Periacetabular Osteotomy (PAO) — Surgical Day Post-Operative Management — Clinical Pathway: Inpatient

Periacetabular Osteotomy (PAO) Clinical Pathway — Inpatient

Surgical Day Post-Operative Management

PACU Management
  • Acute Pain Management Service orders hydromorphone PCA
  • Anesthesia team orders
    • Rescue doses of morphine/hydromorphone
    • Consider diazepam for muscle spasm
    • Use PONV orderset for management of ongoing nausea or vomiting

PACU to Surgical Recovery Floor

  • Goals
    • PCA Initiation
    • Analgesia regimen
    • Early mobilization: log rolling and sit at edge of bed
Pain Management
  • Acute Pain Management Service
    • Initiate hydromorphone PCA and
    • Hydromorphone IV rescue q3hr PRN for severe pain
    • Nalbuphine IV q4hr PRN for itching
    • Methadone 0.1 mg/kg, max 5 mg, 12 hrs after intraoperative dose
      • Hold if over-sedated
      • Caution in children under 12 yrs
      • PO if tolerating small diet
    • Acetaminophen IV q6hr x 3 doses
    • Diazepam PO q6hr PRN for muscle spasticity
    • Ketorolac IV q6hr x 8 doses to start 6 hrs after intraoperative dose
Activity/PT
  • Turn q2hr and PRN until rolling independently
  • Toe-touch weight bearing on affected extremity
  • Hip ROM precautions
    • Flexion 20-90°
    • Abduction/adduction < 20°
    • Internal/external rotation < 20°
  • Use CPM 0-50° on 2 hrs, off 2 hrs while awake when indicated
GI
  • Advance diet as tolerated
  • Start famotidine IV x3 doses
  • Begin bowel regimen at night as ordered
    • Senna 17.2 mg nightly
  • 1st line constipation
    • Bisacodyl suppository 10 mg daily PRN
  • Ondansetron q8hr PRN
  • Dexamethasone IV 0.1 mg/kg, max 4 mg over 15 mins 8 hrs after intraoperative dose
    for nausea
  • Severe PONV rescue plan:
    • Consider 10 ml/kg lactated ringers IV bolus
    • Consider scheduled ondansetron q8hr
    • Additional dexamethasone IV 0.1 mg/kg, max 4 mg over 15 mins x 1 doses
Nutrition
  • IVF at maintenance overnight until tolerating clears
  • Advance diet as tolerated
Tubes/Drains
  • Record Hemovac drain output q8hr
  • Maintain Foley catheter, monitor q4hr
Respiratory
  • Incentive spirometry q2hr while awake
  • Turn, cough, deep breathe
Other Medications Post-operative antibiotic prophylaxis as ordered
Discharge Planning
  • Surgical recovery teaching with family
  • Set up expectation for early movement and oral pain control