Plastics

Attendings: Dr. Clay Burlew Dr. Alex Morton Dr. Fred Pieracci Dr. Campion Dr. Moore

Team: PGY5, PGY3, Intern shared between RGB services, Family Medicine Interns at times

Clinics: Monday - Gray clinic all day (Mandatory) Tuesday - Dr. Morton clinic with afternoon lumps and bumps removal (Optional) Thursday - PM Pieracci Thoracic Clinic (1 resident must cover)

Copper Surgery Information and Bariatric Pathways

Team Chief: Peter [914-523-6713]

R3s: Julia Coleman [614-406-8829], Ryan Gupta [504-931-8419]

Intern: Nick Schmoke [231-690-1360]

Important Contacts

1. Copper 0440
2. Gen Surg Clinic 303-724-2728
3. Bariatric Clinic 720-848-2070
4. Fluoro Read 85969/85263
5. Fluoro Sched 81085
6. Bariatric Clinic 82070
7. Pharmacy: Main 8139, Atrium 84083, ED 88400, PAS 83150
8. Bariatric Dietician (Lisa) p6166
9. Radiology 85343/93438/83434
10. SW/CM/PRL 83779/34527/83784
11. OR Bridge 84351
12. PACU 86203
13. OR Charge 83597
14. OR Room: 307***
15. Montero p0065
16. Schoen p0872
17. Rothchild p2517
18. Chauhan 901-319-8649, p1996

Pathways

General Rules Diet: NPO → GBCLD → GBFLD

• Diet: ‘GI Surgical’ in Epic → choose GBCLD/GBFLD
  

Meds

• No NSAIDS
  
• Some home meds can be restarted- do not typically restart anti-HTN, statins, antiglycemics, etc
  
• NPO: order IV meds
  
• Unordered List ItemGBCLD/GBFLD
  
• Chauhan: pills okay
  
• Occasionally meds need to be liquid if patient is having po intolerance, etc (case by case)
  
• Rothchild/Schoen: liquid meds or crushed only
  
• Sometimes pill is okay if it is small (smaller than peanut) and only formulary (effexor or other psychotropics, for example)
  

Precautions:

• Patient tachy (>110), pain, fever, restless, anxious (call attending)
  

Roux-en-Y Gastric Bypass Pathway:

POD0: D5LR @150 if not diabetic, if diabetic LR @ 150, SQH TID 8hrs post op, protonix IV (pepcid IV BID or lansoprazole-dissolving tablet decent alternatives if PPI reserved for GI bleed), resistant ISS for DM pts, no CPAP/BiPAP x48h (Chauhan ok w/ CPAP/BiPAP in particular circumstances)

POD#1 AM: Consider DC NGT, dc foley, decrease IVF decreased to 125, UGI? If Patient is NPO with NGT post-op with scheduled UGI POD#1 am: NPO until UGI, if UGI negative → advance to sips/chips/GBCLD by afternoon If patient is on GBCLD post op without POD#1 UGI: Continue GBCLD in am

• Occasionally patients will be on GBCLD immediately post op but will still have UGI in am

POD#1 PM: advance to GBCLD or GBFLD, IVF @125, dc PCA (and/or dilaudid IV if no PCA) and start liquid Roxicodone and APAP (pills okay for Chauhan patients)

POD#2: bcivf, advance diet to GBFLD, oral analgesics, dc home if tol 200cc/shift

Sleeve Gastrectomy Pathway:

Same as LRYGB except on POD#1: dc NGT then do UGI for both Schoen and Rothchild (calling fluoro helps get patients in faster in am)

• if no leak → advance to CLD→ FLD + bciv, oral analgesics (apap/oxy- liquid for S/R, pills for AC)
• d/c on FLD when tolerating 20cc/shift

Discharge

1. Make sure follow up appointments are made

• Bari patients: 1 week and 3 week
• Unordered List ItemGen surg: 2 week

1. AVS (depending on what patient has/needs at d/c): attach JP drain document (and make sure patient has drain teaching), Bariatric Full liquid diet document, Lovenox teaching doc (and make sure patient has teaching)
2. Discharge Info

• Meds: Apap/oxy, zofran, PPI (20 mg daily, 9 weeks)
• Chauhan: pills okay
• Schoen/Rothchild: liquid or crushed meds only (or cut to smaller than peanut if particular drug cannot be crushed and is not available as solution)
• Meds: DVT prophylaxis
• Schoen/Rothchild: BMI>50 and RYGB/Sleeve: Lovenox 2 weeks; BMI >50 with hx of PE/DVT: Lovenox 4 weeks
• Chauhan: BMI >50 RYGB: Lovenox 3 weeks, BMI >45 Sleeve: Lovenox 3 weeks
• Home meds:
• Antihypertensives: do NOT restart unless inpatient SBPs >160,
• Unordered List ItemAntiglycemics (metformin, insulin, etc): do not restart metformin, only restart insulin/other antiglycemics if glucose uncontrolled inpatient
• Statins
• Schoen: does not restart statin
• Rothchild: restarts statin

• Diet: Bariatric fulls, multivitamin

I have great smartphrase for basic d/c instructions: Madeline Thomas, starts with ‘mtbari….’