Post Cystectomy Care
Enhanced Recovery After Surgery (ERAS)
Cystectomy operations are unique to all surgeries due to the combination of bowel manipulation and the significant electrolyte and metabolic changes that occur when using the intestine as a urine conduit. The post operative course is different than a bowel resection and requires delicate team work with a multimodal team approach.
Enhanced Recovery After surgery (ERAS) key components (1):
1. minimizing preop oral bowel prep
2. preop fasting 6h prior to for solid food and NPO CLD 2hrs
3. No preanesthetic anxiolytic or anelgesic med
4. DVT prophylaxis
5. Single dose ABX prophylaxis
6. Encourage and inform patient about idm thoracic epidural
7. minimize surgical incisions
8. no NGT routinely
9. normothermia w/ warmed fluids and air heating covver
10. or fluids 2h after surgery w/ target intake 800cc
11. goal of dc fluids POD 1
12. no routine JP
13. catheter drainage until epidural dc'd
14. selective use of antiemetics
15. early mobilization (2h after surgery and every 6h after)
16. dc criteria PO pain meds, no IVF, adequate PO intake, baseline mobility (or independent)
UNC LINEBERGER CYSTECTOMY PATHWAY (2)
*developed after Vanderbilt Cystectomy pathway, emphasis on early feeding
1. Counseling and expectations of surgery
2. Regular diet day prior to surgery w/ NPO>midnight, no oral bowel prep
3. Neomycin enema day of surgeyr 2h prior
4. TED hose & SCD's intraoperatively
5. Perioperative ABX for 24 hrs
6. Removal of NGT at end of surgery
7. DVT prophylaxis post op w/ SQH or lovenox
8. H2 blocker for GI prophylaxis
9. Reglan 10mg IV q8h for 48h
10. Toradol 30mg q6h for 48hrs, then celebrex 200mg BID for 2 weeks
11. Early ambulation and physical therapy
12. Discharge planning, social work starting POD1
13. NPO POD1, CLD POD2 (8oz q8h), CLD POD3, regular POD4
Results: MEAN time to: flatus 2.2d, BM 2.9d, DC 5.0d.
39% complication rate, 16% GI rate, 12% readmit
VANDERBILT CYSTECTOMY PATHWAY (2003) (2)
*the first to not use NGT, developed from open surgeries
1. Preoperative mechanical bowel prep
2. No routine NGT
3. NPO until bowel function
Results: MEAN length of stay 8.52
Enhanced Recovery After surgery (ERAS) key components (1):
1. minimizing preop oral bowel prep
2. preop fasting 6h prior to for solid food and NPO CLD 2hrs
3. No preanesthetic anxiolytic or anelgesic med
4. DVT prophylaxis
5. Single dose ABX prophylaxis
6. Encourage and inform patient about idm thoracic epidural
7. minimize surgical incisions
8. no NGT routinely
9. normothermia w/ warmed fluids and air heating covver
10. or fluids 2h after surgery w/ target intake 800cc
11. goal of dc fluids POD 1
12. no routine JP
13. catheter drainage until epidural dc'd
14. selective use of antiemetics
15. early mobilization (2h after surgery and every 6h after)
16. dc criteria PO pain meds, no IVF, adequate PO intake, baseline mobility (or independent)
UNC LINEBERGER CYSTECTOMY PATHWAY (2)
*developed after Vanderbilt Cystectomy pathway, emphasis on early feeding
1. Counseling and expectations of surgery
2. Regular diet day prior to surgery w/ NPO>midnight, no oral bowel prep
3. Neomycin enema day of surgeyr 2h prior
4. TED hose & SCD's intraoperatively
5. Perioperative ABX for 24 hrs
6. Removal of NGT at end of surgery
7. DVT prophylaxis post op w/ SQH or lovenox
8. H2 blocker for GI prophylaxis
9. Reglan 10mg IV q8h for 48h
10. Toradol 30mg q6h for 48hrs, then celebrex 200mg BID for 2 weeks
11. Early ambulation and physical therapy
12. Discharge planning, social work starting POD1
13. NPO POD1, CLD POD2 (8oz q8h), CLD POD3, regular POD4
Results: MEAN time to: flatus 2.2d, BM 2.9d, DC 5.0d.
39% complication rate, 16% GI rate, 12% readmit
VANDERBILT CYSTECTOMY PATHWAY (2003) (2)
*the first to not use NGT, developed from open surgeries
1. Preoperative mechanical bowel prep
2. No routine NGT
3. NPO until bowel function
Results: MEAN length of stay 8.52