and snap back in
- Won't stop beeping: read error message, may be something simple; hit stop and then start; turn it off then back on; try to reprogram by going to "change", "enter new program" and
starting from scratch (normal settings are 8cc8 mL/hr rate, no loading dose, 3cc mL bolus q15 minutes, lockout of 18 or 20cc20 mL/hr)
- Leaking: make sure the cap is tight on both the line from the pump, to the patient, and on the filter
Trouble shooting epidurals:
- "not working” call from nurse": first check a level, if no level look back at list and see if there was an issue with TEC placement; look at the epidural site (has the statlock LockIt Plus
moved? has the catheter moved? is everything still connected? are all the teggies Tegaderms in tact?); make sure the e-pump is on and flowing (you'd be surprised); consider bolusing
(call your senior prior to this)
-some will bolus with straight lidocaine 1%. some will not because bolusing with 1% can cause profound hypotension. Recommend starting with diluate local such as 1/10th%0.1% or
0.125% bupivacaine.
-proximal occlusion: problem is from bag to pump. Unlock box and make sure all connections intact and line not kinked going into pump
-distal occlusion: problem is from pump to patient. Trace line from pump to patient looking for any kinks. May be positional so try repositioning patient. Try to get ke y and open pump
and make sure cassette is properly seated in the pump. Can also try and bolus with sterile saline to see if catheter will flush....May also be kinked under skin and need to be
sterillysterilely readjusted. . Let senior know if you're going to need to try this, and if you haven't done it yet,If you have not done this before, please ask R1/R2 to come help/show you
how to do this....if all of these measures fail, you may just need a new pump from pharmacy.
- "keeps beeping": see above
- Leaking: look at the TEC site and reinforce with Ttegaderms
- Pt. hypotensive: turn down rate, minimum rate of 2cc2 mL/hr to keep it open; treat hypotension (call your senior to run by whether you want toconsider fluid bolus, phenylephrine, give
neo (good for hypotension with normal or elevated HR), give ephedrine (good for hypotension with low HR), or give calcium) . Decisions about multiple fluid boluses or need for multiple
doses of pressors should be discussed with the attending on call.
Making lists:
- Make sure you have the group censuses updated on Wiz
- Select the correct census in StarPanel
- Click the bed column to organize them in descending order
- Unselect the check boxes for pts. that have been discharged
- Click "Bulk"
- For patients on CPS, click the "pain" tab, for APS click the "anes" tab
- Don’t forget to print the sharepoint list of morning blocks (if you have trouble, open it in excel). To print: file  download  open a copy  print preview  landscape setup & adjust to
55%  print. Will only need page 1 w/actual block list or else a bunch of other wasted pages of random lines will print
Drawing up drugs: *label with concentration, whether it has dex, date, time, and initials (also date and time any vials acc
mLessed if drugs not completely used
TAPs:
2x 30 mLcc syringes. Pharmacy makes 30cc 30 mL 0.25% ropi syringes. Add 1cc 1 mL of dexamethasone (4mg). Also draw up
a 5 mLcc syringe of 1% lido.
Rectus sheath:
1x 30 mLcc syringe. Pharmacy makes 30 mLcc 0.25% ropi syringes. Add 1cc mL of dexamethasone (4mg). This will be used for
both sides. Also draw up a 5 mLcc syringe of 1% lido.
4 quadrant (TAPs + RS):
2x 30 mLcc syringes. Pharmacy makes 30 mLcc 0.25% ropi syringes. Add 1 mLcc of dexamethasone (4mg). Also draw up a 5
mLcc syringe of 1% lido.

