General OR Guidelines

Pre-op visit

• H&P
  • Done within 30 days before the planned surgery due to hospital regulations. The preoperative clinic note should be very thorough including PMHx, medication with doses, complete exam, labs and radiology results, and preop clearance documented; if labs, preop clearance or films are pending, document that. The operating resident should be able to refer only to that note for the info they need for the case and ordering the patient’s previous meds postop.
• Labs and tests
  • All women of childbearing age should have urine pregnancy check in DOSA
  • Consider CXR and EKGs on patients over age 50, particularly H&N cancer patients and anyone with high risk of heart disease, CHF, metastatic disease, lung disease
  • Unless the patient is a young, healthy individual, all patients will require a CBC, BMP
  • check allergies and weights (peds)
  • Any labs/x-ray/EKG/consult you order need to be checked by you. 
  • If a pre-op sleep study is needed, order a “sleep lab PSG” and in comments write “split night PSG”. Do not order a neurology consult so it can be done within 2 weeks
• Other orders
  • For cases longer than 3 hours- Teds & Kendalls (also for hypercoagulable state, eg. cancer), Foley
  • Have a low threshold for consulting Medicine. Most patients with a complicated medical history work-up warrant a referral to surgical comanagement to manage their issues while they are in the hospital. For medical problems during their inpatient stay, page the attending that has seen them and either ask for a visit, or for further instructions
• Consent
  • Risks: standard risks include bleeding, infection, anesthesia risks, injury to structures working on or around, and need for further procedures. 
  • Check the Iowa Protocols for a description of the procedure and specific risks for the consent. Consent should include risks written out to document what was discussed.
• Orders for the procedure must be placed during the first visit

Antibiotic prophylaxis and Pre-operative medications:

Antibiotics are commonly used in otolaryngology surgeries in order to prevent peri-operative infections.  Surgeries are commonly divided into clean (no entry into oral mucosa or oro-digestive tract) and contaminated cases.  Common pre-op antibiotics and meds include:

• Without oral contamination - Ancef 1 gm IV (Peds 30mg/kg) OCTOR and then q8hrs x 3
• With oral contamination - Unasyn  3 gm IV (Peds 30mg/kg) OCTOR and then q8hrs x 3; (alternative is Clindamycin 900 mg IV OCTOR and then q8hrs x 4). Pediatric airway cases Timentin 30 mg/kg
• Glycopyrolate 0.2 mg IM: helps control secretions in oral/airway cases
• Laryngeal/Oral Cavity/Oropharyngeal cases where post-op edema expected- Decadron 10mg IV (Peds 0.25 mg/kg): helps reduce airway inflammation
• Micro-laryngeal cases - Robinol 0.1 - 0.2mg IM one hour prior to procedure. Consider mitomycin C 10mg/cc x 5c available in OR
• SBE prophylaxis: amoxicillin 2g po, clindamycin 600mg PO/IV, Ancef 1g IV, Keflex 2g PO, OR azithromycin or clarithromycin 500 mg PO before surgery

Case specific pearls

Recurrent respiratory papillomatosis

• Associated with HPV 6 and 11 (HPV 16 is related to oropharyngeal cancer)
• Pre-op
  • Order racemic epinephrine 2.25% 0.5ml OCTOR (if no cardiac history; not for Hoffman cases) to decrease the bleeding caused by the microdebrider.  The severe croup dose is 0.05 mL/Kg diluted to 3 mL with NS.  The max dose is 0.5 mL. 
  • Decadron 0.25 mg/kg for peds, 8-10mg for adults
  • MitomycinC and cidofovir must be ordered in advance if it is to be used. It is very expensive so ordering it routinely is not a good idea.  The plan to inject MitomycinC or cidofovir is normally decided during the previous case and so when dictating the OR note, the plan for the next case should be noted. 
    • Mitomycin C dose is usually 3mL of 10 mg/mL or 1%
• OR: Typically use 2.9mm skimmer microdebrider on 500(novice)-1000 rpm.
• Post-op: The op note should mention how many papilloma resection procedures and mitomycinC injections have been performed to date in the indications section. (ie a running total).

 Tonsillectomy and Adenoidectomy

• Pre-op
  • Document palate and tonsil size in H&P
  • Labs: H&H. If personal or family h/o bleeding disorder, then check coags and platelet function. 
  • Unasyn/ clindamycin and Decadron OCTOR for tonsils. Not necessary for adenoids alone.
• Post-op
  • Post-op antibiotics and pain prescription for tonsils only.
  • Tell patients/ parents to set their alarm to wake up the first few nights for Lortab.  Make sure the patient stays well hydrated (more fluids= less pain).  Soft diet for 2 weeks. If they see any bleeding which continues after gargling, especially 5-10 days postop (when eschar sloughes), call or go to local ER or come here to be seen. A small amount of bleeding may signal a spasming vessel that may bleed more.  If you are on call, do not suction off the clot, call your senior to evaluate. 

OR Supplies

• Alloderm
  • Must be ordered the night before. Call DeGowin Blood bank for transfer to the tissue bank and specify your request
  • Options (usually the thin 4x16cm is used)
    • thickenss: thin, medium, thick
    • size: 3x8 cm, 4 x 16cm
• Balloon dilation
  • used for subglottic and tracheal stenoses
  • CRE pulmonary balloons for adults, size 12mm to 18mm. Stored in MOR annex storeroom and in ASC storeroom between ASC3 and 4
  • Cardiac angioplasty balloons for pediatric dilations. Kept in store room next to rm 8.   The Levine insufflators are at the bottom of the first cupboard and the catheters are approximately the third cupboard  over.  This room is kept locked when it is not in use. The key is kept at the charge nurse desk
  • If you are taking them off the unit (such as ASC) , please let Jan or Pat know so they can be counted and reordered.
  • OptaPro cardiac balloon sizing guide
• Mitomycin C – often used when stenoses are dilated, choanal atresia repairs, glottic webs, RRP, etc.  We use a concentration of 10mg/ml and order 3ml for the case.  This needs to be ordered ahead of time

OMFS method of securing nasotracheal tube

• Cut a rectangular piece of foam (~2in x 10in) with a wedge cut out either side on opposing ends. Put Iowa hat on to protect the hair and tape in place with 2” clear tape. Benzoin noise. Tape ETT to nose (1” cloth tape, like taping NG). Put on straight connector with 90deg angle elbow. Put the foam (one wedge side down on nasal dorsum, other wedge side up) at top of forehead. Pass LONG piece of 2in cloth tape under the head and tear it down the middle from the ends. Secure the upper halves under the elbow, and the lower halves above the elbow to pull the tube down. Check there is no pressure on the nasal ala.

Anesthesia considerations  - most commonly modified by Surgical Comanagement Consultation directing medical therapy

• Anticoagulation (defer to Surgical Comanagement Consultation - each patient is individually considered, general guidelines include): Patients with mitral valve prostheses, multiple valve prosthesis, any prosthetic valve with afib, CHF, intra cardiac thrombus, or recent DVT (<3 months) need bridge therapy. Stop Coumadin 4 days before surgery. Start Lovenox 1mg/kg bid. Lovenox last dose should be the AM the day before surgery.
  • Patients with isolated aortic valve prosthesis and no other risk factors, mitral stenosis, nonvalvular afib and no hx of TIA/CVA/intracardiac thrombus, DVT older than 3 months, LV aneurysm, peripheral bypass do NOT need bridge. Stop Coumadin 4 days prior and resume post-op
• Periop guidelines for other anticoagulants (time frame to stop taking before surgery)(defer to Surgical Comanagement Consultation - each patient is individually considered, general guidelines include)
  • ASA --2 weeks
  • NSAIDS: ibuprofen 3days, naproxen 4 days, ketorolac 1-2 days
  • Misc: Plavix 7 days, dipyrimadole 2 days, Vit E/ garlic / ginseng 1 week, St. Johns wort 5 days
  • MAY take for headache or pain pre-op: Tylenol, codeine, darvocet, Excedrin PM, Celebrex
• Periop insulin (defer to Surgical Comanagement Consultation - each patient is individually considered, general guidelines include): Continue basal insulin (eg. bedtime Lantus/NPH). Hold insulin and oral agents on AM of surgery (will give after IV placed). Do not nee to hold metformin. Target BG 100-120.
• Periop antihypertensives (defer to Surgical Comanagement Consultation - each patient is individually considered, general guidelines include)
  • Held day of surgery: ACEI and angiotensin II receptor antagonists (causes hypotension, renal insufficiency, decreased hepatic blood flow) and diuretics, unless necessary for CHF/ respiratory difficulty when held
  • Continue all beta blockers, including those cobined with diuretics
• Meds on morning of surgery (defer to Surgical Comanagement Consultation - each patient is individually considered, general guidelines include)
  • Should take: beta blockers and cardiac meds (see prior section on antihypertensives), antacids, anti-seizure meds, immunosuppressives, psychiatric meds, birth control pills, ADD meds, antibiotics, any prep meds as directed
  • May take: pain meds that do not cause bleeding, nasal sprays, steroids, anti-anxiety meds, antihistamines and decongestants, urology meds, gout mes, thyroid agents, hormonal therapy
  • Should NOT take: oral hypoglycemic agents and insulin, herbal meds, laxatives