***The total amount of dexamethasone for all abdominal plane blocks should equal 8 mg. So for example if you are only
doing bilateral rectus sheath blocks then you need to add 8mg of dexamethasone to the one syringe.
Pop/saph/femoral/sciatic/interscalene/etc. blocks:
1x 30 mLcc syringe per block. Draw up 30 mLcc of 0.5% ropivicaine (no dilution or added dexamethasone). Draw up a 5 mLcc
syringe of lidocaine per block.
CONSULTS:
Consult for Perioperative management, Preoperative evaluation, Medical Optimization: Ortho trauma may request
evaluation of patients on admission and overnight. You will see the patient and determine what testing or optimization is
necessary prior to surgery (if any). Clarify 1) who is the primary service (Ortho, Medicine, or Trauma) and 2) if we will be
managing the patient’s pain and medical comorbidities.
For patients > 65 yr old OR who are medically complex, Ortho will likely request medical management. This includes reconciling
home medications, restarting medications as appropriate, treating pain with meds and blocks, treating nausea, managing
medical comorbidities. Evaluation and management should be discussed with the Periop attending. Start multimodal analgesics
Medications to hold:
Hold ACEI, ARB, CCB, Metformin,
Medications to restart:
Restart B-blockers, chronic pain medications/muscle relaxants Formatted: Font: (Default) Arial
Pain/med management: try and see these if you have time. Call senior and discuss prelim recs but will be officially staffed with
attending in AM
Rib Fracture Consults
-The other main consults besides med management you will get at night. Trauma consults us with the goal of TEC placement so
we need to evaluate if they're a good candidate.
-There are two 3 possible outcomes.
(1) an urgent one that requires attending to come in overnight.
(2) someone who is either a good candidate for one but is stable in the meantime... ...or who may not need/want a TEC at all.
(3) patient with contraindications to epidural (anticoagulation, infection, severe spine injury, elevated ICP)
Either wayRegardless, you will recommend multimodal management for pain and team will re-eval on AM rounds and place or
not place
....either way, always call senior about these consults to discuss them. Call the attending to discuss patients unless epidural is
contraindicated or the patient is very stable.
For these consults, there is certain info you want to know before calling the senior attending to discuss.
1. Which ribs are fractured and where are they as far as anterior/posterior/lateral?
2. What are the other injuries?
3. are Are there any imminent/planned OR procedures?
4. Are they on room air/supplemental O2/intcubated?...Sats??
5. What can they do on incentive spirometry?
6. What are their current or recent PT/INR, platelets? Are they on any anti coagulation chronically or been given any since the
accident?
7. Are there any other contraindications to TEC placement? I.e. Spinal procedures or currently in spinal precautions or in
traction........ if there are any spinal injuries we won't place a TEC until they've been cleared by NSG/ortho spine... .if it's urgent
we may be able to try and call and hurry this along, but often we just have to wait.

***on top of these, just assess their pain level and location of most of their pain if other injuries are present. If they're alert and
able to communicate with you, can discuss the TEC and see if it's something they actually want... consent the patient if
appropriate****
CONSULTS:
Pain/med management: try and see these if you have time. Call senior and discuss prelim recs but will be officially staffed with
attending in AM
Rib Fracture Consults
-The other main consults besides med management you will get at night. Trauma consults us with the goal of TEC placement so
we need to evaluate if they're a good candidate.
-There are two possible outcomes.
(1)an urgent one that requires attending to come in overnight.
(2) someone who is either a good candidate for one but is stable in the meantime......or who may not need a TEC at all. Either
way you will recommend multimodal management for pain and team will re-eval on AM rounds and place or not place
....either way, always call senior about these consults to discuss them.
For these consults, there is certain info you want to know before calling the senior to discuss.
1. Which ribs are fractured and where are they as far as anterior/posterior/lateral?
2. What are the other injuries?
3.are there any imminent/planned OR procedures?
4. Are they on room air/supplemental O2/incubated?...Sats??
5. What can they do on incentive spirometry?
6. What are their current or recent PT/INR, platelets? Are they on any anti coagulation chronically or been given any since the
accident?
7. Are there any other contraindications to TEC placement? I.e. Spinal procedures or currently in spinal precautions.....if there
are any spinal injuries we won't place a TEC until they've been cleared by NSG/ortho spine....if it's urgent we may be able to try
and call and hurry this along, but often we just have to wait.

***on top of these, just assess their pain level and location of most of their pain if other injuries are present. If they're alert and
able to communicate with you, can discuss the TEC and see if it's something they actually want...consent the patient if
appropriate****
Procedure Consults (Central Lines, Dialysis Lines, LP, Blood Patch, Lumbar Drain, etc.)
The periop service has agreed to see these patients to facilitate safe, efficient procedural performance. When consulted, talk to Formatted: Font: (Default) Arial
the person placing the consult to gauge clinical situation, procedural indications/contraindications/alternatives. See patient as
soon as able, since procedure may need to be done quickly.
Lumbar Puncture: Confirm precisely what tests need to be ordered (and that these orders are placed by the primary service) and
which tubes to use for which tests.
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